KAU Rabigh Medical School Tutorial 7 KAU Rabigh Medical School Department of Otolaryngology, Head and Neck Surgery

By Razan A. Basonbul, MBBS Epistaxis By Razan A. Basonbul, MBBS

Epidemiology Epistaxis is the most common bleeding disorder of the head and neck. It is estimated to occur in about 60% of the population. Most cases require no medical intervention. The majority of cases occur in children <10 and adults >50 years old. More common in Males than Females.

Anatomy Blood Supply of the nose is through branches of both : Internal Carotid Artery. External carotid Artery . Epistaxis based on the location of bleeding is described as Anterior. Posterior. About 90% of cases occur in the region of the Kiesselbach’s plexus ( Little’s area) along the anterior septum. It is Susceptible to bleeding due to fragile mucosa and tight adherence to underlying mucosa affording little resistance to mechanical stress. The usual location of posterior bleeding is the Woodruff’s plexus on the lateral wall posterior to inferior/ middle turbinate.

Little’s area ( Kiesselbach’s plexus) Most common site of bleeding (90%) Contributing arteries: IC  Ophthalmic  Anterior ethmoid EC  Facial  Superior Labial EC  Maxillary  Desending palatine  Greater palatine EC  Maxillary  Sphenopalatine ( terminal branches) Woodruff’s plexus : common source for posterior bleeds Contributing Arteries : EC  Maxillary  Sphenopalatine EC  Ascending pharyngeal

Etiology 80% idiopathic Local: Systemic: Osler-weber-rendu Disease Coagulopathies Trauma/nose picking Hemophilia Dry nasal mucosa/ Irritants Thrombocytopenia Tumors Medications (anticoagulants/antihistamin es/antihypertensives/anti- inflammatories) Medications (nasal steroids) Foreign body Allergic rhinitis/sinusitis Hypertension / Aspirin! Systemic infection Recreational drugs Alcohol smoking Systemic: Juvenile nasopharyngeal angiofibroma ?

Evaluation Initial Assessment History Examination Investigation Management

Initial Assessment ABCs ( Airway, Breathing, IV access) Pulse Oxymetry placed prior to the physical exam and record vitals. Unstable patients should have Intravenous (IV) catheters and fluids started. Ask the patient to blow the nose to allow clots to move out decreasing the bleeding. Sit up the patient with body tilted forward to prevent blood from going down the pharynx. Apply continuous pressure to anterior cartilaginous portion the nose for 5-10 min. If stable take a quick history.

History chronic medical conditions ( Hypertension, Liver or Kidney Disease, on regular oxygen and ventilators), Make Sure the patient is stable ! Duration of current episode, known bleeding disorders, Amount of bleeding, Medications, Location of bleeding, recent illnesses, Intermittent VS continuous, recreational drug use, recent trauma, prior surgeries, prior history and treatment, herbal medicines,

Examination Instruments necessary: nasal speculum, light source, suction, and irrigator. Inspect the turbinates and septum to identify the general condition of the mucosa and location of bleeding. Examine Oropharynx for clots ( risk of aspiration) Nasal Endoscopy for chronic, recurrent epistaxis without obvious bleeding source. Systemic examination for other causes including Neck exam and signs of bruises.

Investigations For: Do: Patients with significant bleeding, known liver or renal disease, or on anticoagulation therapy. Do: complete blood count (CBC), Type and cross match, Prothrombin (PT)/partial thromboplastin time (PTT)/ bleeding time , Liver function tests and Creatinine. Patients with recurrent, unexplained epistaxis should be evaluated for a hereditary bleeding disorder. The most common one associated with epistaxis is von Willebrand factor (vWF).

Management Correct hypovolemia ( 3:1 role: for every loss of 100ml blood replace by 300ml crystalloid fluid) If hypertensive control with antihypertensive carefully. If known bleeding disorder, replace by appropriate blood component.

Apply vasoconstrictive ( Phenylephrine, oxymetazoline [ Afrin ] ) and if necessary, Local anesthetic agents ( Lidocaine ) either directly or on a nasal pledge. If minor Bleeding and stopped afterwards, Chemichal Cauterization ( silver nitrate) can be used for localized bleeding. Topical hemostatic agents as Gelfoam, surgicel, floseal can be placed that provides procoagulant effect after cauterization attempts. ( nasal spray is needed for several days to allow resorption).

If bleeding is still active, Nasal Packing is preformed. Anterior Nasal Packing: Nasal Tampons and extendable sponges; provide pressure against nasal mucosa Vaseline Strep-Gauze; placed to posterior choanae, controls most posterior bleeds, Placed for 3-5 days, provided with anti- staphylococcal antibiotics. Posterior Nasal Packing: Foley catheter, pneumatic nasal catheter or posterior packing is placed. Nasal Balloons; ( 2 balloons one in nasopharynx and other in nasal cavity) is advisable Packing of both sides or posterior packing is an indication for Hospital admission!! Call and otolaryngologist!!!

If bleeding persists; In Summery: Posterior packing. Endoscopic cautery. Endoscopic clipping of the sphenopalatine artery. Transantral ligation of internal maxillary artery. Angiograpgy with embolization. In Summery: Squeeze - Look & Cauterize - Anterior Pack - Balloon - Posterior pack - Surgery or Embolization.

Typical contents of an epistaxis tray Typical contents of an epistaxis tray. Top row: nasal decongestant sprays and local anesthetic, silver nitrate cautery sticks, bayonet forceps, nasal speculum, Frazier suction tip, posterior double balloon system and syringe for balloon inflation. Bottom row: Packing materials, including nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel, Gelfoam, and suction cautery.

Anterior Nasal packing Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum (not shown) used for exposure, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is filled.

Posterior Nasal Packing Posterior nasal packing. A. After adequate anesthesia has been obtained, a catheter is passed through the affected nostril and through the nasopharynx, and drawn out the mouth with the aid of ring forceps. B. A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth. C. The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block (not shown) to protect the physician’s finger. D. The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The ties protruding from the mouth, which will be used to remove the pack, are taped to the patient’s cheek.

Nasal Balloon Packing

Complications Complications may occur as a result of any treatment intervention and include: Infection (localized or spread into surrounding tissues), Abscess formation, Septal Necrosis, Septal hematoma, Septal perforation.

Questions ?

Take Home Messages Most common (90%) site of bleeding is Anterior bleeds from Little’s area ( Kiesselbach’s plexus) Most common cause of epistaxis in children is nasal picking (trauma) and dry mucosa and viral URTIs with frequent nose blowing. Systemic illness and medications are important causes of nose bleeding in Adults. Check ABCs and Stabilize the patient first! “Blow your nose”, “Sit up and tilt forward” and apply CONTINOUS pressure for 5-10 min.

Tips to prevent a nosebleed: Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Keep children’s fingernails short to discourage nose- picking. Counteract the effects of dry air by using a humidifier. Use a saline nasal spray to moisten dry nasal membranes. Quit smoking. Smoking dries out the nose and irritates it. Tips to prevent rebleeding after initial bleeding has stopped: Do not pick or blow nose. Do not strain or bend down to lift anything heavy. Keep head higher than the heart.

Admit the person to hospital if: Epistaxis continues despite efforts to stop the bleeding. Bleeding from the posterior area of the nose is suspected. A nasal pack has been inserted in primary care. Consider admission to hospital if the person is elderly or has a comorbid condition (such as coronary artery disease, severe hypertension, clotting disorder, or significant anemia).

Use clinical judgment and consider referral in the following groups: Consider referral to ORL specialist if the person has recurrent episodes and is at high risk of having a serious underlying cause, Use clinical judgment and consider referral in the following groups: Males 12–20 years of age — angiofibroma is possible (but rare). People with any symptoms suggestive of cancer — such as nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), or palpable neck glands. People with a family history of hereditary haemorrhagic telangiectasia and suggestive features upon examination — telangiectasia on the lips, mucous membranes, and fingers. People with occupational exposure to wood dust or chemicals as they are prone to nasopharyngeal cancer.

Thank you  References: Books: Primary care otolaryngology. Taylor’s Manual of family Medicine. Otolaryngology head and neck surgery by Raza Pasha,MD Websites: http://www.entnet.org/EducationAndResearch/cool.cfm http://www.cks.nhs.uk/epistaxis/management/scenario_recur rent_epistaxis/referral