e.n.t 5th year, 2nd lecture/part one (dr. yousif chalabi)

EPISTAXISEPISTAXIS

IntroductionIntroduction

Epistaxis is a Latin word means bleeding Epistaxis is a Latin word means bleeding from the nose.from the nose.

Epistaxis is a common problem and affects Epistaxis is a common problem and affects all age groups , although it is common in all age groups , although it is common in both extremes of life, 5-10% of the both extremes of life, 5-10% of the population experience an episode of population experience an episode of epistaxis each year. 10% of those will see a epistaxis each year. 10% of those will see a physician. 1% of those seeking medical physician. 1% of those seeking medical care will need a specialist.care will need a specialist.

• The nasal fossa generally is supplied by branches of:

• External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

- Superior Labial artery

-

-

• Internal Carotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery

Of maxillary artery

Of facial artery

Of ophthalmic artery

Arterial supply of nasal cavityArterial supply of nasal cavity

Vascular supply of the nasal cavity

Anatomy of the Nasal Cavity and Vasculature

Kiesselbach’s Plexus/Little’s Area:

-Sphenopalatine A - -Greater Palatine A

-Superior Labial A

-Anterior Ethmoid (Opth)

Woodruff’s Plexus:

-Pharyngeal & Post. Nasal branches of Sphenopalatine

Sites of bleedingSites of bleeding

1.Nasal septum : 1.Nasal septum : 75%-90%75%-90%

Little’s area ‘’Kiesselbach’s’’plexus.Little’s area ‘’Kiesselbach’s’’plexus.

often behind a spur often behind a spur ‘bleeding polypus’ (an ‘bleeding polypus’ (an inflammatory granuloma) .inflammatory granuloma) .

2.Inferior turbinate and nasal floor .2.Inferior turbinate and nasal floor .3.Above the middle turbinate.3.Above the middle turbinate. anterior ethmoidal vessels, usually in hypertension.anterior ethmoidal vessels, usually in hypertension.

4.The middle meatus.4.The middle meatus.5.sinuses. 5.sinuses.

EtiologyEtiology

Local factorsLocal factors-congenital (meningocele)-congenital (meningocele)-acquired-acquired

IdiopathicIdiopathic Trauma -F.B, facial trauma, iatrogenicTrauma -F.B, facial trauma, iatrogenic Infectious/InflammatoryInfectious/Inflammatory Neoplasm (benign , malignant)Neoplasm (benign , malignant) Drug induced (rhinitis medica mentosa,local)Drug induced (rhinitis medica mentosa,local) Inhalant (tobacco,wood dust) Inhalant (tobacco,wood dust) DessicationDessication

EtiologyEtiology

Systemic factorsSystemic factors1.Hypertension , 1.Hypertension , not cause epistaxis.not cause epistaxis.

2.Raised venous pressure2.Raised venous pressure , retrocolumelar vein. , retrocolumelar vein.

3.Bleeding disorder:3.Bleeding disorder: -coagulopathy (haemophilia ,Christmas disease…).-coagulopathy (haemophilia ,Christmas disease…). -platelet disorder-platelet disorder -blood vessel disorder-blood vessel disorder -hyper fibrinolysis-hyper fibrinolysis4. Drugs 4. Drugs

(aspirin,NSAIDs,methotrexate,immunosupressive).(aspirin,NSAIDs,methotrexate,immunosupressive).5.Neoplasm.5.Neoplasm.6.Inflammatory disorder (SLE)6.Inflammatory disorder (SLE)7.Others (liver failure, hypothyroidism)7.Others (liver failure, hypothyroidism)

Nasal Fracture with Septal Hematoma

Etiology and AgeEtiology and Age

Children—foreign body, nose pickingChildren—foreign body, nose picking

Adults—trauma, idiopathicAdults—trauma, idiopathic

Middle age—tumorsMiddle age—tumors

Old age--hypertensionOld age--hypertension

Management of Management of EpistaxisEpistaxis

HistoryHistory:: - - quantity of blood lossquantity of blood loss

- - side and site of bleedingside and site of bleeding - - durationduration

- - co morbiditiesco morbidities - - family historyfamily history

ExaminationExamination:: locallocal

- - anterior and posterior rhinoscopyanterior and posterior rhinoscopy - - flexible and rigid nasoendoscopyflexible and rigid nasoendoscopy

generalgeneral- - vital sign , general examination , systemicvital sign , general examination , systemic

Investigation( CBC, Coagulation studies, Investigation( CBC, Coagulation studies, Blood group and cross match)Blood group and cross match) Treatment ( initial , non surgical , surgical)Treatment ( initial , non surgical , surgical)

Immediate managementImmediate management

Pressure on the nostrils Pressure on the nostrils (breath through the mouth and (breath through the mouth and head leant forward)head leant forward)

Ice or cold pack (to bridge of Ice or cold pack (to bridge of nose and roof of mouth)nose and roof of mouth)

mild sedativesmild sedatives

Epistaxis (active bleeding)Epistaxis (active bleeding)

Admission, IV line , blood group and cross match, monitor pulse ,BP. Consider blood transfusion .Treat primary cause .

Identify site of bleeding (anterior, posterior, unclear)

Nasal cautery after cocainization

successful

Naseptin

General advice

unsuccessful

Nasal packing (2-5)days

Anterior ,posterior, both

Still bleeding

Surgical intervention

Remove pack

Ephedrine drop, cautery

Still bleedingSurgical intervention

EpistaxisEpistaxis

Coagulopathy

Family history +ve

Osler Weber disease

Laser cautery Septodermoplasty

Recent bleeding

Bleeding site identified

Ant.Rhinoscopy

Nasal cautery after cocainization (L.A.)

Advise and Topical care (naseptin cream)

monitoring underlying cause

Previous treatmentRecurrent

Nasal cautery (G.A.)

Non-surgical treatmentsNon-surgical treatments

General advise General advise

Avoidance of nose picking/blowingAvoidance of nose picking/blowing

Sneeze with mouth openSneeze with mouth open

Avoid strainingAvoid straining

Elderly and those with other chronic Elderly and those with other chronic diseases may need to be admitted to the diseases may need to be admitted to the ICUICU

Continuous cardiopulmonary monitoringContinuous cardiopulmonary monitoring

AntibioticsAntibiotics

Oxygen supplementation may be Oxygen supplementation may be neededneeded

Mild sedation/analgesiaMild sedation/analgesia

IVFIVF

Indications for surgery/embolizationIndications for surgery/embolization

The patient who continues to bleed every The patient who continues to bleed every time the pack is removed or the bleeding time the pack is removed or the bleeding continue with the pack in situ ,will continue with the pack in situ ,will generally have to be transfused. if severe generally have to be transfused. if severe bleeding or over 4-5 days bleeding has bleeding or over 4-5 days bleeding has not stopped, surgical intervention should not stopped, surgical intervention should be considered.be considered.

Posterior bleed vs. failed medical Posterior bleed vs. failed medical management after >72hrs management after >72hrs

Nasal anomaly precluding packingNasal anomaly precluding packing

Surgical treatmentSurgical treatment

Transmaxillary IMA ligationTransmaxillary IMA ligation

Intraoral IMA ligationIntraoral IMA ligation

Transnasal Sphenopalatine ligationTransnasal Sphenopalatine ligation

External carotid artery ligationExternal carotid artery ligation

Anterior/Posterior Ethmoidal ligationAnterior/Posterior Ethmoidal ligation

Other method of treatmentOther method of treatment

SMRSMR

When bleeding behind prominent spurWhen bleeding behind prominent spur

To improve access for cauteryTo improve access for cautery

To interrupt blood supply from little’s To interrupt blood supply from little’s area ,hemorrhagic nodulearea ,hemorrhagic nodule

Anterior and posterior nasal packing

Balloons

close

Thank youThank you