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Epistaxis

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Dr.zeeshan ahmad

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Epistaxis

  1. 1. EPISTAXIS DR.ZEESHAN AHMAD HOUSE OFFICER ENT SGTH SWAT {IN THE NAME OF ALLAH, THE MOST MERCIFUL AND THE MIGHTIEST}
  2. 2.  Bleeding from nostril, nasal cavity or nasopharynx.  Most often self limited, but can often be serious and life threatening.  5-10% of the population experience an episode of epistaxis each year, 10% of those will seek a physician and 1% of those will need a specialist.  Can occur in all age groups i.e children, adults and old people.  It’s a sign not a disease but presents commonly as an emergency. INTRODUCTION
  3. 3.  Rich vascularity  Supplied by both internal and external carotid system  Various anastomoses between arteries and veins  Blood vessels run under the mucosa unprotected  Larger vessels on the turbinate run in bony canals – cannot contract REASON FOR EXCESSIVE BLEEDING
  4. 4.  Branches of internal carotid system : . Anterior Ethmoidal artery . Posterior ethmoidal artery  Branches of external carotid system : . Sphenopalatine artery- major branch . Greater palatine artery . Superior labial branch of facial artery . Infraorbital branch of maxillary artery VASCULATURE OF NOSE
  5. 5. KIESSELBACH’S PLEXUS (Little’s area)  In anterior inferior part of nasal septum  Most common site for epistaxis  Mainly anterior epistaxis 1. septal br. Of sphenopalatine 2. Anterior ethmoidal 3. Septal br. Of superior labial 4. greater palatine arteries anastomose here.
  6. 6. WOODRUFF’S PLEXUS  Posterior end of middle turbinate  Sphenopalatine artery anastomoses with posterior pharyngeal artery  Most common site for posterior epistaxis
  7. 7. SITES OF EPISTAXIS : 1) Little’s area. In 90% cases. 2) Above the level of middle turbinate. 3) Below the level of middle turbinate. 4) Posterior part of nasal cavity. 5) Diffuse. Both from septum and lateral nasal wall. 6) Nasopharynx.
  8. 8. CLASSIFICATION  Anterior Epistaxis . More common . Occurs in children and young adults . Usually due to nasal mucosal dryness . Alarming as bleeding seen readily but generally less severe  Posterior Epistaxis . Usually older population . HTN and ASVD are the most common causes .Significant bleeding in posterior pharynx . More severe and treatment more challenging
  9. 9. A. Congenital – Hereditary telengiectasia B. Trauma . Nose picking . Facial and skull bone fractures . Foreign body {living and non living} . Iatrogenic trauma . Hard blowing, violent sneeze. C. Infections: Rhinitis,nasal dipththeria,Sinusitis,Tuberculosis syphilis septal perforations. CAUSES OF EPISTAXIS Local causes:
  10. 10. D. Non Specific . Viral – Common cold, Influenza . Bacterial – Secondary bacterial rhinitis sinusitis . Fungal rhinosinusitis . Atrophic rhinitis E. Physiological . High altitude . Extreme cold or hot climate
  11. 11. F. Neoplastic . Benign – Juvenile angiofibroma, angioma of septum, capillary and cavernous hemangioma . Malignant – SCC, Olfactory neuroblastoma, Nasopharyngeal carcinoma G. Miscellaneous . Deviated septum & spur . Rhinitis sicca . Spontaneous rupture of vessels . Rhinolith
  12. 12. SYSTEMIC CAUSES  Hypertension- commonest  Cardiac –CCF, Mitral stenosis  Pulmonary –COPD  Cirrhosis – Vitamin K deficiency  Renal –Nephritis  Drugs – Excessive use of salicylates , anticoagulants  Coagulopathies – Clotting disorders bleeding disorders Agranulocytosis Leukemia Vitamin K deficiency Exanthematous fevers  Hormonal – Vicarious Menstruation, endometriosis, granuloma gravidarum  Idiopathic Causes
  13. 13. Disseminated intra vascular coagulation. Hemophilia. Von willebrand disease. Toxicity {aspirin, warfarin, cocaine, coumarine poisoning, } Nasal foreign body. Allergic rhinitis. Differential diagnosis
  14. 14. MANAGEMENT HISTORY,EXAMINATION,INVESTIGATIONS AND TREATMENT  Previous bleeding episodes  Onset, duration, frequency, amount of blood loss  h/o trauma  Family history of bleeding  Hypertension  Hepatic diseases  Drug history{analgesics or anticoagulants'}  Any other medical ailment  Side of the nose where bleeding occurs.  Bleeding ant or post. PATIENT HISTORY
  15. 15. EXAMINATION: examination of nasal cavity  To locate the bleeding site.  Anterior and posterior rhinoscopy.  Diagnostic nasal endoscopy.  Examination of skin for bruises or petechiae.  Assess vital signs: B.p. pulse , temperature.  INVESTIGATIONS : . Hematological investigations – Hb%, TLC, DLC, BT, CT, Platelet count, prothrombin time . Blood urea, liver function tests . Radiology: x-ray and CT scan of nose, PNS and nasopharynx . Other investigations :depending upon the possible cause
  16. 16. TREATMENT OF EPISTAXIS  First aid . Trotter’s method- Make patient sit up, pinch the nose for 5-10 minutes. Head bent forward. Open mouth and breathe Vasoconstrictors: oxymetazoline0.05%. Anaesthetics: xylocaine. Antibiotics: Mupirocin ointment 2% Ansaids except aspirin. Treatment of the cause.
  17. 17.  CAUTERIZATION . Chemical cautery with Silver nitrate sticks, Chromic acid bead . Electrocautery  Anterior nasal packing or anterior epistaxis balloons for refractory epistaxis.  Posterior nasal packing.  Elevation of mucoepicondrial flap and SMR operation.  Ligation of vessels like: External carotid artery. Maxillary artery.{caldwell-luc operation and transnasal endoscopic sphenopalatine artery light} Ethmoidal artery. Nasal sponge pack and tampon. Foleys catheter and nasal balloons. DEFINITIVE TREATMENT
  18. 18. Anterior nasal packing : •If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing should be done. •Ribbon gauze soaked with liquid paraffin. •About 1 meter gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimeters of gauze are folded upon itself and inserted along the floor, and then the whole nasal cavity is packed tightly by layering the gauze from floor to the root and layering the gauze from floor to the roof and from before backwards. •One or both cavities may need to be packed. •Can be removed after 24 hours if bleeding has stopped. •If it has to be kept for 2 to 3 days; systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.
  19. 19. ANTERIOR NASAL PACKING
  20. 20. METHODS OF INSERTING ANTERIOR NASAL PACK
  21. 21. Posterior nasal packing : •For patients bleeding posteriorly into the throat. •A postnasal pack is prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. •Patients requiring postnasal pack should always be hospitalized. •Foleys' catheter can also be used. •Nasal balloons are also available.
  22. 22. NASAL SPONGE PACK/TAMPON POSTERIOR NASAL PACKING
  23. 23. FOLEY’S CATHETER and EPISTAXIS BALLOON
  24. 24.  Best to place patient on antibiotics to decrease risk of sinusitis and toxic shock syndrome  Advise patient to avoid straining, bending forward or removing pack early  If other nostril is unpacked advise patient topical saline spray or saline gel to moisturize nasal mucosa  Admitted and monitored in severe cases PATIENTS ON NASAL PACK
  25. 25.  Greater palatine foramen block  Septoplasty  Endoscopic cauterization  Internal maxillary artery ligation  Transantral sphenopalatine artery ligation  Intraoral ligation of maxillary artery  Anterior and posterior ethmoid artery ligation  Selective embolisation  External carotid artery ligation OTHER TREATMENTS FOR REFRACTORY EPISTAXIS
  26. 26.  Cauterization {septal perforation}  Anterior nasal packing{rhinosinusitis, toxic shock syndrome, Eustachian tube dysfunction and scarring of the nasal ala}  Posterior nasal packing {as for ANP and dysphagia, hypoventilation.}  Maxillary artery ligation {rhinitis, sinusitis, cheek numbness and trismus}  Ethmoidal artery ligation{ lacrimal duct injury and blindness }  Embolization {facial pain, trismus, stroke, skin necrosis and blindness.} COMPLICATIONS: NECROSIS OF ALA
  27. 27. General Measures in Epistaxis : 1)Make the patient up with a back rest and record any blood loss through spitting or vomiting. 2)Reassure the patient. Mild sedation. 3)Keep check on pulse, BP and respiration. 4)Maintain haemodynamics: Blood transfusion. 5)Antibiotics to prevent sinusitis, if pack is be kept beyond 24 hours. 6)Intermittent oxygen patients with bilateral packs. 7)Investigate and treat the patient for any underlying local or general cause.
  28. 28.  Humidification and moisturization of room.  Dietary measure:  Avoid hot and spicy foods and drink plenty of water.  Avoid strenuous activities, hot showers.  Hot and dry environment.  Avoid digital trauma like nose picking.  Sneeze gently with mouth open.  Avoid drug abuse in adults.  Avoid inappropriate or careless use of drugs like aspirin and warfarin. Long term monitoring PREVENTION OF EPISTAXIS

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