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Epistaxis

hadeel Owies

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Nose anatomy : 2/3 cartilaginous ,1/3 bony.

Bony bridge extremely strong .skin very closely related to the skeleton .

Nose function:

Warming ,moistering and filtering the incoming

air

Detecting olfactory stimuli

Modifying speech vibrations

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Why bleeding from the nose ?

Vascular organ secondary toincredible heating/humidification

requirements

Vasculature runs just under mucosa(not squamous)

Arterial to venous anastamoses

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Blood supply:1.External Carotid

Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

2.Internal Carotid Artery-Anterior Ethmoid artery

-Posterior Ethmoid artery

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Kesselbachs

Plexus/Littles Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruffs Plexus:-Pharyngeal & Post. Nasal

AA of Sphenopalatine A

(IMAX)

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Anterior vs. Posterior

Anterior: younger, usually septal vs.

anterior ethmoid, most common

(>90%), typically less severe Posterior: older population, usually

from Woodruffs plexus, more serious.

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Etiology

Local factorspontaneous

Vascular

Infectious/Inflammatory Trauma

Iatrogenic

Neoplasm

Foreign Bodies/other

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Etiology

general factors

Vascular

Infection/Inflammation

Coagulopathy

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Trauma

Nose picking

Nose blowing/sneezing

Nasal fracture

Nasogastric/nasotracheal intubation

Trauma to sinuses, orbits, middle ear,

base of skull

Barotrauma

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Local Factors -

Infection/Inflammation

Rhinitis/Sinusitis

Allergic

Bacterial

Fungal

Viral

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Local Factors - Iatrogenic nasal

injury

Functional endoscopic sinus surgery

Rhinoplasty

Nasal reconstruction

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Local FactorsNeoplasm

benign tumor: Juvenile nasopharyngeal angiofibroma

Inverted papilloma

Polyps

Malagnant tumor:

scc

Adenocarcinoma

Melanoma

Lymphoma

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Systemic Factors -- Vascular

Hypertension/Arteriosclerosis

From woodruffs area

Elderly

Difficult to stop

May recure

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Systemic Factors

Infection/Inflammation

Tuberculosis

Syphillis

Wegeners Granulomatosis

SLE

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Systemic Factors

CoagulopathiesThrombocytopenia

Platelet dysfunction Systemic disease (Uremia)

drug-induced (Coumadin/NSAIDs/Herbal

supplements)

Clotting Factor Deficiencies Hemophilia

VonWillebrands disease

Hepatic failure

Hematologic malignancies

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Etiology and Age

Childrenforeign body, nose picking

Adultstrauma, idiopathic

Middle agetumors

Old age--hypertension

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Initial Management

ABCs

Medical history/Medications

Vital signs Physical exam

Anterior rhinoscopy

Endoscopic rhinoscopy

Laboratory exam

Radiologic studies

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managmant: If bleeding is from little area:

1. Apply digital pressure on the lower part of theseptum.

2. Pack the nose with cotton plug soaked with

lidocaine or phenylephrine for 5-10 minutes.3. If it didnt work, try to cauterize the site of

bleeding with silver nitrate stick.

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If bleeding is from an unknown site:1. Apply digital pressure on the lower part

of the septum for 5-10 minutes.

2. Let the patient lean forward.

3. Ask the patient to breath from his mouth.4. Spit out the blood and not to swallow it.

5. If healing site is visible we do

cauterization by silver nitrate or

diathermy.

6. Sometimes we need to do post nasal

packing

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Nasal packs

We can use foleys catheter, we insert itfrom the nose and once it is in the

pharynx we inflate the balloon and

pull it back untill its stuck at thenasopharynx.

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Non-surgical treatments

Avoidance of nose picking/blowing

Sneeze with mouth open

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Non-surgical treatments

Control of hypertension

Correction of

coagulopathies/thrombocytopenia

FFP or whole blood/reversal ofanticoagulant/platelets

Topical decongestants/vasocontrictors

Cautery (AgNo3 vs. TCA vs. Bipolar vs.

Bovie) Nasal packing (effective 80-90% of time)

Greater palatine foramen block

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Surgical treatment

Transmaxillary IMA ligation

Intraoral IMA ligation

Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation

External carotid artery ligation

Septodermoplasty/Laser ablation

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Indications for

surgery/embolization Continued bleeding despite nasal

packing

Pt requires transfusion

Nasal anomaly precluding packing

Patient refusal/intolerance of packing

Posterior bleed vs. failed medical

mangmant

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THANK YOU

Hadeel owies