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EPISTAXIS

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Ame Mehadi

This document provides information on epistaxis (nosebleed) including: - The anatomy of the nasal blood supply from both internal and external carotid arteries. The majority of anterior nosebleeds occur from Kiesselbach's plexus. - Types of epistaxis including anterior (85-90% of cases) and posterior (10-15% involving those over 50). - Causes can be local like trauma or tumors, or systemic like infections, blood disorders, or vascular problems. - Treatment depends on location but may include cauterization, nasal packing, balloon catheters, or ligation of arteries in severe cases. Hospitalization is needed for posterior bleeds or those

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EPISTAXIS Kibatu Gebre (BA,BSC,MSC)
Introduction A very common health problem 60% of patients have at least one episode of epistaxis in their life time Most are self limited and treated conservatively Requires meticulous and individualized approach Incidence increases during dry, cold winter months
Anatomy Efficient management of patients with epistaxis requires thorough knowledge of the anatomy of the interior aspect of the nose . This includes : - Blood supply, and - Mucosal morphology and configuration
Blood Supply The nasal mucosa receives its blood supply from branches of both the internal and external carotid arteries A. Internal carotid artery Ophthalmic artery Anterior and posterior ethmoidal arteries -supplies superior anterior nasal cavity
B. External Carotid Artery 1.Internal maxillary artery Greater palatine and sphenopalatine arteries 2. Facial artery(superior labial branch)supplies inferior anterior nasal septum .The posterior and superior nasal septum is supplied by branches of sphenopalatine, anterior and posterior ethmoidal arteries ( kiesselbachs plexus -Little area)
EPISTAXIS
Mucosa morphology and configuration Respiratory Epithelium - Pseudo-stratified columnar ciliated - interspaced goblet cells - protective mucus blanket assured by ciliary activity - abundant network of blood vessels in lamina propria Any interference that may disrupt this structural configuration is apt to end up in bleeding
Types A. Anterior Epistaxis B. Posterior Epistaxis Appropriate control of epistaxis calls for identification of the bleeding site Bleeding may, however, occur from any other sites
Anterior Epistaxis Almost invariably associated with Kiesselbachs Plexus Littles Area Results from any process that causes mucosal hyperemia Most commonly occurs in children Represents 85-90% of all nosebleeds
Posterior Epistaxis Majority of it is associated with the sphenopalatine artery Woodruffs Plexus The sphenopalatine artery is sometimes referred to as the artery of the laryngologist Accounts for 10-15% of nose bleeds Mostly involves those older than 50
Incidence Epistaxis has a bimodal age distribution, most cases occurring before age 10 and between 45 and 65 years of age Serious cases encountered with advancing ages, showing a male preponderance prior to age 49, the gender ratio equalizing thereafter
Causes A. Local - trauma - nasal picking, rhinitis, nasal fracture - foreign body in the nose - rhinoliths - tumors: benign - polyp malignant - nasal , paranasal sinuses B. Systemic - Infection: AFI, typhus, influenza - Blood Diseases, coagulopathies
Vascular and circulatory problem: hypertension and arteriosclerosis Hereditary: HHT (Osler Rendu Weber Disease) Clinical features Unilateral nasal bleeding (anterior) Sensation of blood in posterior throat (posterior)
Evaluation Initial assessment - Airway assessment and CV stability and management with otolaryngologist consultation Hx - Timing, severity, frequency of epistaxis - Previous epistaxis, trauma, head /neck tumor and surgery, radiation therapy, cirrhosis, HIV - Personal and family for bleeding disorders - Medications (warfarin, plavix, ASA, intranasal glucocorticoids) Coagulation profile ,CBC, Cross match
P/E - V/S, mental status, airway - Examination of the nose DDX Bleeding that is not from the nose but escaping from the nostril (s) - Nasopharyngeal tumors - Esophageal varices - Skull base vascular Injury
Treatment General Measures Get ready basic equipment Calm the patient, calm yourself Sit up the patient, head bent forward, mouth breathing, pinching alae of the nose against the septum for 10 minutes Advice the patient to blow through the nose Cold application - nasal root Lower BP, D/C anticoagulant, anti platelates IV fluid, blood transfusion
Specific measures Anterior bleeding - minor bleeding usually resolves spontaneously prior to clinical evaluation or making tamponade Cautery - chemical - AgNo4 stick for 10 seconds - electrical Nasal packing - administer small dose of anxiolytics before insertion - a synthetic open cell foamed polymer nasal tampon-Merocel≒ is preferable than traditional gauze packing
Gauze packing - ribbon gauze impregnated with petrolatum Nasal balloon catheters (Rapid Rhino) - parental narcotics and anxiolytics prior to insertion - Soak the catheter for 30 seconds before insertion Packing should be followed for 24-48 hrs for recurrence of bleeding and has a success rate of 90-95% Prophylaxis antibiotics -Amoxycyllin-cavulinate or cephalexin
Posterior Bleeding Balloon catheters (e.g Epistat,storz-3100) - Pre treat with 2% lidocain and oxymetazoline Foley catheter-10-14 French size Cotton packing Vascular Ligation last option - Sphenopalatine artery - Anterior & posterior ethmoid arteries - External carotid artery
Hospitalization - Posterior source of bleed for cardiac monitoring - Patient with anterior packing who can not be reasonably expected to return for prompt follow up or who have serious co-morbidities or concerning symptoms
Complications of Treatment Pain and Discomfort Cardiopulmonary Failure Pharyngeal Stenosis Alar or Septal stenosis Sinusitis Toxic Shock Syndrome Aspiration Nasal crusting, palatal numbness, Septal perforation
Summary Nosebleed may at times turn out to be life threatening!! .Therefore, effective handling requires: - All round readiness - Pre-consideration of potential complications associated with the designed management - patience to review therapeutic procedure and to be aware of any corrective measures
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EPISTAXIS

  • 2. Introduction A very common health problem 60% of patients have at least one episode of epistaxis in their life time Most are self limited and treated conservatively Requires meticulous and individualized approach Incidence increases during dry, cold winter months
  • 3. Anatomy Efficient management of patients with epistaxis requires thorough knowledge of the anatomy of the interior aspect of the nose . This includes : - Blood supply, and - Mucosal morphology and configuration
  • 4. Blood Supply The nasal mucosa receives its blood supply from branches of both the internal and external carotid arteries A. Internal carotid artery Ophthalmic artery Anterior and posterior ethmoidal arteries -supplies superior anterior nasal cavity
  • 5. B. External Carotid Artery 1.Internal maxillary artery Greater palatine and sphenopalatine arteries 2. Facial artery(superior labial branch)supplies inferior anterior nasal septum .The posterior and superior nasal septum is supplied by branches of sphenopalatine, anterior and posterior ethmoidal arteries ( kiesselbachs plexus -Little area)
  • 7. Mucosa morphology and configuration Respiratory Epithelium - Pseudo-stratified columnar ciliated - interspaced goblet cells - protective mucus blanket assured by ciliary activity - abundant network of blood vessels in lamina propria Any interference that may disrupt this structural configuration is apt to end up in bleeding
  • 8. Types A. Anterior Epistaxis B. Posterior Epistaxis Appropriate control of epistaxis calls for identification of the bleeding site Bleeding may, however, occur from any other sites
  • 9. Anterior Epistaxis Almost invariably associated with Kiesselbachs Plexus Littles Area Results from any process that causes mucosal hyperemia Most commonly occurs in children Represents 85-90% of all nosebleeds
  • 10. Posterior Epistaxis Majority of it is associated with the sphenopalatine artery Woodruffs Plexus The sphenopalatine artery is sometimes referred to as the artery of the laryngologist Accounts for 10-15% of nose bleeds Mostly involves those older than 50
  • 11. Incidence Epistaxis has a bimodal age distribution, most cases occurring before age 10 and between 45 and 65 years of age Serious cases encountered with advancing ages, showing a male preponderance prior to age 49, the gender ratio equalizing thereafter
  • 12. Causes A. Local - trauma - nasal picking, rhinitis, nasal fracture - foreign body in the nose - rhinoliths - tumors: benign - polyp malignant - nasal , paranasal sinuses B. Systemic - Infection: AFI, typhus, influenza - Blood Diseases, coagulopathies
  • 13. Vascular and circulatory problem: hypertension and arteriosclerosis Hereditary: HHT (Osler Rendu Weber Disease) Clinical features Unilateral nasal bleeding (anterior) Sensation of blood in posterior throat (posterior)
  • 14. Evaluation Initial assessment - Airway assessment and CV stability and management with otolaryngologist consultation Hx - Timing, severity, frequency of epistaxis - Previous epistaxis, trauma, head /neck tumor and surgery, radiation therapy, cirrhosis, HIV - Personal and family for bleeding disorders - Medications (warfarin, plavix, ASA, intranasal glucocorticoids) Coagulation profile ,CBC, Cross match
  • 15. P/E - V/S, mental status, airway - Examination of the nose DDX Bleeding that is not from the nose but escaping from the nostril (s) - Nasopharyngeal tumors - Esophageal varices - Skull base vascular Injury
  • 16. Treatment General Measures Get ready basic equipment Calm the patient, calm yourself Sit up the patient, head bent forward, mouth breathing, pinching alae of the nose against the septum for 10 minutes Advice the patient to blow through the nose Cold application - nasal root Lower BP, D/C anticoagulant, anti platelates IV fluid, blood transfusion
  • 17. Specific measures Anterior bleeding - minor bleeding usually resolves spontaneously prior to clinical evaluation or making tamponade Cautery - chemical - AgNo4 stick for 10 seconds - electrical Nasal packing - administer small dose of anxiolytics before insertion - a synthetic open cell foamed polymer nasal tampon-Merocel≒ is preferable than traditional gauze packing
  • 18. Gauze packing - ribbon gauze impregnated with petrolatum Nasal balloon catheters (Rapid Rhino) - parental narcotics and anxiolytics prior to insertion - Soak the catheter for 30 seconds before insertion Packing should be followed for 24-48 hrs for recurrence of bleeding and has a success rate of 90-95% Prophylaxis antibiotics -Amoxycyllin-cavulinate or cephalexin
  • 19. Posterior Bleeding Balloon catheters (e.g Epistat,storz-3100) - Pre treat with 2% lidocain and oxymetazoline Foley catheter-10-14 French size Cotton packing Vascular Ligation last option - Sphenopalatine artery - Anterior & posterior ethmoid arteries - External carotid artery
  • 20. Hospitalization - Posterior source of bleed for cardiac monitoring - Patient with anterior packing who can not be reasonably expected to return for prompt follow up or who have serious co-morbidities or concerning symptoms
  • 21. Complications of Treatment Pain and Discomfort Cardiopulmonary Failure Pharyngeal Stenosis Alar or Septal stenosis Sinusitis Toxic Shock Syndrome Aspiration Nasal crusting, palatal numbness, Septal perforation
  • 22. Summary Nosebleed may at times turn out to be life threatening!! .Therefore, effective handling requires: - All round readiness - Pre-consideration of potential complications associated with the designed management - patience to review therapeutic procedure and to be aware of any corrective measures