Epistaxis Col Ämer Sabih Hydri Head of ENT Department M.H Rawalpindi.
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Transcript of Epistaxis Col Ämer Sabih Hydri Head of ENT Department M.H Rawalpindi.
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Epistaxis
Col Ämer Sabih HydriHead of ENT DepartmentM.H Rawalpindi
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Why nose?
•Situated in 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
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Epidemiology
•Lifelong incidence of epistaxis in general population is about 60%
•Fewer than 10% seek medical attention•Peaks in young children (2 – 10 y) and
older individuals (50 – 80 y)•Males 58%, females 42%
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Blood Supply•Superior part 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
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Kiesselbach’s Plexus
•Little’s area•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
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Woodruff’s Plexus
•Lateral wall 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
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Pathophysiology
•Occurs when mucosa is eroded
•Vessels become exposed and subsequently break
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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
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•Posterior▫Woodruff’s plexus▫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
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Etiology •Most are idiopathic•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
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•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
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▫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
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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
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Physical Examination•Vital signs•Nasal cavity
▫Vasoconstrictor to reduce hemorrhage and pinpoint bleeding site
▫Topical anesthetic to reduce pain▫Clots are suctioned out▫Nasal speculum
•Fiberoptic endoscopy (rigid or flexible)•Skin examination
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Management
•Control significant bleeding or hemodynamic instability before obtaining a lengthy history
•Steps:▫First aid and resuscitation ▫Assess blood loss▫Localize bleeding▫Control bleeding ▫Prevention
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First Aid & Resuscitation•Address ABC •Patient sits upright or leans forward•Neck should not be hyperextended to
prevent blood flow into the stomach or possible aspiration
•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
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•Vital signs and signs of shock•Patient with significant hemorrhage
should receive an IV line and crystalloid infusion
•Cross match for 2 units packed RBC•Continuous cardiac monitoring and pulse
oximetry
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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
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•Rigid endoscope is 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
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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
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Anterior Nasal Packing•Traditional petrolatum gauze filled with
antibiotic ointment•Success rate 85%
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•Expandable Merocel sponges (nasal tampons) which enlarge in the presence of moisture
•Coated with antibiotic and vasoconstrictor•Success rate 85%
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•Rapid Rhino anterior balloon tampon
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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
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•Uncomfortable and difficulty 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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•Foley catheter
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•Double-balloon catheter
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•Gauze method
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Surgical Intervention
•Indications:▫Bleeding continues despite adequate
packing and resuscitation▫Nasal anomaly (septal deviation)▫Patient’s refusal or intolerance to packing
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•Arterial ligation▫External carotid artery▫Internal maxillary artery transorally or
transnasally▫Ethmoidal arteries
•Angiography and vessel embolization
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PreventionControl of hypertension Correction of bleeding disordersHumidifier or vaporizersNasal saline sprays, ointment, vaseline• Avoid hard nose blowing or sneezing• Sneeze with mouth open• Avoid nose picking• Control the use of medications
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Complications
•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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Thank You