2. Epi – from above, staxis – drop by drop flow of
fluid
Bleeding from inside the nasal cavity or
nasopharynx
50% in life time
Bimodal – children and elderly
Children – anterior bleed, Kiesselbach’s plexus,
Little’s area
Elderly – posterior bleed, woodruff’s plexus
Venous – retrocolumellar vein
Sphenopalatine artery
M>F
5. Drugs – aspirin, NSAID, anticoagulants,
quinine
Acute infections – influenza, measles, chicken
pox, typhoid, malaria, rheumatic fever
Miscellenous – room heaters, hot summers,
idiopathic
Types
Anterior epistaxis - MC
Posterior epistaxis
Maxillary sinus ostia is the dividing line
between anterior and posterior epistaxis
6. Anterior Nasal bleed
90% of cases – Little’s area
Above middle turbinate – ethmoidal arteries
Below middle turbinate – sphenopalatine
artery ( br of internal maxillary artery)
Children and young adults
Trauma
Mainly unilateral
Less severe, easy to localize and easy to
manage in OPD under LA
7. Posterior Nasal bleed
Site – posterior part
HTN, Arteriosclerosis
Age > 40 years, elderly
Less common
More severe, spontaneous
Need post nasal pack
Wrongly diagnosed as haematemesis as blood is
swallowed – coffee coloured
Require DNE to localize, difficult localization
Manipulation in OT under GA
8. History taking – Before taking history first
control the bleeding
Site – U/L or B/L
Mode of onset
Amount of blood loss – cups or glasses
Precipitating factor/ Risk factors
Duration and frequency of bleed
Past history of bleed
Family history of bleed - haemophilia
9. Examination – in case of severe bleed place the
patient in lateral position or intubate with cuff tube
For mild bleed – pinch the nose for 5-10 minutes
with mouth open
Vitals – pulse, BP
GPE
ENT
Systemic
DNE
Use 4% lignocaine with phenylephrine for
examination
Can give Botropase (Haemocoagulase) if heavy bleed
10. Investigations
CBC – to rule out anaemia, leukemia,
thrombocytopenia
BT,CT 2-7 minutes/ 8-15 minutes
Prothrombin time (PT) 11-14 seconds
Activated partial thromboplastin time 25-35
seconds
RBS, Blood urea, RFT, LFT
X Ray Chest, PNS
CT/MRI
DSA – To locate bleeding vessel for embolization
11. Home care
Avoid frequent nose cleaning with finger or tissue
Keep nose moist – ointment, saline
Use bedroom humidifier – to reduce dryness
Medical treatment
Pinch the nose with thumb and index finger for 5-10
minutes
Place cotton swabs soaked in decongestant nasal
drops
Trotter’s method – Sit with head bend forward over a
basin to split blood and mouth open
Cold compressers over nose with ice cold water
Reassurance with mild sedation
Sit with back rest
12. Vital monitoring
Intermittent oxygen and antibiotics if nasal pack
placed…
Vitamin C, Vitamin K and Calcium
NASAL CAUTERIZATION
Chemical cautery using 20% silver nitrate/ 50% TCA/
Carbolic acid
Bead/ crystal on a stick – tip in contact with bleeding
area for seconds till greyish white in colour
Endoscopic for posterior bleed
Electrocautery
Before – 4% lignocaine with adrenaline
After – Anterior nasal pack
Avoid bilateral/ deep cautery -perforation
13. ANTERIOR NASAL PACKING
If bleeding not controlled by medical means and
cauterization as bleeder not identified and patient
has got active anterior epistaxis
Clear nose of blood clots
Ribbon gauze I m long, 2.5 cm wide (1.2cm
children)soaked with liquid paraffin/vaseline and
ointment packed layer by layer from floor to top or
vertically
If still bleed doesn’t stop – suspect posterior bleed
Can also use merocel, surgicel, gelfoam
Systemic antibiotics
Remove after 1-3 days
14. POSTERIOR NASAL PACKING
Under GA after hospitalization
For posterior bleed/ cautery and anterior packing
fails
Three threads tied to cone shaped gauze, middle one
in opposite direction
One rubber catheter passed through each nostril
Brought out through oral cavity
Thread attached to each catheter – withdraw the
catheter with pack towards nose – guide the pack into
nasopharynx – tie the threads to columella with
rubber support – third thread attached to cheek
Do anterior nasal packing if anterior bleed
Can use Foley’s catheter/ post nasal balloon
15. ARTERIAL EMBOLIZATION – in refractory cases by
neuroradiologist in angiography suite
For Internal maxillary artery using gelfoam or PVA
Cant be done for ethmoidal artery
ARTERIAL LIGATION –
ECA – at origin of STA (1st branch) in neck
Sphenopalatine branch (terminal branch of ECA) of
internal maxillary artery – by caldwell luc/ endoscopic
ligation(TESPAL – Transnasal Endoscopic
SphenoPalatine Artery Ligation)
Ethmoidal artery by external ethmoidectomy
Surgical treatment –
SMR/Septoplasty – elevation of flaps causes fibrosis
and constriction of blood vessels
16. Complications of Epistaxis
0.6% cases death due to
Shock
Aspiration
Cerebral haemorrhage
Septicemia
Pneumonia
17. Hereditary Haemorrhagic Telangectasia
Congenital vascular anomaly of mucosa of nose,
lips or tongue
Loss of elastic and contractile tissue
Involves anterior septum
Recurrent bleeding
Recurrence common in surrounding areas
Treatment
Electrocautery
LASER
Septodermoplasty – mucosa excised and replaced
by skin graft
18. Leak of CSF from its intracranial location
through the nose
Sites
Anterior skull bone – cribriform plate (mc),
frontoethmoid
Middle and posterior cranial fossa – sphenoid
Petrous temporal bone – mastoid through ET
CSF
Fluid around brain and spinal cord acts as a
buffer against sudden jerk
19. Etiology
Traumatic – could be immediate or delayed (oedema
and inflammation obstructs CSF for upto 3 months)
Accidental - fracture
Iatrogenic – surgeries like FESS, Nasal polypectomy,
skull base surgery
Non traumatic
Congenital - dehiscence, glioma,
meningoencephalocele
Inflammatory – sinus mucocele, osteomyelitis, fungal
infection
Tumours – NP carcinoma, pituitary
Benign intracranial hypertension, hydrocephalus
Idiopathic
20. Clinical features
Dribbing of recurrent clear watery non sticky discharge
from nose on bending forward
Unilateral
Cant be sniffed back
Sweet in taste
Headache
Hyposmia and anosmia
Recurrent meningitis
Reservoir sign – early morning if patient sits upright with
flexed neck – lots of fluid as it gets collected at night
No stiffening of handkerchief on drying (no mucus)
On handkerchief when blood stained – double ring/halo
formed/ double target sign – central blood surrounded by
CSF
21. Investigations
Localization of site -
DNE
Radionuclide Cisternography - Metrizamide
CT Cisternography
MRI Cisternography
HRCT/MRI
Intrathecal fluorescein – dye injected via lumbar
puncture in patient CSF – nasal packs placed – after
30 minutes – after 30 minutes green colour packs/
discharge from nose
Injection of coloured dyes like methylene blue, indigo
carmine, toluidine blue in subarachnoid space
X Ray Skull bone
22. Nasal secretions
Test for glucose - > 30 mg/dl
Test for chloride – raised
Beta 2 transferrin test – specific and sensitive,
seen in CSF
Beta trace protein – seen in CSF
Complications
Meningitis
Pneumocephalus
23. Treatment
Strict complete bed rest
Prophylactic antibiotics – to prevent meningitis
Head end elevation
Avoid coughing, nose blowing, straining
Acetazolamide, Mannitol – to reduce intracranial
pressure
Repeated or continous lumbar puncture
Watch the patient for 14-21 days
NO NASAL PACKING – lead to secondary infection
NO NASAL DROPS
24. Surgical Repair
Transnasal endoscopic repair – MC – 90%
Resect the middle turbinate
Uncinectomy
Ant ethmoidectomy
Hyperventilation of patient to identify CSF leak
Expose the dura at site of leak
Place the graft – temporalis fascia, fat from
thigh/ abdomen, septal/ear conchal cartilage,
cover it with mucosa and support by gelfoam
Pack the middle meatus for 10 days
25. Other surgical approaches
Neurosurgery/ intracranial repair
External ethmoidectomy – for cribriform plate
repair
Osteoplastic flap approach – for frontal bone
repair
Sphenoidal approach – for sphenoid bone
repair
26. Fracture Middle 1/3rd
# Nasal bones
# Zygomatic bone
# Maxilla
# Orbital floor
Fracture Upper 1/3rd
# Frontal sinus
# Supra orbital ridge
# Frontal bone
Fracture Lower 1/3rd
# Mandible
27. Establish airway – ET/Tracheostomy
Maintain breathing – oxygen
Control haemorrhage and hypovolemia
Rule out head and spinal injury
Clean the wound with antiseptic
Remove FB, clots, debris
TT and antibiotics
Examine mandible, maxilla, nasal bones, orbit,
frontal bone to rule out injuries
Suture the wound
Note down the injuries
28. Motor vehicle accidents
Railway, industrial accidents
Sports ijury
Fights
Gun shot injuries
Burns
Animal bites
Can lead to
Abrasions – superficial loss of epithelium
Lacerations – injury involving deeper skin
Can also involve parotid gland and duct, facial
nerve
29. b/w supraorbital ridge and upper teeth
Mobility or displacement of palate
FRACTURE NASAL BONES
MC # of face
3rd mc # of human body – 1st – clavicle, 2nd – wrist
Can be associated with septal #, # cribriform plate,
ethmoids, frontal bone
Types – undisplaced (greenstick)/ displaced – fracture
segments
Depressed fracture – frontal blow, also called open book
fracture, flattening of nasal dorsum, saddle nose deformity
Angulated fracture – lateral blow, crooked nose, deviation
of nasal bridge
Open fracture
Closed fracture
30. Type 1 – limited to nasal bone and septal
cartilage, blow from below, vertical fracture
of septum – Chevalet fracture
Type 2 – significant cosmetic deformity, nasal
bone, frontal process of maxilla, horizontal
fracture of septum , due to blow fromfront –
Jarjavay fracture
Type 3 – Nasal bone, septum, frontal process
of maxilla, ethmoidal labyrinth – naso orbito
ethmoid fracture
31. Symptoms and signs
Epistaxis, pain and swelling, black eye, nasal
blockage, deformity, pre orbital ecchymosis
(purplish patch over the orbit), sub
conjuctival ecchymosis, septal haematoma,
laceration, tenderness, crepitus
Diagnosis
X Ray Nose – AP and lateral, lateral and
occlusal view (right and left)
Clinical diagnosis
32.
33. Treatment
Antibiotics and antiinflammatory
If displaced # , within 4 to 6 hours, before
swelling appears – surgical intervention and
reduction of fracture – walsham and asch forceps
for disimpaction of bony and septal segments
If swelling appears – wait for 5 – 8 days
Not later than 2 weeks as fracture heals
Later stage – septorhinoplasty
Drain the haematoma
Reduction – closed reduction – with forceps
Open reduction – by opening the wound
34. 2nd mc after nasal bone fracture
Combined fracture of arch of zygomatic bone,
zygomatic process of frontal bone, zygomatic
process of maxillary bone – Tripod fracture
Lateral blow to face – force applied to malar bone
or zygomatic bone
C/F
Swelling of cheek/face, flattening of malar
prominence, diplopia (double vision), pre orbital
ecchymosis, step deformity of infra orbital
margin and lateral margins of orbit
35.
36. Paresthesia of cheek, epistaxis, trismus – due
to fracture coronoid process of mandible or
entrapment of temporalis muscle
Orbital contents get herniated into maxillary
sinus
Diagnosis
X Ray PNS
CT Scan
Treatment
ORIF by wiring and plating
37. Le Fort’s # - B/L
Type 1 – Guerin fracture – above and parallel to
palate, involves only palate, transverse fracture,
displacement or mobility of maxillary dental arch and
palate, dental malocclusion
Fracture line involves – lower edge of pyriform
aperture, alveolar process of maxilla, pterygoid
process of sphenoid bone
Type 2 – Pyramidal fracture – fracture en block of
palate and middle 1/3rd of face including nose, mc,
following RTA
Fracture line involves – mid part of nasal bone,
lacrimal bone, orbital floor, infraorbital margin,
pterygoidprocess
38. Type 3 – craniofacial dysfunction - bony facial
framework gets detatched from its cranial
attachment
Fracture line extends from – root of nose, maxillo
frontal, fronto zygomatic and frontoethmoid
suture line, upper part of pterygoid process of
sphenoid bone
Clinical features
Facial swelling and deformity, malocclusion,
epistaxis, epiphora, elongated face, nose block,
CSF Rhinnorhea, diplopia, infra orbital
paresthesia, orbital ecchymosis, proptosis, dish
face deformity (flattening of face), step
deformity, trismus due to spasm of pterygoids
39.
40. Diagnosis
X Ray skull lateral view
X Ray PNS waters view/ caldwell view
X Ray Nasal bones
CT Scan
Nasal endoscopy
Treatment
ORIF – Closed reduction by interdental wiring and
intermaxillary wiring, open reduction using
interosseus wiring
Manage epistaxis and CSF Rhinnorhea
41. Due to blunt injury to orbit
C/F
Enophthalmos – eye ball pushed inwards
Infra orbital paresthesia
Diplopia
Diagnosis
X Ray PNS
CT Scan Coronal view – if orbital content herniates
into antrum – TEAR DROP SIGN (herniation of orbital
fat)
Treatment – open exploration, release of orbital
muscle
Repair of floor using septal cartilage or bone grafts
42. # Mandible
Condylar fracture – mc – 35% - can be as a result of
direct or indirect trauma – to chin or opposite side
Other sites – angle of mandible, body of mandible,
symphysis – direct trauma
C/F
Pain, trismus, tenderness, malocclusion of teeth,
deviation of jaw to opposite side on opening mouth,
step deformity, crepitus
Injury to TM joint
Diagnosis – X Ray skull PA view, X ray mandible –
right and left oblique view
Orthopantomogram (OPG) – Investigation of choice
