EPISTAXIS

Glen Porter, MDFrancis B. Quinn, MD

UTMB-GalvestonGalveston, Texas

Introduction and History5-10% 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.Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”A condition with a long history—Hippocrates to Henry Goodyear.

Anatomy/Physiology of EpistaxisAnatomy

Nasal cavityVascular supply

PhysiologyVascular natureMucosa

Why bleeding from the nose ?Vascular organ secondary to incredible heating/humidification requirementsVasculature runs just under mucosa (not squamous)Arterial to venous anastamosesICA and ECA blood flow

SPF

-class I (35%)

-class II (56%)

-class III (9%)

Anatomy of the Lateral Nasal Wall

External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

Internal Carotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery

Pterygopalatine Vasculature

--Internal maxillary artery

Anatomy of the Nasal Cavity and Vasculature

Sphenopalatine AA

Ethmoid AA

Greater Palatine A

Kesselbach’s Plexus/Little’s Area:-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus:-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

Anterior vs. PosteriorMaxillary sinus ostiumAnterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severePosterior: older population, usually from Woodruff’s plexus, more serious.

EtiologyLocal factors

VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDessicationForeign Bodies/other

EtiologySystemic factors

VascularInfection/InflammationCoagulopathy

Local Factors -- Vascular

ICA Aneurysms extradural cavernous sinus

Local Factors - Infection/Inflammation

Rhinitis/SinusitisAllergicBacterialFungalViral

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

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction

Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma

Local Factors –Dessication

Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis

Local Factors - Other

Self-inflicted (pedi) vs. traumatic foreign bodiesIntranasal parasitesSeptal perforationChemical (cocaine, nasal sprays, ammonia, etc.)

Systemic Factors -- Vascular

Hypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias (OWR)

Systemic Factors –Infection/Inflammation

TuberculosisSyphillisWegener’s GranulomatosisPeriarteritis nodosaSLE

Systemic Factors – CoagulopathiesThrombocytopeniaPlatelet dysfunction

Systemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure

Hematologic malignancies

Etiology and AgeChildren—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o)Adults—trauma, idiopathicMiddle age—tumorsOld age--hypertension

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

Anterior rhinoscopyEndoscopic rhinoscopy

Laboratory examRadiologic studies

gelfoambacitracin

endoscopes

suction bovie/bipolar

Afrin

T.C.A.

epistat

vaseline gauzebayonet forcepts

suction

good lightanesthetic

silver nitrate

merocelssurgicel

Non-surgical treatments Control of hypertension Correction of coagulopathies/thrombocytopenia

FFP or whole blood/reversal of anticoagulant/plateletsPressure/Expulsion of clotsTopical decongestants/vasocontrictorsCautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)Nasal packing (effective 80-90% of time)Greater palatine foramen block

Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest

Nasal packsAnterior nasal packs

TraditionalRecent modifications

Posterior nasal packsTraditional Recent modifications

Ant/Post nasal packing

Pick a Pack, any pack

Pick a pack to pack with

TSS—Nugauze vs. Merocel

Electron microscopy

Posterior Packs – Admission Elderly and those with other chronic diseases may need to be admitted to the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVF

Indications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of <38% (barlow)Nasal anomaly precluding packingPatient refusal/intolerance of packingPosterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

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

Surgical treatment

Transmaxillary IMA ligationIntraoral IMA ligationAnterior/Posterior Ethmoidal ligationTransnasal Sphenopalatine ligationExternal carotid artery ligation

Septodermoplasty/Laser ablation

Transmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA --descending palatine & sphenopalantine most importantRecurrence rate (failure rate) of 10-15%Complication rate of 25-30% (oa fistula,dental, n)

Intraoral IMA ligationPosterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized, clipped and dividedAdvantages: children/facial fracturesDisadvantages: more proximal ligationComplications: trismus, damage to infraorbital n

Ant./Post. Ethmoidal ligationPatients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclearLynch incisionFronto-ethmoidsuture line12-24-6 (14-18, 8-10, 4-6)

Transnasal Endoscopic Sphenopalatine Artery ligation

Follow 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.

Septodermoplasty/LaserRemove mucosa from anterior ½ septum, floor of nose, lateral wallSTSG vs. cutaneous, myocutaneous, microvascular free flaps vs. AutograftsNeodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod diseaseStill bleed, but not as badDefinitive treatment (severe disease)—closure of nose

Statistically speaking,….Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.Others compared all medical treatment to surgery and showed cost cut using medical management.Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equalFailure rates: PP-30%, Sx-17%, Emb-4%

Tips and PearlsRed rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more (not on both sides of septum)Antihistamines to prevent rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels (2 or more) injected with cortisporin oticAmicar spray

Tips and PearlsHot water irrigationCold water irrigationSalt PorkDon’t pack nose in unconscious person with suspected skull fractures.Antibiotic cream vs. silver nitrateIntranasal pressureEstrogen cream to nasal septum

Tips and PearlsTransnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed)Submucosal supraperichondrial dissection of nasal septumNot all hospitals have embolization-trained interventionalistsNo hard-set outline. Do what is best for your particular patient

CASE REPORT45 yo Vietnamese fisherman--stable, but uncomfortableProfuse nasal bleeding since 0200 this a.m.History: No known medical problems. Drinks 6-12 beers/day. Takes no medications. No history of easy bleeding. No family history.Physical exam: Profuse bleeding from both nostrils L>R and bleeding down the back of his throat—coughing up clots. Unable to locate precise location of bleed—appears to be posterior/superior.

Case 1 – cont’dHgb 12.5Lactated Ringers IVF bolusNasal packs – removed two days later in the clinic,…rebleeds.Requires transfusion for Hgb of 6.5Angiography—no obvious bleed/EmbolizationAnt/Post Ethmoid Artery ligation