Common%20ENT%20problems

1
Common ENT problems

• Suthee Ratanathummawat
• Department of Otolaryngology
• Phramongkutklao college of Medicine

2
Case 1

• A 55-year old lady has come in with a severe
  nose bleed and we are getting vital signs.

3
Epistaxis

• Epidemiology
• Child and adult anterior epistaxis
• Elderly posterior epistaxis
• 90 of epistaxis occur at anterior site
• More common in winter

anterior epistaxis
posterior epistaxis
4
Two types of nosebleeds
Anterior NB (most common)
Posterior NB (less common, but more severe)
5
Kiesselbachs plexus (Littles area)

• Most common site of
• anterior epistaxis
• Blood supply
• 1. Anterior Ethmoidal a.
• 2. Superior Labial a.
• 3. Greater palatine a.
• 4. Sphenopalatine a.

Littles area
6
Causes of epistaxis

• Trauma
• Infection
• Foreign body
• Neoplasm
• Systemic disease
• Coagulation defect

7
Etiology

• Systemic causes
• -Atherosclerotic vascular disease ( HT,
  old age)
• -Coagulation deficits
• -Hereditary hemorrhagic telangiectasia
  (Osler-weber-Rendu)
• -Idiopathic cause (10)

Hereditary hemorrhagic telangiectasia
8
Osler-weber-Rendu)

• an autosomal dominant
• mucocutaneous telangiectasia
• insufficient smooth muscle contractile element
• arteriovenous malformations

9
???????????????????????

• ??? Vital sign
• ??????????????????? ???????????????? Venous
  pressure
• ??????????? 5-8 ????
• Pack ??????????????? Adrenaline 0.1 or
  Ephedrine 1 (????????????? HT)

10
How to stop an anterior nosebleed...
11
5 minute pressure - correct
Incorrect
12
??????????????????????? (???)

• Cold compress
• ???????????? ???? Trichloracetic acid 30
• Anterior nasal packing ???? Gel foam
• ???? Finger cot ???? Vaseline gauze
• Mouth care and Rest ???????????????????

13

• Visualization of the nose without topical
  anesthesia and decongestant will result not only
  in severe discomfort for the patient, but also
  possibly precipitate additional bleeding.
  Spending the extra several seconds or so to
  anesthetize and decongest the nose will
  dramatically decrease the discomfort experienced
  by the patient.

14
Nosebleed Tray
15
(No Transcript)
16
(No Transcript)
17
Merocel
Expandable cellulose nasal pack
18
Finger cot
19
Anterior nasal packing
20
Anterior packing
21

• After you place and expand an expandable
  methylcellulose nasal pack in her nose she
  continues to bleed. Blood is only oozing from her
  nose but she is still spitting out bright red
  blood and clots from her mouth.

22
Posterior nasal bleeding

• ?????? ????????????? ??????????????
  JuvinileAngiofibroma ???????? ???????????????????
  ??????? ??????????? Sphenopalatine artery

23
Sphenopalatine artery
24
???????????????????????

• ??? Vital sign, Pain ???????????????????
• ???????????????????????? cold compress
• ???????????????
• ???????? Posterior nasal packing

25
??????????????????????? (???)

• ??????????? ???????? Cold compress
• ???? Hematocrit ?????? Bleeding
• ???????????? mouth care
• ??????????? ?? Aspirin ?????????????
• ??? Vital sign, Pain
• ????????????????? ??????????

26
Posterior nasal packing
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
Posterior Nose Bleed
31

• She was admitted to the ICU, monitored and
  sedated.
• Urgent referral to an ENT made for definitive
  treatment.
• Later that afternoon she is transferred to the
  otolaryngologist in the adjacent town. The
  following day you receive a call from him and are
  told that she rebled during the night. He is
  planning to take her to the operating room
  urgently to perform endoscopic clipping of the
  sphenopalatine artery.

32
Endoscopic clipping of the sphenopalatine artery.
33

• Later that day you receive another call from the
  otolaryngologist. Following uneventful endoscopic
  ligation of the sphenopalatine artery the
  bleeding continued so he clipped the anterior
  ethmoid artery as well.

34
Ligation blood vessel

• Anterior ethmoid a.
• Posterior ethmoid a.
• Internal maxillary a.
• External carotid a.

35
Ethmoid artery ligation
36
Anterior Ethmoidal Artery
Nasal Septum
37
Treatment

• Artery ligation

External carotid artery ligation - Easy but
high failure rate(45)
Internal maxillary ligation Failure rate 0-25
38
Treatment

• Embolization
• Indication

1. Fail from other treatment 2.
Contraindication to surgery
39
conclusion

• Anterior epistaxis
• pressure cautery
  ant.packing
• fail
• Posterior epistaxis
• Post.packing ligation
  embolization