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Epistaxis
Epistaxis, or nosebleeds, can be caused by local factors within the nose or systemic factors elsewhere in the body. The vascular supply and common bleeding sites within the nose are described. Epistaxis is classified as anterior or posterior depending on the location of bleeding. Initial treatment involves local pressure and examination to locate the source before proceeding to cauterization, nasal packing, or other measures. Surgical ligation of arteries or angiographic embolization may be needed for severe or recurrent bleeding. Guidelines for managing epistaxis in children emphasize expectant treatment for mild cases over invasive procedures.
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Epistaxis
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- 2. Epistaxis, derived fromthe Greek term epistazein, is defined as bleeding from the nose
- 3. HISTORY Hippocratic technique Pilz (1869)=1st surgically treated epistaxis (Ligation of CCA) James Little (1879) Wilhem Kisselbach
- 4. Saiffert (1928)= viamaxillary sinus ligated internal maxillary artery Woodruff (1949) Sokoloff= first undertook angiographic embolisation for epistaxis in 1972
- 5. Vascular supply ofnasal cavity Various anastomoses on the ipsilateral side between the internal and external carotid systems exist as well as crossover to the contralateral side Knowledge of these anastomosis is important in addressing most distal site of bleeding
- 6. Vascular supply ofnasal cavity
- 7. Anterior and Posteriorethmoidal arteries
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- 9. Common bleeding sites 1.Little’s area 2. Woodruff’s plexus 3. Retrocolumellar vein
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- 12. Retrocolumellar vein Run 2mmbehind and parallel to columella Common cause of venous epistaxis in children
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- 14. Anterior epistaxis Posteriorepistaxis More common Less common Mostly occurs in children and young adults After age of 40 years Mostly from Little’s area or anterior part of lateral wall Mostly from posterosuperior part of nasal cavity Cause= Mostly trauma Cause= Spontaneous Bleeding is mild and controlled by local pressure or anterior pack Bleeding is severe Require hospitalization Postnasal pack often required
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- 17. Systemic causes Hypertension: Nodirect causal relationship Altered clotting abilities= Drugs (NSAIDs, apsirin, clopidogrel), Liver disease Inherited blood diatheses= Hemophilia (Factor VIII deficiency), Von Willebrand’s disease Hereditary hemorrhagic telengiectasia (HHT) - Autosomal dominant - widespread cutaneous, mucosal and visceral telengiectasia
- 18. Approach to apatient with epistaxis A} History of epistaxis - Onset - Frequency - Duration - Quantity - Uni/Bilateral - Previous episodes - Hematemesis/Hemoptysis B} History of - Trauma - Exanthematous fever - Foreign body - Bleeding disorders - Hypertension - Drug intake
- 19. C} Examination ofnose and PNS D} Systemic examination E} Blood investigations= BT,CT, Coagulation profile F} Radiological investigations= X ray, CT scan G} Biopsy E} Endoscopy
- 20. Management of epistaxis 1.Establish the site of bleeding 2. Stop the bleeding 3. Treat the cause
- 21. Management of epistaxis •Epistaxis • First aid • Pinch nose with index and thumb for 5 min • Trotter’s maneuver
- 23. If bleeding continues • Allayanxiety • Ice packs over nose • Quick examination of nose nasopharynx • Systemic examination • Exclude general causes • Anterior/Posterior rhinoscopy/ endoscopy If bleeding size localised • Cauterization Silver nitrate Bipolar diathermy
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- 25. If bleeding still continues •Anterior nasal packing
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- 28. • Send bloodfor Hb, blood counts, BT, CT, PT, aPTT, Blood group Bleeding continues • Posterior nasal packing
- 30. Posterior nasal packs Bivonanasal pack Foley’s catheter
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- 32. Complications of nasalpacking Septal hematoma/ abscess Sinusitis Pressure necrosis Toxic shock syndrome
- 33. Bleeding continues • Blood transfusion •Surgical Mx • Ligation of arteries (Sphenopalatine artery, Anterior and posterior ethmoid artery, maxillary artery ligation, ECA ligation) • Septal surgeries • Embolization
- 34. Endoscopic ligation ofsphenopalatine artery
- 35. Anterior and posteriorethmoidal artery ligation Lynch incision (curvilinear incision halfway between medial canthus and tip of the nasal dorsum
- 36. Maxillary artery ligation Sublabialapproach - Antrostomy formed Mucosa of posterior wall of antrum elevated Window made through pterygopalatine fossa Ligation of maxillary artery done
- 37. External carotid arteryligation Horizontal skin incision is made between the hyoid bone and the superior border of the thyroid cartilage Subplatysmal skin flaps are then raised, and the sternocleidomastoid muscle is retracted posteriorly. Carotid sheath is opened and its contents exposed Usually ligated just distal to the superior thyroid artery
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- 39. Epistaxis in children Causes CommonLess common Idiopathic Infection Trauma: Nose picking Vestibulitis Nasal allergy Local= septal deformity, tumors Systemic= coagulopathies HHT
- 40. Guidelines for Managementof epistaxis in children Expectant treatment in mild cases= Pinching nose, allay anxiety of child and parents Petrolium jelly used as primary treatment= forms water resistant film over affected area Nasal barrier cream (Chlorhexidine, neomycin)offer limited benefit If cautery is considered: Silver nitrate is optimum method Electrocautery should rarely considered
- 41. Laser therapy, fibringlue and septoplasty have limited role based on individual basis Neither systemic or local tranexamic acid has any place in treatment of childhood epistaxis Endoscopic ligation of arteries have limited role in children
- 42. References Scott-Brown's Otorhinolaryngology: Head andNeck Surgery 7Ed Cummings otolaryngology, Head and neck surgery 5th Ed Ballenger’s otorhinolaryngology, Head and neck suregry
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