EPISTAKSIS

1. Faktor yg mempengaruhi : season (winter), sex (male), age (>50)

Lokal Desiccation Kelembaban lingkungan rendah
Cairan hidung kurang (efek obat, sistemik
illness)
Trauma External
Internal
Neoplasma Juvenile nasopharyngeal angiofibroma
Inverted papilloma
Carsinoma
Luar tubuh
Inflamasi kronik Infeksi
Perforasi septal
Rhinitis atrophik
Sistemik Koagulopati Antikoagulasi
Penyakit hepatik
Trombositopenia
Penyakit hati
Hemofilia
Hereditary hemorrhagic
telangiectasia

Gangguan inflamasi sistemik Wegener granulomatosis
Sarcoidosis
Churg-Strauss sindrom

2. Anatomi
Arteri karotis eksternal lateral nasal dan cabang septal
Arteri Maxilaris internal splenopalatina, lateral nasal, dan cabang septal

Area perdarahan
Anteroinferior : Little area / Pleksus Kiesselbach
Posterior : Pleksus Woodruff

The feeding arteries :
1. The middle septal branch of the sphenopalatine artery (SPA) posteriorly terbanyak
2. The anterior ethmoidal artery from above
3. The superior labial branch of the facial artery anteriorly

Posteriorly on the lateral nasal wall is the area known as Woodruff plexus at the posterior
end of the inferior turbinate where the sphenopalatine and posterior pharyngeal arteries
anastomose.
SPA dibagi jadi 2 cabang besar :
1. Nasal septal branch melintasi bag bawah dinding anterior di sinus sphenoideus dan
berjalan ke arah septum dalam mukosa. Penyuplai terbesar septum posterior.
2. Posterior lateral nasal artery penyuplai sebagian besar mukosa di dinding nasal lateral.

Cavitas nasi juga disuplai oleh arteri ethmoidalis anterior dan posterior.

3. Klinis dan Lab
Bila terjadi pendarahan hebat, pasien mungkin menunjukkan keadaan syok dan
memerlukan penyadaran menurut prinsip2 yg benar.

Evaluasi pertama kali adlh dari hidung luar. Tanda penting yg ditemukan mencakup
bukti trauma dan sisi perdarahan anterior.

Anterior rhinoscopy with nasal speculum and headlight will commonly reveal a
bledding source on the anterior nasal septum, evidence of the anterior septal
trauma, an eschar, a nasal septal perforation, or dilated vessels.

Intranasal endoscope evaluation is the best performed following adequate local
anesthesia and the topical application of a vasocontrictive afent such as
oxymetazoline.

Perdarahan posterior lebih serius dan lebih sulit dikontrol perhatikan kadar Hb

Supplies for epistaxis kit
Headlight
Nasal speculum
Suction Tubing, Canister, Frazier tip
Oxymetazoline-lidocaine spray
Silver nitrate
Bayonet forceps
Nasal packing supplies Inflatable nasal packs
Petroleum gauze strip
Absorbable packing material(Surgicel, Gelfoam)
Hemostatic sealants
Foley catheters
Endoscopes Flexible fiberoptic
Variety of rigid
Endoscopic cautery equipment Bipolar, Suction cautery
Saline irrigation

4. Manajemen Klinis dan Prognosis
Medical Management :
Having the patient to hold the nose putting pressure on the anterior septum. A
frequently useful adjunct produce is to add oxymetazoline ot phenylephrine as a
vasoconstricting agent.
For the chronic reccurent epistaxis, the most commonly used medical management
is the application of a moisturizing/humidifying agent to prevent desiccation. (nasal
saline mist, nasal saline gels, irrigation, foam, etc)
For acute hemorrhagic process indentify the bledding vessel. If the bledding cant
be controlled need tamponade nasal packing.
Traditional methods of nasal packing include use of an inflated foley catheter/gause
roll in the nasopharynx for the posterior pack with layered petroleum, based
ointment, coated gauze packed anteriorly.
Other methods of anterior-posterior packing include inflatable premanufactured
balloon device with separate anterior and posterior inflation chambers.
The Merocel nasal pack popular, easy to use, available in most emergency
departments.

Kekurangan nasal packing :
Sangat tidak nyaman dan bisa disertai nasal obstruksi, tersedak, sakit, dan disphagia.
Selain itu, bisa menyebabkan septikemia, dan resiko rendah alar nekrosis, serous
otitis media, infeksi lokal, sinusitis akut, dan septal perforasi.
Tidak efektif dibandingkan operasi/embolisasi.
Selain itu, bisa terjadi toxic shock syndrome (TTS) toksin yg dihasilkan Stap.
Aureus & Strep. Pyogenes.

Hemostatic Agents
Biasa digunakan untuk menghindari penggunaan nasal packing. Co/ antifibrinolitik
agents, biodegradable hemostatic sealant compounds (Floseal)
Lebih mudah, lebih byk diminati, lebih di toleransi pada pasien, namun lebih mahal.

Surgical Treatment and Embolization
Dipakai ketika tindakan konservatif gagal
Surgery lebih berhasil dan lebih murah drpd embolization
Embolisasi dpt menyebabkan komplikasi serius seperti internal carotid artery intimal
injury requiring antocoagulantion, nekrosis jaringan lunak, facial paralysis, miokard
infark, kebutaan, stoke.
Teknik terbaru adalah endoskopi, yg skrg jadi first line surgery treatment.

Hereditary Hemorrhagic Telangiectasia
Dikenal juga dgn Osler-Weber-Rendu sindrom
I Nosebleeds, spontaneous, rekuren
II Telangiectases, multiple, at characteristic sites
include lips, oral cavity, fingers and nose

III Internal lessions such as :

GI telangiectasia
Pulmonary arteriovenous malformations
(AVM)
Hepatic AVM
Cerebral AVM
Spinal AVM
IV Family history A first degree relative
Diagnosis is definite if 3 criteria are present
Diagnosis is possible/suspected if 2 criteria are present
Diagnosis is unlikely if fewer than 2 criteria are present

Treatment :
1. Fokus pada pencegahan & pengobatan epistaxis rekuren.
2. Endonasal Nd: YAG/KTP laser treatment
3. Septodermoplasty

Pertanyaan dr Mira:
1. Apa sebab/darimana epistaxis pada dewasa?
2. Pendarahan di Plexus Kiesselbach anastomosisnya apa aja? Ada 1 macem lagi apa?


-Nat2-
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