A Brief overview of Epostaxis (nosebleeds) and the medical managment

2. Introduction and History
Acute hemorrhage from the nostril, nasal cavity, or
nasopharynx
5-10% of the population experience an episode of
epistaxis each year. 10% of those will see a physician.
1% of those seeking medical care will need a specialist.

3. REASONS FOR EXCESSIVE
BLEEDING
Vascularity of nose
Both external and internal carotids.
Anastomsis between arteries and veins.
Blood vessels run just under the mucosa-
unprotected.
Larger vessels on the turbinate run in bony
canals- cannot contract.
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4. 4
Frank Netter. Ciba

5. 5
Frank Netter. Ciba

6. Kiesselbach‘s Plexus a.k.a
Little’s area
1/2 inch from the caudal border of the septum
antero-inferiorly.
Vessels anastomosing are; Anterior ethmoid,
greater palatine, and sphenopalatine, and
septal branch of superior labial.
Bleeding may be arterial or venous.
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7. Kisselbach’s Plexus
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8. Underlying Causes
Local irritation
Use of ASA or NSAIDS
Hypertension
Coagulapathies / Bleeding disorders
Platelet dysfunction

9. Underlying Causes
Occupational exposure
Allergies
Malignancy
 Systemic disease such as granulomatous
disease(Wegener’s sarcoidosis)
Hereditary hemorrhagic
telangiectasia(Osler-Weber-Rendu
syndrome)
Cirrhosis, Renal Failure
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10. Underlying Causes - Trauma
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear, base of skull
Barotrauma

11. Underlying causes - Iatrogenic
nasal injury
Functional endoscopic sinus surgery
Rhinoplasty
Nasal reconstruction

12. Local Factors –
Dessication
Cold, dry air—more common in wintertime
Dry heat—Phoenix and Death valley
Nasal oxygen
Anatomic abnormalities
Atrophic rhinitis
Nasal septal deviation
Nasal septal perforation

13. Initial Management
ABC’s
Medical history/Medications
Vital signs—need IV?
Physical exam
Anterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiologic studies

14. Laboratory Studies
CBC
PT / PTT
Bleeding Time
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15. Treatment
IV Access
IV Fluids
Blood or Blood product transfusion
Control of hypertension
Correct coagulapathy
FFP, Vit. K, Protamine

16. Basic Treatment
Make the patient sit up, pinch nose, open
mouth and breath.
Ice on fore head and or gargle ice water
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17. Ask the Patient
Patients will almost always tell you the side of
bleeding
Which side did it start on
Was in coming out the front or draining down
the throat
Nosebleeds rarely have bilateral sources

18. Anterior or Posterior
Anterior
Bright red blood from front of nose
Posterior
Nausea, hematemesis, anemia, hemoptysis or
melena.
No visualized anterior source of bleeding
Post nasal drip of blood

19. Treatment
Be Prepared
Adequate equipment to the bedside
Headlight
Nasal Speculum
Suction
Packs
Cautery
Anesthetic
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20. suction
good light
anesthetic
silver nitrate
merocels
gelfoam
bacitracin
endoscopes
suction bovie/bipolar
Afrin
Surgicel / Floseeal
epistat
bayonet forcepts
vaseline gauze

21. Treatment
Locate the point after packing the nose with 4%
xylocaine and oxymetazoline
Suction the Nose
Have patient blow clots out of the nose

22. CAUTERIZATION
Chemicals
Silver Nitrate stick
Electrical
Bovie
Bipolar
Avoid bilateral or excessive cautery
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23. Pick a Pack, any pack

24. Nasal packs
Anterior nasal packs
Merocel – Nasal Tampon
Vaseline Gauze
Inflatable Packs
Surgicel or Gelfoam

26. Posterior Epistaxis Packing

27. Posterior Epistaxis Packing

28. Epistaxis - Complications
Sinusitis
Possibility of airway obstruction
Toxic shock syndrome
Septal hematoma or abscess
Septal perforation
Loose pack obstructing the airway
Nasal scarring or stenosis
Alar necrosis

29. Treatment after Packing
Removed as soon as possible
Typically 3-5 days
Antibiotics
Posterior or bilateral packing requires
admission
Transfuse
Continue treatment of underlying condtions
Oxygen
ICU Admit

30. Surgery / embolization
Indications
Continued bleeding with packing
Required transfusion
Nasal anomaly precluding packing
Patient intolerance to packing
Posterior bleed vs. failed medical mgmt
after >72hrs
Other Treatments

31. Surgery
Ligation of vessels
Maxillary artery
Ethmoid arteries
External Carotid artery

32. Transmaxillary IMA ligation
Waters view
Caldwell-Luc
Electrocautery of posterior wall before removal
Microscopic dissection and ligation of IMA
--descending palatine & sphenopalantine most
important
Recurrence rate (failure rate) of 10-15%
Complication rate of 25-30% (oa fistula,dental, n)
Imax ligation now done commonly through
endoscopic approach

34. Ant./Post. Ethmoidal ligation
Patients s/p IMAX ligation still bleeding, superior
nasal cavity epistaxis, or in conjunction when source
unclear
Lynch incision
Fronto-ethmoid
suture line
12-24-6
(14-18, 8-10, 4-6)

35. Transnasal Endoscopic
Sphenopalatine Artery ligation
Follow Middle Turbinate to posteriormost aspect
Vertical mucoperiosteal incision 7-8mm anterior to
post middle turb (between mid. and inf. turbs)
Elevation of flap—ID neurovascular bundle at
foramen
Ligation with titanium clip
Reapproximate flap
Complications –few, Failures—0-13%

36. Transnasal Spheno-
palatine Artery ligation

37. ECA ligation
Effectiveness
Anterior border of SCM
ID ECA/ICA
Ligation after clear that surrounding structures are
safe.

38. Selective
Angiography/embolization
Helps identify location of bleeding
Embolization most effective in patients who
Still bleeding after surgical arterial ligation
Bleeding site difficult to reach surgically
Comorbidities prohibit general anesthetic
Effective only when bleeding is >.5 ml/min
90+% success rate, complication rate of 0.1%
Only able to embolize external carotid & branches
Complications: minor (18-45%)/major (0-2%)
Contraindicated in bad atherosclerosis, Ethmoid
bleed

39. Treatment after Discharge
Humidity/emolients
Discontinue offending meds
Nasal saline sprays
Avoidance of nose picking/blowing
Sneeze with mouth open
Avoid straining/bedrest