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Epistaxis is the medical term for "nasal bleeding". This ppt is more of use for medical students ....a compilation of all the required knowledge about epistaxis.
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EpistaxisDr. Sushmita Pal
theAurals:your ENT destination
From a Greek term “epistazo” which means “to bleed from nose”.
Anatomy
Why nose?
•Situated in a vulnerable position as it protrudes on the face
•Has a very rich blood supply
•Vasculature runs just under the mucosa
•Exposed to the drying effect of inspiratory current
Epidemiology
•Lifelong incidence of epistaxis in general population is about 60%
•Fewer than 60% seek medical attention•Peaks in young children (2 – 10 y) and
older individuals (50 – 80 y)•Males 58%, females 42%
Blood Supply•Superior part of the nose (Internal carotid artery)
▫Ophthalmic artery Anterior ethmoidal artery Posterior ethmoidal artery
• Inferior part of the nose (External carotid artery)▫Maxillary artery
Greater palatine artery Sphenopalatine artery
▫Facial artery Superior labial artery vestibule of the nose
Kiesselbach’s Plexus
•Little’s area•Anteroinferior part of the nasal septum•Anastomosis between upper and lower
arteries▫Anterior ethmoidal artery▫Posterior ethmoidal artery▫Sphenopalatine artery▫Greater palatine artery▫Septal branch of superior labial artery
Woodruff’s Plexus
•Lateral wall of inferior meatus•Blood vessels have very little muscle
tissue within their walls, therefore hemostasis is poor
•Anastomosis between:▫Pharyngeal artery▫Posterior nasal artery▫Sphenopalatine artery▫Posterior septal artery
Pathophysiology
•Occurs when mucosa is eroded
•Vessels become exposed and subsequently break
Classification
•Anterior▫90% of all cases of epistaxis▫Kiesselbach’s plexus▫Younger population▫Typically less severe▫A constant ooze, rather than profuse
pumping of blood
•Posterior▫Woodruff’s plexus▫Older population▫Profuse, prolonged and more difficult to
control▫Associated with bleeding from both nostrils▫Greater flow of blood into the mouth▫Greater risk of airway compromise and
aspiration of blood
Etiology •Most are idiopathic•Local causes
▫Spontaneous▫Trauma
Nose picking/blowing, sneezing, fractures, barotraumas
▫Foreign bodies▫Iatrogenic
FESS, rhinoplasty, nasal cannula ▫Inflammation/infection▫Tumors
Polyps, nasopharyngeal carcinoma/angiofibroma▫Hereditary telengiectasia▫Leech infestation
•Systemic causes▫Cardiovascular conditions
Hypertension Increased venous pressure
Mitral valve stenosis, heart failure, mediastinal tumors
▫Coagulopathies Hemophilia, von Willebrand’s disease Hepatic cirrhosis Anticoagulant therapy Thrombocytopenia
▫Fever (rare) Influenza
▫Drugs NSAIDs, aspirin, coumadin, warfarin,
isotretinoin, etc
▫Infection Tuberculosis, syphilis
▫Alcohol▫Anemia▫Uremia ▫Connective tissue disorders
SLE▫Hematological malignancy▫Vasculitis
Wegener’s granulomatosis▫Vitamin C or K deficiencies ▫Osler-Weber-Rendu syndrome▫Pregnancy▫Vicarious menstruation
History• Age • Onset, duration, severity, frequency• Bilateral or unilateral• Preceding factors: exercise, sleep, migraine,
trauma• Bleeding from other sites• Aggravating and relieving factors• Nasal discharge• Medical conditions• Current medications• Smoking and drinking habits• Previous epistaxis, recurrent bleeding, easy
bruising• Family history of bleeding disorders
Physical Examination•Vital signs•Nasal cavity•Fiberoptic endoscopy (rigid or flexible)•Skin examination
Management
•Control significant bleeding or hemodynamic instability before obtaining a lengthy history
•Steps:▫First aid and resuscitation ▫Assess blood loss▫Localize bleeding▫Control bleeding ▫Prevention
First Aid & Resuscitation•Address ABC •Neck should not be hyperextended to
prevent blood flow into the stomach or possible aspiration
•Trotter’s triad @ Blood in mouth should not be
swallowed@ Mouth breathing@ Direct pressure over the cartilaginous part of the nose@ 5 – 10 minutes is usually sufficient
•Gauze moistened with epinephrine may be placed to promote vasoconstriction
•Vital signs and signs of shock•Patient with significant hemorrhage
should receive an IV line and crystalloid infusion and reptilase/ethamsylate in bolus or infusion
•Cross match for 2 units packed RBC•Continuous cardiac monitoring and pulse
oximetry
Localization of Bleeding•Pledgets soaked with anesthetic-
vasoconstrictor solution are inserted into the nasal cavity to anesthetize and shrink nasal mucosa
•Allow them to remain for 10 – 15 minutes•Visualize cavity with speculum + good
light source•Aspirate excess blood and clots •If the bleeding originated from Little’s
area, it is clearly visible
•Rigid endoscope is used to localize posterior bleeding▫Superior optics▫Allow endoscopic suction and cauterization
•Points suggesting posterior source:▫Anterior surface cannot be visualized▫Bilateral bleeding▫Constant dripping of blood in the posterior
pharynx▫Bleeding in the pharynx with the anterior
nasal packing in place
Control of Bleeding•Topical vasoconstrictors
▫Otrivin (xylomethazoline)▫Cocaine
•Chemical cauterization with silver nitrate stick▫Rolled over mucosa until a grey eschar forms▫Only one side should be cauterized to
prevent septal necrosis or perforation
•Thermal cauterization with an electrocautery device for more aggressive bleeding under LA or GA
Anterior Nasal Packing•Roller gauze soaked with petroleum jelly
and an antibiotic ointment•Success rate 85%
Posterior Nasal Packing•Indications:
▫Failure of anterior packing▫High suspicion of posterior bleeding▫Older patient with atherosclerosis▫Patient with bleeding diathesis
•Contraindications ▫Facial trauma▫Shock▫Altered mental status
•Uncomfortable and difficulty in breathing•Risk of hypoventilation and hypoxia•Admission, bed rest, sedation•Supplemental oxygen:
▫Elderly patients▫Cardiac disorders▫COPD
•Monitor blood pressure and hemoglobin level
•Control coexistent hypertension
•Foley catheter
•Double-balloon catheter
•Gauze method
Surgical Intervention
•Indications:▫Bleeding continues despite adequate
packing and resuscitation▫Nasal anomaly (septal deviation)▫Patient’s refusal or intolerance to packing
•Arterial ligation▫External carotid artery▫Internal maxillary artery transorally or
transnasally▫Ethmoidal arteries▫Most commonly ligated vessel is
SPHENOPALATINE ARTERY
•Angiography and vessel embolization
PreventionControl of hypertension Correction of bleeding disordersHumidifier or vaporizersNasal saline sprays, ointment, vaseline• Avoid hard nose blowing or sneezing• Sneeze with mouth open• Avoid nose picking• Control the use of medications
Complications of Epistaxis $ Nasal packing •Rhinosinusitis •Cardiovascular compromise•Septal perforation•Toxic shock syndrome•Hypoxia•Aspiration pneumonia•CVA associated with embolization•Recurrent epistaxis•Re-bleeding on nasal pack removal
Thank You