Management of epistaxisSusritha

Pg 2nd year

ASRAM;eluru.

Classification:

Anterior epistaxis: Bleeding from a source anterior to the plane of the piriform

aperture.

This includes bleeding from the anterior septum and rare bleeds from the vestibular skin and mucocutaneous junction.

Posterior epistaxis: Bleeding from a vessel situated posterior to the piriform

aperture.

This allows further subdivision into lateral wall, septal and nasal floor bleeding.

Management of epistaxis

direct Bleeding point specific

Endoscopic control

bipolar diathermy,

chemical cautery (difficult in

posterior bleeds), electrocautery

or direct pressure from miniature targeted packs

silver nitrate cautery.

indirectDonot require

identification of bleeding points

Indir

ect

th

era

pie

sNasal packing

Hot water irrigation

Systemic medical therapies

Nasal packing:

Ribbon gauze impregnated

with petroleum jelly or

(BIPP) 24 and 72 hours.

sinusitis, septal perforation, alar necrosis, hypoxia

andmyocardial infarction

Hot water irrigation:

vasodilatation and reduction in

nasal lumen dimensions

Hot water irrigation 50C

Systemic medical therapy:Tranexamic acid &

epsilon aminocapro

ic aci

reduce the severity and risk of

rebleeding

at a

dose of 1.5 g

three

times a day.

Preexisting

thromboembolicdisease is a

contraindication

Surgical management

Posterior packing

Ligation techniques

Septal surgery

embolisation

Posterior nasal packing

General anaesthesia is preferrable.

Nasopharyngeal tamponade is achieved using special gauze packs inserted transorally and positioned by means of tapes passed from the posterior choana to the anterior nares bilaterally.

Alternative is to insert a Foley urethral catheter (size 12 or 14) along the floor of the nasal cavity until the nasopharynx is reached.

The Foley catheter is inflated with up to 15mL of water, pulled forward to engage in the posterior choana and anterior packing is then inserted.

The Foley catheter needs to be secured anteriorly, taking care not to cause pressure over the columella.

Complications : Posterior packing causes considerable

pain and may cause hypoxia secondary to soft palate oedema.

Sinusitis and middle ear effusions are common.

More serious complications include necrosis of the septum and columella.

Ligation:

Ligation should be performed as close as possible to the likely bleeding point. sphenopalatine artery;

internal maxillary artery;

external carotid artery;

anterior/posterior ethmoidal artery.

sphenopalatine artery:

An incision is made approximately 8mm anterior to and under cover of the posterior end of the middle turbinate.

The incision is carried down to the bone and a mucosal flap is elevated.

The foramen can be difficult to identify, but its location is signalled by the crista ethmoidalis.

Once the main vessel is identified, it can be ligated using haemostatic clips and divided or coagulated using bipolar diathermy

internal maxillary artery:

The artery is exposed transantrally via anterior (sublabial) or

combined anterior and medial(endoscopic) techniques.

In the traditional sublabial approach, an antrostomy is formed taking care to preserve the infraorbital nerve.

The mucosa of the posterior wall of the antrum is then elevated and a window is made through into the pterygopalatine fossa.

The branches of the internal maxillary artery are identified pulsating within the fat of the fossa and are carefully dissected out prior to clipping with haemostatic clips.

The proximal internal maxillary artery, descending palatine and sphenopalatine branches are all clipped and ideally divided.

An endoscopic variation on this technique uses a middle meatus antrostomy, as an instrument port with a 4-mm endoscope is inserted through a small canine fossa antrostomy.

Transantral ligation controls haemorrhage in 89 percent of cases.

Complications include sinusitis, damage to the infraorbital nerve, oroantral fistula, dental damage and anaesthesia and rarely ophthalmoplegia and blindness.

ECAL: This procedure can be carried out

under local or general anaesthetic using either a skin crease incision or a longitudinal incision parallel with the anterior border of the sternomastoid.

The carotid bifurcation is identified and the external carotid confirmed, double-checked for arterial branches and then ligated in continuity.

Complications wound infection,

haematoma and

neurovasculardamage.

Anterior/posterior ethmoidal artery ligation:

The arteries are approached by a medial canthal incision which is carried down to the bone of the anterior lacrimal crest.

Periosteal elevators are then used to elevate and laterally retract the bulbar fascia.

The anterior ethmoidal artery is seen as a fibroneurovascular mesentry running from the bulbar fascia into the anterior ethmoidal foramen.

The vessel is clipped and divided and dissection is continued to identify the posterior artery which is located approximately 12mm behind.

Septal surgery:

When epistaxis originates behind a prominent septal deviation or vomeropalatine spur, septoplasty or submucosal resection (SMR) may be required to access the bleeding point.

the blood supply to the septum is interrupted and haemostasis secured.

embolization:

It is essential to exclude arteriovenous malformations, aneursyms and fistulae prior to embolization.

Once the bleeding vessel is identified, a fine catheter is passed into the internal maxillary circulation and particles (polyvinyl alcohol, tungsten or steel microcoils) are used to embolize the vessels.

The ipsilateral facial artery is also embolized inorder to prevent recirculation.

Complications includeskin necrosis, paraesthesia, cerebrovascular accident.

Secondary epistaxis:

Epistaxis is commonly observed in patients with coagulopathy secondary to liver disease, leukemia or myelosuppression.

Hereditary haemorrhagic telangiectasia

(HHT)or Rendu–Osler–Weber disease, is an autosomal dominant condition affecting blood vessels in the skin, mucous membranes and viscera.

The classical features are telangiectasia, arteriovenous (AV) malformations and aneurysms. Recurrent epistaxis occurs in 93 percent of cases.

Management involves packing, cautery, antifibrinolytics, systemic or topical oestrogens, coagulative lasers, septal dermoplasty, ligation and embolization and, as a last resort, permanent surgical closure of the nostrils (Young’s operation)

Paediatric epistaxis:

Enquire about the use of nasal sprays as intranasal steroid sprays can cause localized nasal mucosal trauma often in the region of the anterior end of the inferior turbinate which can give rise to epistaxis.

A concomitant vestibulitis should raise the suspicion of a retained nasal foreign body.

Idiopathic thrombocytopoenic purpura (ITPP) may present as epistaxis.

Nasal mycoses may need to be considered, particularly in immunocompromised children, such as those receiving chemotherapy.

Commonly used methods for the management of recurrent epistaxis in children are the prophylactic application of petroleum jelly to the nasal

vestibule and septum,

the use of topical antiseptic creams, and

cautery of Little’s area or the retrocollumellar veins.

If the bleeding is persistently from one side, often we find either a leash of vessels around Little’s area on the affected side or a prominent retrocollumellar vein

Cautery nowadays is most often undertaken using a silver nitrate impregnated stick.

Petroleum jelly is thought to be effective because it forms a water-resistant film over the affected area of mucosa.

In addition, antiseptic creams are thought to sterilize localized infection in the region of the vestibule and the nasal septum.

Summary:

First line: direct therapy (bipolar/cautery, endoscopic if required);

Second line: indirect therapy (anterior packing);

Third line: surgical therapy (ESPAL);

Fourth line: angiography and embolization.

Thank you…

Journal club---04.04.2014

By dr.bala teja (laryngeal amyloidosis)