Blood Supply of Nose Little’s Area & Importance Causes & Classification of Epistaxis Management of Epistaxis Angiofibroma and its Etiology Pathology of Angiofibroma Diagnosis of Angiofibroma Treatment of Angiofibroma

1. EPISTAXIS & ANGIOFIBROMA
ABDUL HANNAN
FATIMA BATOOL
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
1

2. Learning Objectives
 Blood Supply of Nose
 Little’s Area & Importance
 Causes & Classification of Epistaxis
 Management of Epistaxis
 Angiofibroma and its Etiology
 Pathology of Angiofibroma
 Diagnosis of Angiofibroma
 Treatment of Angiofibroma
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
2

3. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
3
Lateral Wall
Internal Carotid System
 Anterior Ethmoidal Artery
 Posterior Ethmoidal Artery
External Carotid System
 Sphenopalatine Artery
 Greater Palatine Artery
 Branch of Facial Artery to Nasal Vestibule
Nasal Septum
Internal Carotid System
 Anterior Ethmoidal Artery
 Posterior Ethmoidal Artery
External Carotid System
 Sphenopalatine Artery
 Greater Palatine Artery
 Superior Labial Artery
Blood Supply of Nose

4. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
4
• Situated in the anterior inferior part of nasal septum.
• Four arteries anastomose here to form a vascular plexus “Kiesselbach’s Plexus”
• Usual site for Epistaxis in children & young adults.
• Another plexus of veins is situated inferior to posterior end of inferior turbinate,
called “Woodruff’s Plexus”. It is a site of posterior epistaxis.
Little’s Area & Importance

5. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
5
General
 Trauma
 Infections
 Foreign Bodies
 Neoplasms
 Atmospheric Changes
 Deviated Nasal Septum
 Adenoiditis
 Juvenile Angiofibroma
 Malignant Tumours
Local
Causes of Epistaxis
 Cardiovascular System
 Disorders of Blood & Blood Vessels
 Liver Disease
 Kidney Disease
 Drugs
 Mediastinal Compression
 Acute General Infection
 Vicarious Menstruation

6. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
6
• Blood flows back into the throat.
• Less common.
• Mostly from posterosuperior part
of nasal cavity.
• Cause is spontaneous often due to
hypertension or arteriosclerosis.
• Bleeding is severe, requires
hospitalization, post nasal pack
often required.
Posterior Epistaxis
• Blood flows out from front of nose.
• More common.
• Mostly from little’s area.
• Mostly trauma
• Bleeding is usually mild & can be
controlled by local pressure or
anterior pack.
Anterior Epistaxis
ClassificationofEpistaxis

7. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
7
In anycase of epistaxis, it is important to know:
 Mode of onset.
 Duration & frequency of bleeding.
 Amount of blood loss.
 Side of nose from where bleeding is occurring.
 Whether bleeding is of anterior or posterior type.
 Any known bleeding tendency in the patient or family.
 History of known medical ailment.
 History of drug intake.
Management of Epistaxis

8. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
8
First Aid
Cauterization
Anterior Nasal Packing
Posterior Nasal Packing
Endoscopic Cauterization
Ligation of Vessels
Transnasal Endoscopic Sphenopalatine Artery Ligation (TESPAL)
Management of Epistaxis

9. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
9
• Rare tumour though it is the commonest of all benign tumors of nasopharynx.
ANGIOFIBROMA

10. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
10
• Exact cause is unknown.
• It is mostly seen in adolescent males so it is thought to be testosterone dependent.
• The amount of collagen fibers decide if tumor is soft or firm.
Site of Origin & Growth
 Earlier, it was thought to arise from the roof of nasopharynx or anterior wall of
sphenoid bone.
 Now, it is believed to arise from the posterior wall of the nasal cavity close to the
superior margin of sphenopalatine foramen.
 From here, tumor grows into the nasal cavity, nasopharynx, and into the
pterygopalatine fossa.
 Laterally, it extends into pterygomaxillary fossa and then to infratemporal fossa and
cheek.
Etiology of Angiofibroma

11. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
11
• Angiofibroma, as the name implies, is made up of vascular and fibrous tissues.
• Mostly, the vessels are just endothelium lined spaces with no elastic and muscle coat
• This accounts for the severe bleeding as the vessels lose the ability to contract.
• Also, the bleeding cannot be controlled by application of adrenaline.
Extensions of Nasopharyngeal Fibroma
Nasopharyngeal fibroma is a benign tumor but local invasive and destroys the
adjoining structures. It may extend into:
• Nasal cavity
• Paranasal sinuses
• Pterygomaxillary fossa, infratemporal fossa and cheek.
• Orbits (giving rise to proptosis and frog faced deformity)
• Cranial cavity
Pathology of Angiofibroma

12. Clinical Features
• Age and Sex: almost exclusively in males in the age group of 10 to 20 years.
• Profuse, Recurrent and Spontaneous epistaxis: most common presentation.
• Progressive nasal obstruction and denasal speech: due to mass in the postnasal
space
• Conductive hearing loss and otitis media with effusion: due to obstruction of
eustachian tube.
• Mass in the nasopharynx: tumor is sessile, lobulated or smooth and obstructs one
or both choanae. it is pink or purplish in color. Consistency is firm but digital
examination should never be done at the time of operation.
• Other clinical features: broadening of nasal bridge, proptosis, swelling of cheek.
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
12

13. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
13
• Mostly based on clinical picture
• Biopsy of the tumor is attended with profused bleeding and is therefore avoided.
• If essential, biopsy can be done under general anesthesia.
Investigations
• CT scan of the head (anterior bowing of the posterior wall of maxillary sinus, often
called antral sign or Holman-Miller sign)
• MRI
• Carotid angiography shows extent of tumor.
Diagnosis of Angiofibroma

14. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
14
Surgery
Surgical excision is treatment of choice.
Surgical approaches used to remove angiofibroma depending on its origin and
extensions are:
• Transpalatine
• Transpalatine + sublabial (Sardana’s approach)
• Endoscopic removal
• Tranmaxillary approach
• Maxillary spring approach
• Infratemporal fossa approach
• Intracranial-extracranial approach
Radiotherapy
Hormonal therapy
Chemotherapy
Treatment of Angiofibroma

15. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
15
A 14yo adolescent boy presented to the ER with profused nasal bleeding and bilateral
nasal obstruction. He had similar episodes of bleeding 2-3 times before. He noticed
broadening of nasal bridge and protrusion of left eye since 4 days. As an ENT doctor:
1. What specific questions you would ask in history to aid and elicit the diagnosis?
2. Give your differential diagnosis.
3. Give diagnostic investigations for most probable diagnosis. Illustrate the
pathognomonic sign seen on the CT scan.
4. Describe the extensions and complications of the disease.
5. Illustrate the treatment options both medical and surgical.
CBL 11

16. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
16
• Antrochoanal Polyp
• Enlarged Adenoids
• Olfactory Neuroblastoma
• Lobular Capillary Hemangioma
• Hemangiopericytoma
Differential Diagnosis

17. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
17