Transcript Epistaxis-4th-year

Epistaxis
Col Ämer Sabih Hydri
Head of ENT Department
M.H Rawalpindi
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 10% 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
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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:
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Pharyngeal artery
Posterior nasal artery
Sphenopalatine artery
Posterior septal artery
Pathophysiology
• Occurs when mucosa is eroded
• Vessels become exposed and subsequently break
Classification
• Anterior
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90% of all cases of epistaxis
Kiesselbach’s plexus
Younger population
Typically less severe
A constant ooze, rather than profuse pumping of
blood
• Posterior
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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
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Hemophilia, von Willebrand’s disease
Hepatic cirrhosis
Anticoagulant therapy
Thrombocytopenia
▫ Fever (rare)
 Influenza
▫ Drugs
 NSAIDs, aspirin, coumadin, warfarin, isotretinoin, etc
▫ Infection
 Tuberculosis, syphilis
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Alcohol
Anemia
Uremia
Connective tissue disorders
 SLE
▫ Hematological malignancy
▫ Vasculitis
 Wegener’s granulomatosis
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Vitamin C or K deficiencies
Osler-Weber-Rendu syndrome
Pregnancy
Vicarious menstruation
History
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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
▫ Vasoconstrictor to reduce hemorrhage and
pinpoint bleeding site
▫ Topical anesthetic to reduce pain
▫ Clots are suctioned out
▫ Nasal speculum
• Fiberoptic endoscopy (rigid or flexible)
• Skin examination
Management
• Control significant bleeding or hemodynamic
instability before obtaining a lengthy history
• Steps:
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First aid and resuscitation
Assess blood loss
Localize bleeding
Control bleeding
Prevention
First Aid & Resuscitation
• Address ABC
• Patient sits upright or leans forward
• Neck should not be hyperextended to prevent
blood flow into the stomach or possible
aspiration
• 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
• 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
• Traditional petrolatum gauze filled with
antibiotic ointment
• Success rate 85%
• Expandable Merocel sponges (nasal tampons)
which enlarge in the presence of moisture
• Coated with antibiotic and vasoconstrictor
• Success rate 85%
• Rapid Rhino anterior balloon tampon
Posterior Nasal Packing
• Indications:
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Failure of anterior packing
High suspicion of posterior bleeding
Older patient with atherosclerosis
Patient with bleeding diathesis
• Contraindications
▫ Facial trauma
▫ Shock
▫ Altered mental status
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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
• Angiography and vessel embolization
Prevention
 Control of hypertension
 Correction of bleeding disorders
 Humidifier or vaporizers
 Nasal saline sprays, ointment, vaseline
• Avoid hard nose blowing or sneezing
• Sneeze with mouth open
• Avoid nose picking
• Control the use of medications
Complications
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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