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Epistaxis
Epistaxis, or nosebleed, occurs due to the unique anatomy of the nasal cavity and is classified into anterior and posterior types, with anterior being more common. Management includes identifying the cause, controlling bleeding, and various interventions like nasal packing and cauterization, with surgical interventions considered in persistent cases. Preventive measures focus on controlling underlying conditions and maintaining nasal moisture.
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Epistaxis
- 1. Epistaxis Dr. Sushmita Pal theAurals:yourENT destination
- 2. From a Greekterm “epistazo” which means “to bleed from nose”.
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- 6. Why nose? • Situatedin 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
- 7. Epidemiology • Lifelong incidenceof 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%
- 8. Blood Supply • Superiorpart 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
- 10. Kiesselbach’s Plexus • Little’sarea • 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
- 11. Woodruff’s Plexus • Lateralwall 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
- 13. Pathophysiology • Occurs whenmucosa is eroded • Vessels become exposed and subsequently break
- 14. 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
- 15. • Posterior ▫ Woodruff’splexus ▫ 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
- 16. Etiology • Most areidiopathic • 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
- 17. • 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
- 18. ▫ 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
- 19. 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
- 20. Physical Examination • Vitalsigns • Nasal cavity • Fiberoptic endoscopy (rigid or flexible) • Skin examination
- 21. Management • Control significantbleeding or hemodynamic instability before obtaining a lengthy history • Steps: ▫ First aid and resuscitation ▫ Assess blood loss ▫ Localize bleeding ▫ Control bleeding ▫ Prevention
- 22. 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
- 23. • Vital signsand 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
- 24. 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
- 26. • Rigid endoscopeis 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
- 28. 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
- 30. Anterior Nasal Packing •Roller gauze soaked with petroleum jelly and an antibiotic ointment • Success rate 85%
- 33. 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
- 34. • Uncomfortable anddifficulty 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
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- 38. Surgical Intervention • Indications: ▫Bleeding continues despite adequate packing and resuscitation ▫ Nasal anomaly (septal deviation) ▫ Patient’s refusal or intolerance to packing
- 39. • Arterial ligation ▫External carotid artery ▫ Internal maxillary artery transorally or transnasally ▫ Ethmoidal arteries ▫ Most commonly ligated vessel is SPHENOPALATINE ARTERY • Angiography and vessel embolization
- 40. Prevention Control of hypertension Correctionof 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
- 41. 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
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