Introduction and History

Acute hemorrhage from the nostril, nasal cavity, or nasopharynx

5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.

REASONS FOR EXCESSIVE BLEEDING

Vascularity of noseBoth external and internal carotids. Anastomsis between arteries and veins.Blood vessels run just under the mucosa-

unprotected.Larger vessels on the turbinate run in bony

canals- cannot contract.

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4Frank Netter. Ciba

5Frank Netter. Ciba

Kiesselbach‘s Plexus a.k.a Little’s area

1/2 inch from the caudal border of the septum antero-inferiorly.

Vessels anastomosing are; Anterior ethmoid, greater palatine, and sphenopalatine, and septal branch of superior labial.

Bleeding may be arterial or venous.

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Kisselbach’s Plexus

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Underlying CausesLocal irritation Use of ASA or NSAIDSHypertensionCoagulapathies / Bleeding disordersPlatelet dysfunction

Underlying CausesOccupational exposureAllergiesMalignancy Systemic disease such as granulomatous

disease(Wegener’s sarcoidosis)Hereditary hemorrhagic

telangiectasia(Osler-Weber-Rendu syndrome)

Cirrhosis, Renal Failure

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Underlying Causes - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma

Underlying causes - Iatrogenic nasal injury

Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction

Local Factors – Dessication

Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitisNasal septal deviationNasal septal perforation

Initial ManagementABC’sMedical history/MedicationsVital signs—need IV?Physical exam

Anterior rhinoscopyEndoscopic rhinoscopy

Laboratory examRadiologic studies

Laboratory StudiesCBCPT / PTTBleeding Time

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TreatmentIV AccessIV FluidsBlood or Blood product transfusionControl of hypertensionCorrect coagulapathy

FFP, Vit. K, Protamine

Basic TreatmentMake the patient sit up, pinch nose, open

mouth and breath.

Ice on fore head and or gargle ice water

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Ask the PatientPatients will almost always tell you the side of

bleedingWhich side did it start on Was in coming out the front or draining down

the throatNosebleeds rarely have bilateral sources

Anterior or PosteriorAnterior

Bright red blood from front of nose Posterior

Nausea, hematemesis, anemia, hemoptysis or melena.

No visualized anterior source of bleedingPost nasal drip of blood

TreatmentBe Prepared

Adequate equipment to the bedside HeadlightNasal SpeculumSuctionPacksCauteryAnesthetic

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suction

good lightanesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

Surgicel / Floseeal

epistat

bayonet forceptsvaseline gauze

TreatmentLocate the point after packing the nose with 4%

xylocaine and oxymetazolineSuction the NoseHave patient blow clots out of the nose

CAUTERIZATIONChemicals

Silver Nitrate stickElectrical

BovieBipolar

Avoid bilateral or excessive cautery

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Pick a Pack, any pack

Nasal packsAnterior nasal packs

Merocel – Nasal TamponVaseline GauzeInflatable PacksSurgicel or Gelfoam

Posterior Epistaxis Packing

Posterior Epistaxis Packing

Epistaxis - ComplicationsSinusitisPossibility of airway obstructionToxic shock syndromeSeptal hematoma or abscessSeptal perforation Loose pack obstructing the airwayNasal scarring or stenosisAlar necrosis

Treatment after PackingRemoved as soon as possible

Typically 3-5 days AntibioticsPosterior or bilateral packing requires

admissionTransfuseContinue treatment of underlying condtionsOxygenICU Admit

Surgery / embolization Indications

Continued bleeding with packingRequired transfusion Nasal anomaly precluding packingPatient intolerance to packingPosterior bleed vs. failed medical mgmt

after >72hrs

Other Treatments

SurgeryLigation of vessels

Maxillary arteryEthmoid arteriesExternal Carotid artery

Transmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA

--descending palatine & sphenopalantine most important

Recurrence rate (failure rate) of 10-15%Complication rate of 25-30% (oa fistula,dental, n)Imax ligation now done commonly through

endoscopic approach

Ant./Post. Ethmoidal ligationPatients s/p IMAX ligation still bleeding, superior

nasal cavity epistaxis, or in conjunction when source unclear

Lynch incisionFronto-ethmoid suture line12-24-6 (14-18, 8-10, 4-6)

Transnasal Endoscopic Sphenopalatine Artery ligationFollow Middle Turbinate to posteriormost aspectVertical mucoperiosteal incision 7-8mm anterior to

post middle turb (between mid. and inf. turbs)Elevation of flap—ID neurovascular bundle at

foramenLigation with titanium clipReapproximate flapComplications –few, Failures—0-13%

Transnasal Spheno-palatine Artery ligation

ECA ligationEffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are

safe.

Selective Angiography/embolizationHelps identify location of bleedingEmbolization most effective in patients who

Still bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min90+% success rate, complication rate of 0.1%Only able to embolize external carotid & branchesComplications: minor (18-45%)/major (0-2%)Contraindicated in bad atherosclerosis, Ethmoid

bleed

Treatment after DischargeHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest