EPISTAXISEPISTAXIS

Introduction and HistoryIntroduction and History

Epistaxis is defined as bleeding from Epistaxis is defined as bleeding from nasal cavities. nasal cavities.

Hipprocrates technique ( pinching the ala Hipprocrates technique ( pinching the ala ))

simplest treatment for nasal bleed simplest treatment for nasal bleed Common occurrenceCommon occurrence Most episodes are minor in natureMost episodes are minor in nature Minor bleed – children and adultsMinor bleed – children and adults Severe bleeding - > 50 yearsSevere bleeding - > 50 years

Anatomy/Physiology of Anatomy/Physiology of EpistaxisEpistaxis

AnatomyAnatomy Nasal cavityNasal cavity Vascular supplyVascular supply

PhysiologyPhysiology Vascular natureVascular nature MucosaMucosa

External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

Internal Carotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery

Arterial Supply of the Nose

Kesselbach’s Plexus/Little’s Area:-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus

Why bleeding from the Why bleeding from the nose ?nose ?

• Vasculature runs Vasculature runs just under mucosa just under mucosa (not squamous)(not squamous)

• Arterial to venous Arterial to venous anastamosesanastamoses

• ICA and ECA blood ICA and ECA blood flowflow

Anterior vs. PosteriorAnterior vs. Posterior

Anterior: younger, usually septal vs. Anterior: younger, usually septal vs. anterior ethmoid, most common anterior ethmoid, most common (>90%), typically less severe(>90%), typically less severe

Posterior: older population, usually Posterior: older population, usually from Woodruff’s plexus, more from Woodruff’s plexus, more serious.serious.

EtiologyEtiology Local factorsLocal factors

Trauma (most common)Trauma (most common) VascularVascular Infectious/InflammatoryInfectious/Inflammatory IatrogenicIatrogenic NeoplasmNeoplasm DessicationDessication Foreign Bodies/otherForeign Bodies/other

Local Factors - TraumaLocal Factors - Trauma Nose pickingNose picking Nose blowing/sneezingNose blowing/sneezing Nasal fractureNasal fracture Nasogastric/nasotracheal intubationNasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle Trauma to sinuses, orbits, middle

ear, base of skullear, base of skull BarotraumaBarotrauma

Local Factors - Local Factors - Infection/InflammationInfection/Inflammation

Rhinitis/SinusitisRhinitis/Sinusitis AllergicAllergic BacterialBacterial FungalFungal ViralViral

Local Factors - Iatrogenic Local Factors - Iatrogenic nasal injurynasal injury

Functional endoscopic sinus surgeryFunctional endoscopic sinus surgery RhinoplastyRhinoplasty Nasal reconstructionNasal reconstruction

Local Factors - NeoplasmLocal Factors - Neoplasm Juvenile nasopharyngeal Juvenile nasopharyngeal

angiofibromaangiofibroma Inverted papillomaInverted papilloma SCCASCCA AdenocarcinomaAdenocarcinoma MelanomaMelanoma EsthesioneuroblastomaEsthesioneuroblastoma LymphomaLymphoma

Local Factors – Local Factors – Dessication Dessication

Cold, dry air—more common in Cold, dry air—more common in wintertimewintertime

Nasal oxygenNasal oxygen Anatomic abnormalitiesAnatomic abnormalities Atrophic rhinitisAtrophic rhinitis

EtiologyEtiology Systemic factorsSystemic factors

Vascular - HypertensionVascular - Hypertension

Infection/Inflammation – Infection/Inflammation – Tuberculosis,SyphilisTuberculosis,Syphilis

Coagulopathy : Hemophillia , vWD , HHTCoagulopathy : Hemophillia , vWD , HHT

Hereditary Hemorrhagic Hereditary Hemorrhagic TelangiectasiaTelangiectasia

Autosomal dominantAutosomal dominantClassical features are Classical features are

telangectasia , AV malformation telangectasia , AV malformation and aneurysms, recurrent epistaxis.and aneurysms, recurrent epistaxis.

Laser photocoagulation.Laser photocoagulation.

Initial ManagementInitial Management ABC’sABC’s Medical history/MedicationsMedical history/Medications Vital signs—need IV?Vital signs—need IV? Physical examPhysical exam

Anterior rhinoscopyAnterior rhinoscopy Endoscopic rhinoscopyEndoscopic rhinoscopy

Laboratory examLaboratory exam Radiologic studiesRadiologic studies

ResuscitationInitial Examination

Vessel not located Vessel located

Endoscopy

Vessel not located

Anterior nasal pack

Continued bleedingPosterior packing

Ligation of blood vessels

Direct therapyBipolar cautery

Bleeding controlledPack for 48 hours

Management of EpistaxisManagement of Epistaxis Medical ManagementMedical Management Nasal PackingNasal Packing Cautery – Silver Nitrate, Endoscopic Cautery – Silver Nitrate, Endoscopic

electrocautery and Laser cauteryelectrocautery and Laser cautery EmbolizationEmbolization LigationLigation Surgery – Septoplasty and Surgery – Septoplasty and

SeptodermoplastySeptodermoplasty

Nasal packsNasal packs Anterior nasal packsAnterior nasal packs

TraditionalTraditional Recent modificationsRecent modifications

Posterior nasal Posterior nasal packspacks Traditional Traditional Recent modificationsRecent modifications

Ant/Post nasal Ant/Post nasal packingpacking

Indications for Indications for surgery/embolizationsurgery/embolization

Continued bleeding despite nasal Continued bleeding despite nasal packingpacking

Pt requires transfusion/admit hct of Pt requires transfusion/admit hct of <38% <38%

Nasal anomaly precluding packingNasal anomaly precluding packing Patient refusal/intolerance of packingPatient refusal/intolerance of packing Posterior bleed vs. failed medical Posterior bleed vs. failed medical

mgmt after >72hrsmgmt after >72hrs

Take Home MessageTake Home Message Epistaxis affects all agesEpistaxis affects all ages Epistaxis can be life threateningEpistaxis can be life threatening Common causes are idiopathic and traumaCommon causes are idiopathic and trauma Systemic disorders are rare but should not Systemic disorders are rare but should not

be overlookedbe overlooked The majority of nose bleeds are from the The majority of nose bleeds are from the

anterior septum and can easily be controlled anterior septum and can easily be controlled by cauterisation or anterior nasal packingby cauterisation or anterior nasal packing

Surgical ligation of the arterial supply may Surgical ligation of the arterial supply may be necessary in severe casesbe necessary in severe cases