EPISTAXIS

Morgan Yost DO NRMC Kirksville, MO OGME-4 11/27/2012

Introduction and History

5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.

Anatomy/Physiology of Epistaxis
Anatomy
Nasal cavity Vascular supply

Physiology
Vascular nature Mucosa

Anatomy of the Lateral Nasal Wall

Anatomy of the Nasal Cavity and Vasculature

External Carotid Artery -Sphenopalatine artery

-Greater palatine artery

-Posterior nasal artery -Superior labial artery Internal Carotid Artery -Anterior ethmoid artery

-Posterior ethmoid artery

Kesselbachs Plexus/Littles Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX) -Greater Palatine (IMAX)

Woodruffs Plexus:
-Pharyngeal & Post. Nasal A of Sphenopalatine A (IMAX)

Anterior vs. Posterior

Maxillary sinus ostium Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe Posterior: older population, usually from Woodruffs plexus, more serious.

Etiology
Local factors
Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Desiccation Foreign Bodies/other

Local Factors - Trauma

Nose picking Nose blowing/sneezing Nasal fracture Nasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle ear, base of skull Barotrauma

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction

Local Factors - Neoplasm

Juvenile nasopharyngeal angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Esthesioneuroblastoma Lymphoma

Local Factors Desiccation

Cold, dry airmore common in wintertime Dry heatPhoenix and Death valley Nasal oxygen Anatomic abnormalities Atrophic rhinitis

Systemic Factors Coagulopathies

Thrombocytopenia Platelet dysfunction
Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor Deficiencies

Hemophilia VonWillebrands disease Hepatic failure

Hematologic malignancies

Etiology and Age

Childrenforeign body, nose picking Adultstrauma, idiopathic Middle agetumors Old age--hypertension

Initial Management
ABCs Medical history/Medications Vital signsneed IV? Physical exam
Anterior rhinoscopy Endoscopic rhinoscopy

Laboratory exam Radiological studies

bayonet forcepts

suction

bacitracin
gelfoam

good light
anesthetic Afrin epistat

endoscopes
silver nitrate

suction bovie/bipolar

merocels

surgicel

Non-surgical treatments
Control of hypertension Correction of coagulopathies/thrombocytopenia
FFP or whole blood/reversal of anticoagulant/platelets

Pressure/Expulsion of clots Topical decongestants/vasocontrictors Cautery (AgNo3 vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time

Non-surgical treatments on d/c

Humidity/emolients Discontinue offending meds Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining/bedrest

Nasal packs
Anterior nasal packs
Traditional

Posterior nasal packs

Traditional

Ant/Post nasal packing

Pick a Pack, any pack

Indications for surgery/embolization

Continued bleeding despite nasal packing Pt requires transfusion/admit hct of <38% Nasal anomaly precluding packing Patient refusal/intolerance of packing Failed medical mgmt after >72hrs

Surgical treatment
Transmaxillary IMA ligation Intraoral IMA ligation Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation External carotid artery ligation

Tips and Pearls

Dont pack nose in unconscious person with suspected skull fractures. Oral antibiotics and pain meds while pack in place Antibiotic cream, humidification Estrogen cream to nasal septum Smoking cessation

Just for fun