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EPISTAXIS final.pdf
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- 2. SURGICAL ANATOMY OFNASAL VASCULAR SYSTEM
- 4. SPHENOPALATINE ARTERY Mostimportant supply to nasal cavity. COURSE-Enters through sphenopalatine foramen and immediately divides into middle turbinate arteries Post septal post lateral rami Inferior turbinate arteries
- 5. INTERNAL CAROTID ARTERY OPTHALMIC ARTERY ANTERIOR ETHMOIDAL POSTERIOR ETHMOIDAL ARISE IN ORBIT,RUNS UNDER SO muscle Runs medially, passes above SO muscle Anterior ethmoidal canal enter posterior ethmoidal foramen Terminate in region of ethmoid fovea it is accompanied by sphenoethmoidal ,branch of ciliary N
- 6. ANTERIOR ETHMOIDAL POSTERIORETHMOIDAL Meningeal branch large branch to meningeal branch branch to nasal roof olfactory sulcus olfactory cleft spheno -ethmoidal recess Superior turbinate postero –superior nasal cavity Posterior ethmoidal artery is smaller than anterior ethmoidal.And it is present in only 80 % individuals.
- 7. VENOUS DRAINAGE LATERALLY ANTERIORY Veinsdrains through sphenopalatine foramen via superior labial and greater palatine veins Pterygoid venous plexus and Facial vein Internal jugular vein External jugular vein RETROCOLUMELLAR VEIN- 2 mm behind and parallel to columella IMPORTANCE- This vein is in particulary superficial area so common cause of venous epistaxis in children./
- 8. Woodruff plexus Plexusof prominent blood vessels lying just inferior to posterior end of inferior turbinate. IMPORTANCE – Frequent site of adult epistaxis( posterior epistaxis) RECENT STUDY with endoscopic photography and anatomical microdissection confirmed That plexus does indeed exist but showed it to be a venous plexus thus very unlikely to be important in epistaxis
- 9. ANTERIOR ETHMOIDAL ARTERYIN ENDOSCOPIC SINUS SURGERY AND IN TRAUMATIC EPISTAXIS Artery is frequently encountered in a mesentry just below the skull base between ethmoid fovea and lamina papyracea. Inadvertant damage to mesentry can lead to troublesome bleeding from artery. TRANSECTION OF VESSEL DURING SINUS SURGERY Retraction of bledding end into orbit subsequent pressure hematoma and risk of visual loss
- 10. ORBITOETHMOIDAL FRACTURES Severe and often intermittent epistaxis TREATMENT- open ligation only treatment to control bleeding. External approach Endoscopically (medial canthal) ( Transethmoidal) Medial orbital incision given Most reliable and preferred method.
- 11. SURGICAL ANATOMY OFSPHENOPLATINE FORAMEN LOCATION –Laterally – Pterygopalatine fossa Posterosuperiorly- Sphenoid formed by u shaped notch in vertical portion of palatine bone. TRANSMIT – Sphenopalatine artery and vein Nasal palatine nerve IMPORTANCE- Clinically this foramen is key to procedure of ESPAL (Endoscopic spenopalantine artery ligation) LANDMARK- Surgical localization of foramen can be difficult in 96% cases bony projection which lies anterior to foramen is called CRISTA ETHMOIDALIS Its recognization during surgery may help in findingthe foramen.
- 13. SURGICAL ANATOMY OFBLOOD SUPPLY OF INFERIOR TURBINATE IMPORTANCE- Severe secondary epistaxis occurs as a serious complication of inferior turbinectomy COURSE OF INFERIOR TURBINATE ARTERY At its origin inferior turbinate artery runs anteroinferiorly in submucosa On reaching Inf turbinate it divide into 3 parallel branches each of which run in bony tunnels within substance of inferior turbinate These tunnels with their periarterial cuff of fibrous tissue and venous elements prevent artery constricting following turbinectomy Predispose to post operatively haemorrhage.
- 14. TREATMENT-Attempts tocontrol haemorrhage following turbinectomy directed towards posterosuperior aspect of inferior turbinate where pressure or bipolar to submucosal segment of artery should prove effective
- 15. CLASSIFICATION OF EPISTAXIS CLINICAL CLASSIFICATION ADULT OR CHILDHOOD – Bimodal distribution of onset of epistaxis common in childhood, less common in early adult life and peak at 6th decade CHILDHOOD –Less than 16 years ADULT-More than 16 years PRIMARY OR SECONDARY PRIMARY- 70-80 % -Idiopathic, spontaneous bleeds - without any precipitant or causal factor SECONDARY- Clear and definite cause Trauma ,surgery , anticoagulant overdose
- 16. ANTERIOR ANDPOSTERIOR EPISTAXIS – Definitions are imprecise and inconsistent ANTERIOR EPISTAXIS POSTERIOR EPISTAXIS Bleeding from source anterior to piriform Bleeding from source posterior to piriform Aperture. aperture i.e from within nasal cavities/posterior Includes bleeding from Bleeding points further divided into Anterior septum lateral wall Rare bleeding from vestibular skin and septal Mucocutaneous junction nasal floor bleeding Clinicially easily locate bleeding point Management should be simple
- 17. BASED ONSEVERITY AND FREQUENCY Severity of epistaxis is inversely proportion to frequency RECURRENT PRIMARYEPISTAXIS ACUTE SEVERE EPISTAXIS Minor One time event Non life threatening Result in hospitalization Easily managed High morbidity
- 18. ADULT PRIMARY EPISTAXIS DEMOGRAPHY- Slight male predominance Mainly a disease of elderly. In elderly patients it is associated with significant morbidity and mortality After head and neck cancer epistaxis stands out as prominent cause of mortality in ENT patients 7-14 % adults have epistaxis at sometime but only 6% seen by ENT doctors. ETIOLOGY By definition etiology is unknown but there are clear suggestions that systemic factors may be important
- 19. SUMMARY OFETIOLOGICAL EVIDENCE OF ADULT PRIMARY EPISTAXIS WEATHER- Proven association NSAID – Proven association ALCOHOL- Proven association HYPERTENSION – No proven association SEPTAL DEVIATION – No proven association CHRONOBIOLOGY- Frequency of admission is greatest in autumn and winter months Onset of bleeding and hospitalization show a biphasic pattern with peaks in morning and late evening.
- 20. NSAIDS i.e aspirin– mediated via antiplatelet aggregation effect due to altered membrane physiology. ALCOHOL Patients more likely to have consumed alcohol within 24 hrs of hospital admission than other emergency admissions. Associated with prolongation of BT despite normal platelet counts and coagulation factor activity. HYPERTENSION Long been considered cause of epistaxis but no of studies failed to show casual relationship between hypertension and epistaxis.
- 21. SEPTAL DEVIATION– Common 1-80 % population have significant deviation. There is no clear case control evidence of association between septal abnormalities and adult epistaxis. Perceived association with epistaxis and septal deviation could be coincidence after given such high prevalence.
- 22. RESUSCITATION Givenhigh prevalence of coexistant cardiovascular disease prompt and effective resuscitation required. FIRST AID – Hippocratic technique HISTORY AND EXAMINATION INTRAVENOUS ACCESS AND BASELINE BLOOD ESTIMATIONS ROUTINE COAGULATION STUDY ASSESSMENT Patient should be assessed in semirecumbent position
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- 24. Nursing assistancemandatory Everyone should wear protective visors and clothing Basic requirements should be present DIRECT MANAGEMENT Logically and theoretically superior Facilitate out patient management Decreased inpatient stay
- 25. ANTERIOR EPISTAXISPOSTERIOR EPISTAXIS 90 % Cases can be controlled by Once bleeding point is identified bleeding is controlled by Silver nitrate Bipolar diathermy Cautery Chemical cautery (difficult in posterior bleeding) Electrocautery Direct pressure from miniature targeted packs ENDOSCOPIC CONTROL Failure to indicate bleeding point on initial examination then do rod lens endoscope.
- 26. ADVANTAGES Identifysource of posterior epistaxis in over 80 % cases. Enable targetedhemostasis of bleeding vessel using insulated hot wire cautery or modern single fibre bipolar electrodes Success rate for immediate control under endoscopic guidance is 90 %. MONOPOLAR DIATHERMY Should not be used in nasal cavity as there have been reports of blindness due to current propagation
- 27. INDIRECT THERAPIES NASAL PACKING Done anterior nasal packing( mainstay of treatment for centuries) and posterior nasal packing HOW DONE Ribbon gauze impregnated with petroleum jelly or bismuth iodoform paraffin paste is inserted the entire length of nasal cavity in an attempt to tamponade bleeding DURATION – Left in situ for 24-72 hrs under antibiotic cover COMPLICATIONS- Sinusitis ,septal perforation, alar necrosis, hypoxia, MI Continued or rebleeding with packs in situ observed in 40% cases. Persistent bleeding/ Rebleeding is indication for further examination of nasal cavity and renewed search for bleeding point. Patients who continued to bleed is proceed to bleed are proceed to surgery sooner than later
- 30. MODERN VARIATIONS Specialtampons – MEROCEL And KALTOSTAT Balloon catheters – BRIGHTON OR EPISTAT Preferred by non specialist as first line but similar rates of complications and rebleeding. DISADVATAGES – If balloon overinflated ,balloon will prolapse anteriorly and posteriorly ,causes risk of hypoxia and alar necrosis.
- 31. MEROCEL Itis made up of hydroxylated polyvinyl acetate sponge. SALIENT FEATURES Highly absorbent , biocompatible ,hemostatic, strong, non shredding ,soft and atraumatic when hydrated, durable, and long lasting, and can be trimmed , no chemical residues or starch, controlled pore size ranges (0.0001 mm -0.2 mm) . Its swelling property allows sufficient adaptation to the individual anatomy. Rapid expansion provides gentle , evenly distributed pressure against the tissues to control the bleeding, while platelets aggregate on surface to enhance clot formation.
- 33. AGREED PROTOCOL INAUTHOR INSTITUTION All admitted patients should be hemostased within 24 hrs of admission. If not achieved rhinologist should be summoned to review the case. Patient should not left on ward with blood oozing from nasal packs or tampons while
- 34. HOT WATER IRRIGATION Done at 50 degree. Alternative to nasal packing. Same results compared to anterior packing and balloon tamponade DISADVANTAGE- IN 1/3 rd patients difficult to tolerate so irrigation catheters recommended MOA- Exact MOA is unclear but may paradoxically involve reflex vasodilation and decrease in nasal flow dimensions.
- 35. SYSTEMIC MEDICAL THERAPY Transexamic acid and Epsilon aminocaproic acid. Systemic inhibitors of fibrinolysis. DOSE – 1.5 gm TDS Tranexamic acid – decrease severity risk of rebleeding ADVANTAGE – Doesnot increase fibrin deposition so doesnot increased risk of thrombosis. CONTRAINDICATION- Pre –existing thrombo- embolic disease RECENT STUDY –Best reserved as adjuvant therapy in recurrent and refractory cases.
- 36. TOPICAL HEMOSTATIC AGENTS Topical thrombin compounds marketed for operative field hemostasis in surgery. FLOSEAL ( Baxter healthcare) – authors finds no real benefit. Especially as additional tool for management of difficult ( especially secondary) bleeds. Should never replace main aim of identifying and directly treatment the source of bleeding.
- 37. SURGICAL MANAGEMENT Iftechnique described above fail then surgical intervention required. Endoscopic diathermy of the bleeding point under anaesthesia may control bleeding But if vessel cannot located or bleeding controlled Surgical therapy indicated. Posterior packing ligation technique Septal surgery techniques Embolization techniques
- 38. POSTERIOR NASAL PACKING Should be viewed as largely obsolete INDICATIONS- In extreme cases DONE UNDER- LA or GA MECHANISM- Nasopharyngeal tamponade achieved using special gauze packs Inserted transorally Positioned by means of tapes tied over padding Positioned to protect columella from necrosis. COMPLICATION – Considerablepain hypoxia secondary to swelling of soft palate necrosis of septum and columella
- 39. Antibiotics andopiate analgesia required Left in position for 48 Hrs ALTERNATIVE Foley catheter ( size 12 or 14Fr ) along floor of nose until nasopharynx reached. Inflated with 15 ml water pulled forward to engage in posterior choana and anterior nasal packing is then inserted Needs to secure anteriorly- taking care not to cause pressure over columella
- 42. • LIGATION TECHNIQUES INDICATIONS Reserved for intractable bleeding where source cannot be located or controlled by techniques described PERFORMED As close as possible to the likely bleeding point. HIERARCHY OF LIGATION IS Sphenopalatine artery Internal maxillary artery External carotid artery Anterior/posterior ethmoidal artery
- 43. ENDONASAL ENDOSCOPIC SPHENOPALATINEARTERY LIGATION Procedure of choice Most logical target Performed with operating microscopes but much more commonly using modern endoscopic techniques. Done under GA/ LA Success rate is 100 % COMPLICATIONS – less common than other procedures Rebleeding Infection Nasal adhesions
- 44. PROCEDURE Incision– Made approx. 8 mm anterior to and under cover of posterior end of middle turbinate Incision carried down to the bone Mucosal flap elevated posteriorly until the fibroneurovascular sleeve arising from sphenopalatine foramen is identified once the main vessel identified, ligated using hemostatic clips, divided, coagulated using bipolar diathermy
- 46. INTERNAL MAXILLARY ARTERYLIGATION Frequently used prior to development of ESPAL APPROACH Transantrally via anterior ( sublabial ) combined anterior and medial ( endoscopic) ADVANTAGES Trans -antral ligation control haemorrhage in 89 % cases and is comparable to emboliztion in both cost and efficacy COMPLICATIONS Sinusitis, damage to infraorbital nerve oroantral fistula, dental damage, anaesthesia, rarely opthaloplegia and blindness
- 47. SUBLABIALAPPROACH Traditionally anantrostomy is formed is through sublabial approach taking care to preserve infra – orbital nerve Mucosa of posterior wall of antrum is then elevated, window is made through pterygopalatine fossa Branches of internal maxillary artery identified pulsating within fat of fossa and carefully dissected prior to clipping with hemostatic clips Proximal internal maxillary , descending and sphenopalatine branches are all clipped and ideally clipped
- 48. EXTERNAL CAROTID ARTERYLIGATION INDICATIONS Step further away from nasal source of bleeding Uses in extreme cases ANAESTHESIA – LA or GA INCISION – Skin crease incision or longitudinal incision parallel with anterior border of sternocleidomastoid Carotid bifurcationis identified and EC Confirmeddouble checked for arterial branches ligated in continuity
- 49. ‘SUCCESS RATE– ECAL secured hemostasis in 14 out of 15 patients. COMPLICATIONS Wound infection heamatoma neurovascular damage ADJUVANT –Anterior and posterior ethmoidal artery ligation.
- 50. ANTERIOR/POSTERIOR ETHMOIDAL ARTERY LIGATION INDICATIONS Best reserved as an adjuvant to ECAL Confirmed ethmoidal artery bleeding ( ethmoidal fracture , iatrogenic tear ) PROCEDURE –Medial canthal incision carried down to bone of anterior lacrimal crest periosteal elevators used to elevate and laterally retract bulbar fascia Anterior ethmoidal artery seen as fibro -neurovascular mesentry running from bulbar fascia to anterior ethmoidal foramen vessel is clipped and divided , direction is continued to identify posterior artery
- 52. SEPTAL SURGERY INDICATIONS– When epistaxis originate behind prominent septal deviation or vomero -palatine spur Septoplasty or SMR required to access bleeding point MECHANISM – Elevating the muco -perichondial flap for septoplasty or SMR Blood supply to septum is interrupted and hemostasis achieved..
- 53. EMBOLIZATION DONE –Under angiographic guidance to control severe epistaxis in between 82 % and 97 % cases PROCEDURE Under LA TRANSFEMORAL SELDINGER ANGIOGRAPHY Used to identify bleeding points and display nasal circulation fine catheter passed into internal maxillary circulation particles (polyvinyl alcohol , tungsten,or steel microcoils) used for embolization
- 54. INDICATIONS- Failedligations -where no rhinologicalsurgical expertise is available. CONTRAINDICATIONS -A-V malformation, aneurysms, fistula . Ethmoidal arteries cann,t embolized COMPLICATIONS Skin necrosis Paraesthesia CVA Groin hematomas ADVANTAGE – Similar efficacy as ligation techniques so choice will depend on local expertise, availability, and experience.
- 55. ADULT RECURRENT EPISTAXIS INCIDENCE –More commonly seen in children When occur in adults secondary is most likely. PRESENTATION- Minor and troublesome uncommon to see bleeding by the time patient presents. ETIOLOGY- Full detailed H/O and examination should identify factors Aspirin use liver disease margins of septal perforation rarely nasal tumours- blood stained discharge not epistaxis Topical nasal medications( particulary steroid sprays ) minor recurrent bleeds
- 56. TREATMENT Ifbleeding point identified- cautery is used. Topical antiseptic creams ( chlorhexidine and neomycin ) decrease frequency of bleeding in children, but unproven in children. If H/O Cardiovascular disease or vascular graft surgery then aspirin shouldn’t discontinued Otherwise temporary cessation of aspirin may be required to allow recurrent bleeding to settle.
- 57. SECONDARY EPISTAXIS Commonlyobserved in patients with coagulopathy secondary to liver disease, leukemia, myelosuppression. So close examination and consult with hematologist and physician done. ETIOLOGY TRAUMA (A) Frontoethmoid fracture - Persistent bleeding refractory to packing occurs - In this vessels may be lacerated , incompletely divided, or even held open by fractures through their bony mesentry. - Management by open approach ligation. (B) Head injury - Catastrophic bleeding occurs due to delayed rupture of internal carotid artery pseudoaneurysm - Persistent or unexpectedly severe bleeding after head injury should be seen as indication for CT scanning and angiography.
- 58. POST SURGICAL Can occur after almost any nasal surgery Seldom difficult to manage EXCEPTION – Severe hemorrhage occurs in between 3-9% of inferior turbinectomies. - Treatment is bipolar to main branch of inferior turbinate artery Anterior subtotal thyroidectomy decreased risk of post op nasal bleeding IATROGENIC DAMAGE TO ANTERIOR ETHMOIDALARTERY DURING ENDOSCOPIC SINUS SURGERY - Should be managed by bipolar of vessel - Retraction of vessel into orbit rise to tension hematoma of orbit and it is surgical emergency INJURY TO ICA DURING POSTERIOER ETHMOID AND SPHENOID SINUS SURGERY - Massive and fatal epistaxis occurs. -Packing, angiography, embolization may be tried.
- 59. WARFARIN Constitutebetween 9-17% epistaxis admissions. Overdose or loss of control cause bleeding. But can also occur in patients whose INR is within therapeutic range. TREATMENT Direct therapies seldom work because bleeding occurs from multiple sites and attempts at instrumentation lead to further mucosal damage and bleeding. Packing may be required. After resuscitation gently anterior nasal packing done. Large areas of bleeding/oozing – Fibrin glue used as hemostatic dressing. When decides to decrease, stop, or even reverse warfarin, medical history and severity of epistaxis must be considered If INR is within therapeutic range and treatment seems to be controlling the bleeding may be safe to continue warfarin.
- 60. NEW ORALANTICOAGULANTS New target specific are RIVAROXABIN and DABIGATRIN Reversal is difficult to achieve and incomplete unlike vitamin K antagonists. Advised to consult at earliest opportunity with local hematology team No steps are taken to stop or reverse agents without first clarifying the indication for medication Consult with cardiologist required to avoid catastrophic complications (eg stent occlusion)
- 61. HEREDITARY HAEMORRHAGIC TELENGIECTASIAOR OSLER WEBER RENDU DISEASE DEFINITION Autosomal dominant Affecting blood vessels in skin ,mucous membranes and viscera. INCIDENCE Penetrance is variable Reaches 97% by age 50 years Occasional atavistic cases observed ABNORMALITY Genetic abnormality located to chromosome 9q(HHT1) and chromosome 12q(HHT2) CLINICAL FEATURES Telengiectasia A-V malformations and aneurysm Recurrent epistaxis in 93% cases occurs on anterior part of the septum
- 62. TREATMENT Packing Cautery Angio -fibrinolytics Systemic or topical estrogens Ligation and embolization Coagulative lasers Laser photocoagulation- Nd YAG, Argon,KTP532 lasers used. Has become most popular therapy. Septo -dermoplasty – where anterior part of septum is excised and replaced by split skin graft. Permanent surgical closure of nostrils (young operation ) – as a last resort. Trials of systemic, topical or locally injectables BEVACIZUMAB have been produced conflict results.
- 63. MANAGEMENT RECURRENT EPISTAXISIN HHT NO BLOOD TRANSFUSIONS BLOOD TRANSFUSIONS MILD MODERATE SEVERE Coagulation laser septodermoplasty Nasal closure hormones Arterial ligation Antifibrinolytic Selective embolization
- 64. TUMOURS Nasaltumors seldom present as epistaxis Most commonly tumors present with nasal discharge associated with other nasal complaint such as U/L nasal obstruction ,pain, swelling. Endoscopy done to rule out tumor. JUVENILE ANGIOFIBROMAAND HEMANGIOPERICYTOMAare rare vascular tumors which can present with recurrent or severe epistaxis associated with nasal obstruction. Treatment is mainly surgical May include pre operative embolization.