EPISTAXIS EPISTAXIS
May 24, 2015
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
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-
• 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
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