Epistaxis

hadeel Owies

 Nose

anatomy :

2/3 cartilaginous ,1/3 bony. Bony bridge extremely strong . skin very closely related to the skeleton .

Nose

function:

Warming ,moistering and filtering the incoming air Detecting olfactory stimuli Modifying speech vibrations

Why bleeding from the nose ?

Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa (not squamous) Arterial to venous anastamoses

Blood supply:1.External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery -Posterior nasal artery -Superior Labial artery 2.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 AA of Sphenopalatine A (IMAX)

Anterior vs. Posterior

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

Etiology

Local factor
spontaneous Vascular Infectious/Inflammatory Trauma Iatrogenic Neoplasm Foreign Bodies/other

Etiology

general factors
Vascular Infection/Inflammation Coagulopathy

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

Local Factors Infection/Inflammation

Rhinitis/Sinusitis
Allergic Bacterial Fungal Viral

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction

Local Factors Neoplasm benign tumor:

Juvenile nasopharyngeal angiofibroma Inverted papilloma Polyps Malagnant tumor: scc Adenocarcinoma Melanoma Lymphoma

Systemic Factors -- Vascular

Hypertension/Arteriosclerosis From woodruffs area Elderly Difficult to stop May recure

Systemic Factors Infection/Inflammation

Tuberculosis Syphillis Wegeners Granulomatosis SLE

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 signs Physical exam

Anterior rhinoscopy Endoscopic rhinoscopy

Laboratory exam Radiologic studies

managmant:

If bleeding is from little area: 1. Apply digital pressure on the lower part of the septum. 2. Pack the nose with cotton plug soaked with lidocaine or phenylephrine for 5-10 minutes. 3. If it didnt work, try to cauterize the site of bleeding with silver nitrate stick.

 If bleeding is from an unknown site: 1. Apply digital pressure on the lower part of the septum for 5-10 minutes. 2. Let the patient lean forward. 3. Ask the patient to breath from his mouth. 4. Spit out the blood and not to swallow it. 5. If healing site is visible we do cauterization by silver nitrate or diathermy. 6. Sometimes we need to do post nasal packing

Nasal packs
We can use foleys catheter, we insert it from the nose and once it is in the pharynx we inflate the balloon and pull it back untill its stuck at the nasopharynx.

Non-surgical treatments
Avoidance of nose picking/blowing Sneeze with mouth open

Non-surgical treatments
Control of hypertension Correction of coagulopathies/thrombocytopenia

FFP or whole blood/reversal of anticoagulant/platelets

Topical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time) Greater palatine foramen block

Surgical treatment

Transmaxillary IMA ligation Intraoral IMA ligation Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation External carotid artery ligation Septodermoplasty/Laser ablation

Indications for surgery/embolization

Continued bleeding despite nasal packing Pt requires transfusion Nasal anomaly precluding packing Patient refusal/intolerance of packing Posterior bleed vs. failed medical mangmant

THANK YOU Hadeel owies