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Kiesselbach’s Plexus/Little’s Area:
-Anterior Ethmoid (ICA)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Woodruff’s Plexus:
- Sphenopalatine A (Pharyngeal & Post. Nasal
branches) (IMAX)
-Posterior ethmoid (ICA)
Classification:
Anterior epistaxis (90%) Bleeding from Little’s area. Controlled by an anterior pack Younger patients
Posterior epistaxis (10%) Occurs in the area of Woodruff’s plexus Older patients Epistaxis not controlled by anterior nasal
packing.
Local Factors - Inflammation
URI allergic rhinitis Sinusitis
Increased vascularity and greater friability of vessels in inflamed mucosa
Etiology :
-Trauma
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear,
base of skull
Barotrauma
-Iatrogenic nasal injury
Functional endoscopic sinus surgery
Septoplasty or Rhinoplasty
Nasal reconstruction
-Others:
Cold, dry air—more common in wintertime
Dry heat. Anatomic abnormalities (ie: nasal septal deformity - turbulent flow (dry mucosa leading to crusting) Atrophic rhinitis
: -Vascular
Hypertension Hereditary hemorrhagic telangiectasia
(Osler-Weber-Rendu disease) subepidermal vessels lacking elastic tissue in
capillary wall and deficiency of smooth muscle
–Coagulopathies
Primary coagulopathies (hemophilia, von Willebrand’s disease, thrombocytopenia and polycythemia vera).
Secondary coagulopathies (uremia, alcoholism, chronic liver disease, leukemia, myeloma, aplastic anemia, idiopathic thrombocytopenis purpura or hypovitaminosis).
Iatrogenic coagulopathies (heparin)
Etiology and Age
Children - foreign body, nose picking
Adults - trauma, idiopathic
Middle age - tumors
Old age - hypertension
Management:
ABC’s. Vital signs—need IV. Medical history/Medications. Labs. Physical exam –
Rhinoscopy
Initial Management:
Non-surgical treatments
Topical decongestants/vc. Cautery (AgNo3) Nasal packing. Control of hypertension Correction of:
coagulopathies/thrombocytopenia
Nasal packing:
Anterior nasal packs Traditional Recent modifications
Posterior nasal packs Traditional Recent modifications
Posterior Packs – Admission
Elderly and those with other chronic diseases may need to be admitted to the ICU
Continuous cardiopulmonary monitoring Antibiotics Oxygen supplementation may be needed Mild sedation/analgesia IVF
Discharge instructions
Humidity/emolients Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining Avoid hot/spicy food
Indications for surgery:
Continued bleeding despite nasal packing
Nasal anomaly interfering with packing
Patient refuse/intolerance of packing
Posterior bleeding with failed non
surgical treatment after >72hrs
:Surgical treatment
Transmaxillary IMA ligation Transnasal Sphenopalatine ligation External carotid artery ligation Anterior/Posterior Ethmoidal A.
ligation
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