EPISTAXIS BY

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EPISTAXISBY
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Introduction

• Epistaxis is a greek word meaning nose bleed.
  has been a part of the human experience from
  earliest times
• Hippocrates commented that holding pressure on
  the nose helped to abate bleeding. Kiesselbach
  and Little(1879) were the first to identify the
  nasal septums anterior plexus as a source of
  nasal bleeding.
• Pilz(1869) was the first to surgically treat
  epistaxis with arterial ligation

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Incidence

• Epistaxis, has been reported to occur in up to 60
  percent of the general population. It has a
  bimodal distribution, with peaks at ages younger
  than 10 years and older than 50 years.
• Affected persons usually do not seek medical
  attention, particularly if the bleeding is minor
  or self-limited. In rare cases, however, massive
  nasal bleeding can lead to death.
• The incidence increases with advancing age,
  during the winter months, and is more common in
  males

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Anatomy

• The rich vascular supply of the nose originates
  from the ethmoidal branches of the internal
  carotid arteries and the facial and internal
  maxillary divisions of the external carotid
  arteries. Although nasal circulation is complex
  epistaxis usually is described as either anterior
  or posterior bleeding. This simple distinction
  provides a useful basis for management.

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Blood supply of nose
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Common bleeding Sites

• Kiesselbachs plexus Littles area
• Woodruffs Area
• Retrocolumellar vein
• Middle turbinate

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Local causes

• Epistaxis digitorum (nose picking) Trauma
• Foreign bodies
• Intranasal neoplasm or polyps
• Irritants (e.g., cigarette smoke)
• Medications (e.g., topical corticosteroids)
• Rhinitis, Sinusitis acute and chronic
• Septal deviation , Septal perforation
• Adenoids
• Vascular malformation or telangiectasia

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Systemic causes

• Haemophilia
• Hypertension
• Leukemia
• Liver disease (e.g., cirrhosis,Factor defeciency)
• Medications e.g., aspirin, anticoagulants,
  nonsteroidal anti-inflammatory drugs
• Platelet dysfunction Thrombocytopenia
• Others
• Diffuse oozing, multiple bleeding sites, or
  recurrent bleeding may indicate a systemic process

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Idiopathic

• Vast majority of cases come under this category

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Bleeding patterns

• Septum littles area
• Above the middle turb ethmoidal vessels
• Below the middle turb sphenopalatine A
• Posterior woodruffs area
• Generalized bleeding disorder

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Site and age relationship

• Anterior 1/3 bleeds in adults
• Commonest from littles area
• Posterior 2/3 bleeds in old age
• At the juntion of floor and lateral
  wall

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Examination

• Every attempt should be made to locate the source
  of bleeding that does not respond to simple
  compression and nasal plugging.
• The examination should be performed in a
  well-lighted room, with the patient seated and
  clothing protected by a sheet or gown.
• The doctor should wear gloves and other
  appropriate protective equipment (e.g., surgical
  mask, safety glasses).
• A headlamp /head mirror and a nasal speculum
  should be used for optimal visualization

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Examination contd

• Clots and foreign bodies in the anterior nasal
  cavity can be removed with a small suction tip,
  irrigation, forceps, and cotton-tipped
  applicators.

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Initial Management

• Application of direct pressure to the septal area
  and plugging of the affected cavity with gauze
  or cotton that has been soaked in a topical
  decongestant.
• Direct pressure should be applied continuously
  for at least five minutes, and for up to 20
  minutes.
• Tilting the head forward prevents blood from
  pooling in the posterior pharynx, thereby
  avoiding nausea and airway obstruction.
• Hemodynamic stability and airway patency

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Management Principles

• Although most patients with epistaxis can be
  treated as out patients, hospital admission and
  close observation should be considered for
  elderly and patients with posterior bleeding or
  coagulopathy. Admission also may be prudent for
  patients with complicating comorbid conditions
  such as IHD, severe hypertension or significant
  anemia

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ANTERIOR EPISTAXIS

• If a single anterior bleeding site is found,
  vasoconstriction should be attempted with topical
  application of oxymetazoline or phenylephrine
  solution. For bleeding that is likely to require
  more aggressive treatment, a local anesthetic,
  such as a
• 4 Xylocaine solution, should be used. Adequate
  anesthesia should be obtained before treatment
  proceeds.

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Cautrization

• Larger vessels generally respond more readily to
  electrocautery. However, it must be performed
  cautiously to avoid excessive destruction of
  healthy surrounding tissues.
• Use of electrocautery on both sides of the septum
  may increase the risk of septal perforation.
• Some studies found no difference in efficacy or
  complication rate between chemical cautery
  (silver nitrate ) and electrocautery

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Anterior nasal packing

• anterior nasal cavity should be packed, from
  posterior to anterior, with ribbon gauze
  impregnated with petroleum jelly or polymyxin
  B-bacitracin zinc-neomycin . Nonadherent gauze
  impregnated with petroleum jelly and Bipp also
  works well .Bayonet forceps and a nasal speculum
  are used to approximate the layers of the gauze,
  which should extend as far back into the nose as
  possible. Each layer should be pressed down
  firmly before the next layer is inserted .Once
  the cavity has been packed as completely as
  possible, a gauze "drip pad may be taped over
  the nostrils and changed periodically.

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Anterior nasal packing
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Complications of nasal packing

• Procedures include septal hematomas and abscesses
  from traumatic packing, sinusitis, syncope during
  packing, and pressure necrosis secondary to
  excessively tight packing.
• possibility of toxic shock syndrome with
  prolonged nasal packing

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POSTERIOR EPISTAXIS

• Much less common than anterior bleeding .
  Posterior packing may be accomplished by passing
  a catheter through one nostril (or both
  nostrils), through the nasopharynx, and out the
  mouth . A gauze pack then is secured to the end
  of the catheter and positioned in the posterior
  nasopharynx by pulling back on the catheter until
  the pack is seated in the posterior choana,
  sealing the posterior nasal passage and applying
  pressure to the site of the posterior bleeding.
• It requires special training and usually is
  performed by an otolaryngologist

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Post nasal packing
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Foleys catheter

• A Foley catheter (10 to 14 French) with a 30-mL
  balloon may be used. The catheter is inserted
  through the bleeding nostril and visualized in
  the oropharynx before inflation of the balloon.
  The balloon then is inflated with approximately
  10 mL of saline, and the catheter is withdrawn
  gently through the nostril, pulling the balloon
  up and forward. The balloon should seat in the
  posterior nasal cavity and tamponade a posterior
  bleed. With traction maintained on the catheter,
  the anterior nasal cavity then is packed as
  previously described. Traction is maintained by
  placing an clamp on the catheter beyond the
  nostrils, which should be padded to prevent soft
  tissue damage. As with anterior epistaxis,
  topical antistaphylococcal antibiotic ointment
  may be used to prevent toxic shock syndrome.
  However, use of oral or intravenous antibiotics
  for posterior nasal packing is documented

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PERSISTENT BLEEDING

• Patients with anterior or posterior bleeding that
  continues despite packing or balloon procedures
  may require treatment by an otolaryngologist.
  Endoscopy may be used to locate the exact site of
  bleeding for direct cauterization.
• Hot water irrigation, a technique described more
  than 100 years ago, has been reexamined recently.
  This technique has shown promise in reducing
  discomfort and length of hospitalization in
  patients with posterior epistaxis.

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Danger signals in a severe nosebleed

• Heavy bleeding.
• Palpitation, shortness of breath and turning
  pale.
• Swallowing large amounts of blood, which will
  cause you to vomit.

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Indications for surgical intervention

• have been widely debated, but usually include
  failure of medical treatment after 72 hours,
• nasal anatomy that precludes local treatments,
  patient refusal of medical management,
• initial hematocrit of lt38 (males),
• and the need for transfusion.
• Many authors have argued that a posterior bleed
  that will necessitate a posterior pack is
  indication enough to pursue surgical treatment.

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Surgical measures

• Arterial ligation
• maxillary artery
• anterior ethmoidal artery
• posterior ethmoidal artery
• external carotid artery
• Embolization
• Septal surgery
• lasers

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How to avoid nosebleeds

• Avoid damaging the nose and excessive
  nose-picking.
• Seek medical treatment for any disease causing
  the nosebleeds.
• Get a humidifier if you live in a dry climate or
  at high altitude.

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summary

• The medical communitys understanding of
  epistaxis has increased dramatically. Our
  treatment, though somewhat modified over the
  years, has continued to include techniques first
  noted several thousand years ago.

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Summary

• Epistaxis is the manifestation of many different
  disease processes.
• Its treatment is as varied as its etiologies.
  Treatment will be most effective when underlying
  medical problems are understood, nasal anatomy is
  appreciated, and the patients response to
  treatment and general medical status are taken
  into account.
• The otolaryngologist should be familiar with
  treatment options and be able to offer surgical
  intervention, if necessary.
•