epistaxis dr. vishal sharma. definition & causes bleeding from within the nasal cavity. causes:...
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![Page 1: Epistaxis Dr. Vishal Sharma. Definition & Causes Bleeding from within the nasal cavity. Causes: 1. Idiopathic (55 %) 2. Local 3. General](https://reader038.vdocuments.net/reader038/viewer/2022102602/55169089550346f6208b4683/html5/thumbnails/1.jpg)
Epistaxis
Dr. Vishal Sharma
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Definition & Causes
Bleeding from within the nasal cavity.
Causes:
1. Idiopathic (55 %)
2. Local
3. General
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Local causes (nose & P.N.S.) Congenital: hereditary telengiectasia
Trauma: nose picking, injury to nose / face /
skull base, nasal surgery, foreign
body
Infection: vestibulitis, sinusitis, atrophic
rhinitis, rhinosporodiosis,
rhinoscleroma
Neoplasms: angiofibroma, hemangioma,
inverted papilloma,
malignancy
Deviated nasal septum (spur)
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General causes• Hypertension
• Bleeding disorders: haemophilia,
thrombocytopenia, leukemia
• Drugs: aspirin, anticoagulants
• Physiological: cold + dry climate, high
altitude, vicarious menstruation,
violent exertion, barotrauma
• Liver failure
• Exanthematous fevers
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Common causes of epistaxis
• Child: nose picking, foreign body,
exanthematous fever
• Adolescent: nasopharyngeal angiofibroma,
trauma, sinusitis
• Adults: sinusitis, trauma
• Elderly: hypertension, malignancy
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Common sites of epistaxis• Little’s area (80-90 %): Kiesselbach’s arterial
plexus at antero-inferior part of septal cartilage.
Common in children.
• Woodruff’s venous (?) plexus: near posterior
end of middle turbinate. Common in elderly,
hypertensives.
• Retro-columellar vein: common in adults.
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Common sites of epistaxis
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Common sites of epistaxis
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Anterior Epistaxis
Posterior Epistaxis
Incidence More common Less common
Localization Easy Difficult
Common site Little’s area Woodruff plexus
Age < 18 yr > 40 yr
Common Cause Trauma Hypertension
Treatment Anterior pack Posterior pack
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Evaluation of pt. with epistaxis• mode of onset, duration, frequency, amount,
side, site, previous bleeding
• nasal trauma, purulent nasal discharge
• hypertension, hepatic diseases, family history
of bleeding, bleeding from other sites, use of
anticoagulants, aspirin
• measurement of pulse & blood pressure
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Investigations• Hemoglobin, Packed Cell Volume
• Blood grouping & cross-matching
• Bleeding Time, Clotting Time
• Activated Partial Thromboplastin Time
• Prothrombin Time
• Platelet count
• Diagnostic Nasal Endoscopy (D.N.E.)
• C.T. scan paranasal sinus
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General treatment• Record pulse & blood pressure
• Reassurance + bed rest in sitting posture with
back rest
• Adequate sedation (Diazepam)
• Inj. Ethamsylate 500 mg IV Q8H
• Amlodipine / Nifedipine for hypertension
• IV fluids / blood transfusion for shock
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Anterior epistaxis• Pinch nostrils + ice pack
Bleeding continues
• Insert cotton pledgets soaked in 1: 1000
adrenaline in nasal cavity
Bleeding continues
• Chemical cautery with AgNO3 or electrical
cautery (if bleeder is localized) or anterior nasal
packing
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Trotter’s method
Elderly pt in sitting
position, leaning forward,
mouth open allowing
bleeding to continue till
hypotension develops.
May lead to coronary
thrombosis + death.
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Adrenaline soaked pledget
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Chemical cautery
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Anterior nasal packing
Anterior nasal packing for 48-72 hrs antibiotic
cover with:
• Liquid paraffin + antibiotic cream gauze
• Vaseline gauze
• Bismuth Iodoform Paraffin Paste gauze
• Merocel tampoon
• Simpson balloon
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Anterior nasal gauze packing
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Anterior nasal gauze packing
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Anterior nasal gauze packing
• Ribbon gauze soaked with liquid paraffin +
antibiotic cream used.
• Both nasal cavities packed tightly by layering
from floor to roof. Pack removed after 48 hrs.
• Systemic antibiotics given to prevent sinus
infection & toxic shock syndrome.
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Merocel nasal tampoon
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Simpson’s nasal balloon
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Posterior epistaxis• Posterior + anterior nasal packing for 48-72
hrs antibiotic cover with:
• Post nasal gauze pack
• Foley’s catheter
• Brighton balloon (double lumen)
• Epistat balloon (double lumen)
• Bivona balloon (triple lumen)
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Antero-Posterior Nasal Packing
with gauze pack
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Posterior nasal gauze pack
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Catheter introduction
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Tying of pack to catheter tip
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Guiding pack into nasopharynx
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Tying of anterior strips
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Anterior nasal packing
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Outer nasal packing
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Posterior nasal packing
• Post nasal pack prepared by tying 3 ribbon
gauze strips to piece of gauze roll
• 2 Foley’s catheters passed through each nostril
& their ends brought out via mouth
• 2 ends of gauze strips attached to nasal pack
tied to catheter tips & withdrawn from nose
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Posterior nasal packing
• Pack that follows ribbon gauze strips, is guided
into nasopharynx with index finger.
• Anterior nasal packing done. 2 ribbon gauze
strips tied over a gauze piece on columella.
• 3rd gauze strip brought out from mouth & taped
to cheek. Pack removed after 48-72 hr.
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Antero-Posterior Nasal Packing with Foley’s
catheter
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Foley’s catheter
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Catheter introduction
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Catheter tip in nasopharynx
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Anterior nasal packing
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Brighton’s nasal balloon
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Epistat nasal balloon
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Bivona triple lumen catheter
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Epistaxis set
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Surgical intervention for refractory
epistaxis
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1. Arterial ligation by external approach
• external carotid artery: ligated in neck, distal to
superior thyroid
artery
• internal maxillary artery: ligated in pterygo-
palatine fossa (Caldwell-Luc
opn)
• anterior or posterior ethmoidal artery: ligated in
orbit (Lynch-Howarth incision)
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External Carotid ligation
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2. Angiography and embolization
3. Submucosal Resection of septum
4. Septo-dermoplasty:
for hereditary telengiectasia
5. Endoscopic cautery & clipping:
Sphenopalatine artery
Anterior or posterior ethmoidal artery
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Angiography + embolization
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Endoscopic clipping
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Thank You