Slide 1

EpistaxisDr. Vishal Sharma

1Definition & CausesBleeding from within the nasal cavity.

Causes: 1. Idiopathic (55 %) 2. Local 3. General 2Local causes (nose & P.N.S.) Congenital: hereditary telengiectasia Trauma: nose picking, injury to nose / face / skull base, nasal surgery, foreign body Infection: vestibulitis, sinusitis, atrophic rhinitis, rhinosporodiosis, rhinoscleroma Neoplasms: angiofibroma, hemangioma, inverted papilloma, malignancy Deviated nasal septum (spur)3General causesHypertensionBleeding disorders: haemophilia, thrombocytopenia, leukemiaDrugs: aspirin, anticoagulants Physiological: cold + dry climate, high altitude, vicarious menstruation, violent exertion, barotraumaLiver failure Exanthematous fevers4Common causes of epistaxisChild: nose picking, foreign body, exanthematous feverAdolescent: nasopharyngeal angiofibroma, trauma, sinusitisAdults: sinusitis, traumaElderly: hypertension, malignancy5Common sites of epistaxisLittles area (80-90 %): Kiesselbachs arterial plexus at antero-inferior part of septal cartilage. Common in children.Woodruffs venous (?) plexus: near posterior end of middle turbinate. Common in elderly, hypertensives.Retro-columellar vein: common in adults.6Common sites of epistaxis

7Common sites of epistaxis

8Anterior EpistaxisPosterior EpistaxisIncidenceMore commonLess commonLocalizationEasyDifficultCommon siteLittles areaWoodruff plexusAge< 18 yr> 40 yrCommon CauseTraumaHypertensionTreatmentAnterior packPosterior pack9Evaluation of pt. with epistaxismode of onset, duration, frequency, amount, side, site, previous bleedingnasal trauma, purulent nasal discharge hypertension, hepatic diseases, family history of bleeding, bleeding from other sites, use of anticoagulants, aspirinmeasurement of pulse & blood pressure10InvestigationsHemoglobin, Packed Cell Volume Blood grouping & cross-matching Bleeding Time, Clotting Time Activated Partial Thromboplastin Time Prothrombin Time Platelet count Diagnostic Nasal Endoscopy (D.N.E.)C.T. scan paranasal sinus11General treatmentRecord pulse & blood pressureReassurance + bed rest in sitting posture with back restAdequate sedation (Diazepam)Inj. Ethamsylate 500 mg IV Q8HAmlodipine / Nifedipine for hypertensionIV fluids / blood transfusion for shock12Anterior epistaxisPinch nostrils + ice pack Bleeding continuesInsert cotton pledgets soaked in 1: 1000 adrenaline in nasal cavity Bleeding continuesChemical cautery with AgNO3 or electrical cautery (if bleeder is localized) or anterior nasal packing13Trotters method Elderly pt in sitting position, leaning forward, mouth open allowing bleeding to continue till hypotension develops. May lead to coronary thrombosis + death.

14Adrenaline soaked pledget15Chemical cautery

16Anterior nasal packing Anterior nasal packing for 48-72 hrs antibiotic cover with:Liquid paraffin + antibiotic cream gauzeVaseline gauzeBismuth Iodoform Paraffin Paste gauzeMerocel tampoon Simpson balloon17Anterior nasal gauze packing

18Anterior nasal gauze packing

19Anterior nasal gauze packingRibbon gauze soaked with liquid paraffin + antibiotic cream used. Both nasal cavities packed tightly by layering from floor to roof. Pack removed after 48 hrs. Systemic antibiotics given to prevent sinus infection & toxic shock syndrome. 20Merocel nasal tampoon

21Simpsons nasal balloon

22Posterior epistaxisPosterior + anterior nasal packing for 48-72 hrs antibiotic cover with:Post nasal gauze packFoleys catheterBrighton balloon (double lumen) Epistat balloon (double lumen) Bivona balloon (triple lumen)23Antero-Posterior Nasal Packing with gauze pack24Posterior nasal gauze pack

25Catheter introduction

26Tying of pack to catheter tip

27Guiding pack into nasopharynx

28Tying of anterior strips

29Anterior nasal packing

30Outer nasal packing

31Posterior nasal packingPost nasal pack prepared by tying 3 ribbon gauze strips to piece of gauze roll 2 Foleys catheters passed through each nostril & their ends brought out via mouth 2 ends of gauze strips attached to nasal pack tied to catheter tips & withdrawn from nose 32Posterior nasal packingPack that follows ribbon gauze strips, is guided into nasopharynx with index finger.Anterior nasal packing done. 2 ribbon gauze strips tied over a gauze piece on columella. 3rd gauze strip brought out from mouth & taped to cheek. Pack removed after 48-72 hr.33Antero-Posterior Nasal Packing with Foleys catheter34Foleys catheter

35Catheter introduction

36Catheter tip in nasopharynx

37Anterior nasal packing

38Brightons nasal balloon

39Epistat nasal balloon

40Bivona triple lumen catheter

41Epistaxis set

42Surgical intervention for refractory epistaxis431. Arterial ligation by external approachexternal carotid artery: ligated in neck, distal to superior thyroid artery internal maxillary artery: ligated in pterygo-palatine fossa (Caldwell-Luc opn)anterior or posterior ethmoidal artery: ligated in orbit (Lynch-Howarth incision)44

45External Carotid ligation

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472. Angiography and embolization3. Submucosal Resection of septum 4. Septo-dermoplasty: for hereditary telengiectasia5. Endoscopic cautery & clipping: Sphenopalatine artery Anterior or posterior ethmoidal artery48Angiography + embolization

49Endoscopic clipping

50Thank You

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