Epistaxis prof. g.kopalakrishnan-09.05.16

1. EPISTAXISEPISTAXIS

2. Introduction and HistoryIntroduction and History
 Epistaxis is defined as bleeding from nasalEpistaxis is defined as bleeding from nasal
cavities.cavities.
 Hipprocrates technique ( pinching the ala )Hipprocrates technique ( pinching the ala )
simplest treatment for nasal bleedsimplest treatment for nasal bleed
 Common occurrenceCommon occurrence
 Most episodes are minor in natureMost episodes are minor in nature
 Minor bleed – children and adultsMinor bleed – children and adults
 Severe bleeding - > 50 yearsSevere bleeding - > 50 years

3. Anatomy/Physiology of EpistaxisAnatomy/Physiology of Epistaxis
 AnatomyAnatomy
 Nasal cavityNasal cavity
 Vascular supplyVascular supply
 PhysiologyPhysiology
 Vascular natureVascular nature
 MucosaMucosa

4. 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
Arterial Supply of the Nose

5. Kesselbach’s
Plexus/Little’s Area:
-Anterior Ethmoid (Opth)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Woodruff’s Plexus

7. Why bleeding from the nose ?Why bleeding from the nose ?
• Vasculature runs justVasculature runs just
under mucosa (notunder mucosa (not
squamous)squamous)
• Arterial to venousArterial to venous
anastamosesanastamoses
• ICA and ECA bloodICA and ECA blood
flowflow

8. Anterior vs. PosteriorAnterior vs. Posterior
 Anterior: younger, usually septal vs. anteriorAnterior: younger, usually septal vs. anterior
ethmoid, most common (>90%), typically lessethmoid, most common (>90%), typically less
severesevere
 Posterior: older population, usually fromPosterior: older population, usually from
Woodruff’s plexus, more serious.Woodruff’s plexus, more serious.

9. EtiologyEtiology
 Local factorsLocal factors
 Trauma (most common)Trauma (most common)
 VascularVascular
 Infectious/InflammatoryInfectious/Inflammatory
 IatrogenicIatrogenic
 NeoplasmNeoplasm
 DessicationDessication
 Foreign Bodies/otherForeign Bodies/other

10. Local Factors - TraumaLocal Factors - Trauma
 Nose pickingNose picking
 Nose blowing/sneezingNose blowing/sneezing
 Nasal fractureNasal fracture
 Nasogastric/nasotracheal intubationNasogastric/nasotracheal intubation
 Trauma to sinuses, orbits, middle ear, base ofTrauma to sinuses, orbits, middle ear, base of
skullskull
 BarotraumaBarotrauma

11. Local Factors -Local Factors -
Infection/InflammationInfection/Inflammation
 Rhinitis/SinusitisRhinitis/Sinusitis
 AllergicAllergic
 BacterialBacterial
 FungalFungal
 ViralViral

12. Local Factors - Iatrogenic nasalLocal Factors - Iatrogenic nasal
injuryinjury
 Functional endoscopic sinus surgeryFunctional endoscopic sinus surgery
 RhinoplastyRhinoplasty
 Nasal reconstructionNasal reconstruction

13. Local Factors - NeoplasmLocal Factors - Neoplasm
 Juvenile nasopharyngeal angiofibromaJuvenile nasopharyngeal angiofibroma
 Inverted papillomaInverted papilloma
 SCCASCCA
 AdenocarcinomaAdenocarcinoma
 MelanomaMelanoma
 EsthesioneuroblastomaEsthesioneuroblastoma
 LymphomaLymphoma

15. Local Factors –Local Factors –
DessicationDessication
 Cold, dry air—more common in wintertimeCold, dry air—more common in wintertime
 Nasal oxygenNasal oxygen
 Anatomic abnormalitiesAnatomic abnormalities
 Atrophic rhinitisAtrophic rhinitis

16. EtiologyEtiology
 Systemic factorsSystemic factors
 Vascular - HypertensionVascular - Hypertension
 Infection/Inflammation – Tuberculosis,SyphilisInfection/Inflammation – Tuberculosis,Syphilis
 Coagulopathy : Hemophillia , vWD , HHTCoagulopathy : Hemophillia , vWD , HHT

17. Hereditary Hemorrhagic TelangiectasiaHereditary Hemorrhagic Telangiectasia
Autosomal dominantAutosomal dominant
Classical features are telangectasia , AVClassical features are telangectasia , AV
malformation and aneurysms, recurrentmalformation and aneurysms, recurrent
epistaxis.epistaxis.
Laser photocoagulation.Laser photocoagulation.

18. Initial ManagementInitial Management
 ABC’sABC’s
 Medical history/MedicationsMedical history/Medications
 Vital signs—need IV?Vital signs—need IV?
 Physical examPhysical exam
 Anterior rhinoscopyAnterior rhinoscopy
 Endoscopic rhinoscopyEndoscopic rhinoscopy
 Laboratory examLaboratory exam
 Radiologic studiesRadiologic studies

19. Resuscitation
Initial Examination
Vessel not located Vessel located
Endoscopy
Vessel not located
Anterior nasal pack
Continued bleeding
Posterior packing
Ligation of blood vessels
Direct therapy
Bipolar cautery
Bleeding controlled
Pack for 48 hours

20. Management of EpistaxisManagement of Epistaxis
 Medical ManagementMedical Management
 Nasal PackingNasal Packing
 Cautery – Silver Nitrate, EndoscopicCautery – Silver Nitrate, Endoscopic
electrocautery and Laser cauteryelectrocautery and Laser cautery
 EmbolizationEmbolization
 LigationLigation
 Surgery – Septoplasty and SeptodermoplastySurgery – Septoplasty and Septodermoplasty

21. Nasal packsNasal packs
 Anterior nasal packsAnterior nasal packs
 TraditionalTraditional
 Recent modificationsRecent modifications
 Posterior nasal packsPosterior nasal packs
 TraditionalTraditional
 Recent modificationsRecent modifications
 Ant/Post nasal packingAnt/Post nasal packing

23. Indications forIndications for
surgery/embolizationsurgery/embolization
 Continued bleeding despite nasal packingContinued bleeding despite nasal packing
 Pt requires transfusion/admit hct of <38%Pt requires transfusion/admit hct of <38%
 Nasal anomaly precluding packingNasal anomaly precluding packing
 Patient refusal/intolerance of packingPatient refusal/intolerance of packing
 Posterior bleed vs. failed medical mgmt afterPosterior bleed vs. failed medical mgmt after
>72hrs>72hrs

24. Take Home MessageTake Home Message
 Epistaxis affects all agesEpistaxis affects all ages
 Epistaxis can be life threateningEpistaxis can be life threatening
 Common causes are idiopathic and traumaCommon causes are idiopathic and trauma
 Systemic disorders are rare but should not beSystemic disorders are rare but should not be
overlookedoverlooked
 The majority of nose bleeds are from the anteriorThe majority of nose bleeds are from the anterior
septum and can easily be controlled by cauterisation orseptum and can easily be controlled by cauterisation or
anterior nasal packinganterior nasal packing
 Surgical ligation of the arterial supply may be necessarySurgical ligation of the arterial supply may be necessary
in severe casesin severe cases