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ENT 2 Epistaxis

This document discusses epistaxis, or nosebleeds. It defines epistaxis and outlines the key anatomical areas involved. The etiology of epistaxis includes local causes like trauma, infections, tumors, and systemic causes like hypertension. Management involves initial first aid, taking a thorough history, examining the patient, investigating to determine the cause, treating the underlying condition, and preventing recurrences. Treatment options range from cauterization to nasal packing and arterial ligation for severe or intractable cases.

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Ju Ju
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16 views24 pages

ENT 2 Epistaxis

This document discusses epistaxis, or nosebleeds. It defines epistaxis and outlines the key anatomical areas involved. The etiology of epistaxis includes local causes like trauma, infections, tumors, and systemic causes like hypertension. Management involves initial first aid, taking a thorough history, examining the patient, investigating to determine the cause, treating the underlying condition, and preventing recurrences. Treatment options range from cauterization to nasal packing and arterial ligation for severe or intractable cases.

Uploaded by

Ju Ju
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DEFINITION

• Bleeding from the nasal cavity- anterior nasal or post nasal.


• Epi: From above, Staxis: drop by drop drip of fluid
ANATOMICAL CONSIDERATIONS

• Nasal cavity- Mucosa and turbinates are very vascular


• Receives blood supply from both internal and external carotid systems
• Network of arteries- Kiessalbach’s plexus anteriorly and Woodruff’s plexus
posteriorly
LITTLE’S AREA

• Caudal part of the nasal septum


• Septal branches of
• Anterior ethmoidal
• Sphenopalatine
• Greater palatine
• Superior labial
ETIOLOGY OF EPISTAXIS

• Local causes
• Systemic causes
• Idiopathic (Primary)
LOCAL CAUSES
I. Congenital: Telengectasia (Osler-Weber-Rendau
syndrome), hemangioma
II. Infections
• Viral: Influenza, measles
• Bacterial:
✓ Nonspecific-Acute/chronic rhinitis/ Sinusitis, atrophic
rhinitis
✓ Specific- Diphtheria, TB, Syphilis, other granulomas
• Fungal: Rhinosporidiosis, fungal sinusitis
• Parasites: Maggots
LOCAL CAUSES
III. Trauma
• Microtrauma- nose picking
• FB
• Iatrogenic
• Accidental, # facial/skull bones
• Barotrauma
IV. Neoplastic
• Benign: JNA, inverted papilloma, hemangioma
• Malignant: Nose/PNS/Nasopharynx
V. Miscellaneous
• DNS, Spur, rhinolith
SYSTEMIC CAUSES

• Hypertension
• Cardiac- CCF, mitral stenosis
• Pulmonary- COPD
• Cirrhosis- Vit K def.
• Hemotological: Anaemia, Bleeding/ clotting disorders, leukemia, lymphoma,
agranulocytosis
• Renal: Nephritis
• Vicarious menstruation,endometriosis, granuloma gravidarum
MANAGEMENT

• First aid- local and systemic


• History and clinical examination
• Investigations
• Definitive treatment
• Prevention of recurrences
FIRST AID
• Make patient sit up, pinch the nose for 5-10 minutes, open
mouth and breath
• Ice pack on the nose
• Sedation/ sublingual antihypertensives in case of
hypertensive epistaxis
History
Ask about:

1. Which side is bleeding


2. Estimate amount of blood lost
3. Is it recurrent
4. Is the blood in the pharynx
5. Recent trauma
6. Symptoms of hypovolemia
7. Past medical history
Concentrate on:

1. Volume status
2. Blood pressure
3. Adequacy of airway
4. Oral and nasal exam
INVESTIGATIONS

• Complete blood picture


• Hb., TC/DC,ESR
• Peripheral smear
• Bleeding profile-BT,CT,PT,APTT,Platelets
• Blood grouping/ cross matching
• Diagnostic nasal endoscopy
• X-ray PNS/CT scan
• DSA and embolization
• Biopsy if indicated
CAUTERIZATION

• Silver nitrate 10-20%


• 3% Trichloro acetic acid
• Chromic acid
• Electrocautery
ANTERIOR PACKING
 Unable to control
bleeding.
 Ribbon, tampon,
splints.
 BIPP, Polyfax
Balloon Catheter Nasal Sponge
Balloon Catheter

Advantages of its use:


- Quick to place
- Gives some posterior
tamponade
- Breathing hole in centre
- Can adjust pressure while
in situ
SPECIAL CASES

• Hemophilia
• Replace factor VII, fresh blood
• Other clotting deficiency
• FFP
• Purpura
• Platelets
• Anticoagulants
• Stop drug or titrate
• Heparin is reversed with protamine sulphate
• Warfarin with Vit K

• Unconscious head injury/ CSF rhinorrhoea


• Dangerous to pack with skull base #

• Telengectasia
• Septodermoplasty
INTRACTABLE EPISTAXIS

➢Ligation of vessals
• Maxillary artery- ‘Caldwel-luc approach’
• Anterior/ posterior ethmoidal artery- ‘Howarth approach’
• External carotid artery ligation
OTHER TREATMENTS

• DSA and selective arterial embolization


• Catheters with iced water lavage

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