Epistaxis Col Ämer Sabih Hydri Head of ENT Department M.H Rawalpindi

Why nose? Situated in a vulnerable position as it protrudes on the face Has a very rich blood supply Vasculature runs just under the mucosa Exposed to the drying effect of inspiratory current

Epidemiology Lifelong incidence of epistaxis in general population is about 60% Fewer than 10% seek medical attention Peaks in young children (2 – 10 y) and older individuals (50 – 80 y) Males 58%, females 42%

Blood Supply Superior part of the nose (Internal carotid artery) ▫Ophthalmic artery  Anterior ethmoidal artery  Posterior ethmoidal artery Inferior part of the nose (External carotid artery) ▫Maxillary artery  Greater palatine artery  Sphenopalatine artery ▫Facial artery  Superior labial artery  vestibule of the nose

Kiesselbach’s Plexus Little’s area Anteroinferior part of the nasal septum Anastomosis between upper and lower arteries ▫Anterior ethmoidal artery ▫Posterior ethmoidal artery ▫Sphenopalatine artery ▫Greater palatine artery ▫Septal branch of superior labial artery

Woodruff’s Plexus Lateral wall of inferior meatus Blood vessels have very little muscle tissue within their walls, therefore hemostasis is poor Anastomosis between: ▫Pharyngeal artery ▫Posterior nasal artery ▫Sphenopalatine artery ▫Posterior septal artery

Pathophysiology Occurs when mucosa is eroded Vessels become exposed and subsequently break

Classification Anterior ▫90% of all cases of epistaxis ▫Kiesselbach’s plexus ▫Younger population ▫Typically less severe ▫A constant ooze, rather than profuse pumping of blood

Posterior ▫Woodruff’s plexus ▫Older population ▫Profuse, prolonged and more difficult to control ▫Associated with bleeding from both nostrils ▫Greater flow of blood into the mouth ▫Greater risk of airway compromise and aspiration of blood

Etiology Most are idiopathic Local causes ▫Spontaneous ▫Trauma  Nose picking/blowing, sneezing, fractures, barotraumas ▫Foreign bodies ▫Iatrogenic  FESS, rhinoplasty, nasal cannula ▫Inflammation/infection ▫Tumors  Polyps, nasopharyngeal carcinoma/angiofibroma ▫Hereditary telengiectasia ▫Leech infestation

Systemic causes ▫Cardiovascular conditions  Hypertension  Increased venous pressure  Mitral valve stenosis, heart failure, mediastinal tumors ▫Coagulopathies  Hemophilia, von Willebrand’s disease  Hepatic cirrhosis  Anticoagulant therapy  Thrombocytopenia ▫Fever (rare)  Influenza ▫Drugs  NSAIDs, aspirin, coumadin, warfarin, isotretinoin, etc

▫Infection  Tuberculosis, syphilis ▫Alcohol ▫Anemia ▫Uremia ▫Connective tissue disorders  SLE ▫Hematological malignancy ▫Vasculitis  Wegener’s granulomatosis ▫Vitamin C or K deficiencies ▫Osler-Weber-Rendu syndrome ▫Pregnancy ▫Vicarious menstruation

History Age Onset, duration, severity, frequency Bilateral or unilateral Preceding factors: exercise, sleep, migraine, trauma Bleeding from other sites Aggravating and relieving factors Nasal discharge Medical conditions Current medications Smoking and drinking habits Previous epistaxis, recurrent bleeding, easy bruising Family history of bleeding disorders

Physical Examination Vital signs Nasal cavity ▫Vasoconstrictor to reduce hemorrhage and pinpoint bleeding site ▫Topical anesthetic to reduce pain ▫Clots are suctioned out ▫Nasal speculum Fiberoptic endoscopy (rigid or flexible) Skin examination

Management Control significant bleeding or hemodynamic instability before obtaining a lengthy history Steps: ▫First aid and resuscitation ▫Assess blood loss ▫Localize bleeding ▫Control bleeding ▫Prevention

First Aid & Resuscitation Address ABC Patient sits upright or leans forward Neck should not be hyperextended to prevent blood flow into the stomach or possible aspiration Blood in mouth should not be swallowed Mouth breathing Direct pressure over the cartilaginous part of the nose 5 – 10 minutes is usually sufficient Gauze moistened with epinephrine may be placed to promote vasoconstriction

Vital signs and signs of shock Patient with significant hemorrhage should receive an IV line and crystalloid infusion Cross match for 2 units packed RBC Continuous cardiac monitoring and pulse oximetry

Localization of Bleeding Pledgets soaked with anesthetic-vasoconstrictor solution are inserted into the nasal cavity to anesthetize and shrink nasal mucosa Allow them to remain for 10 – 15 minutes Visualize cavity with speculum + good light source Aspirate excess blood and clots If the bleeding originated from Little’s area, it is clearly visible

Rigid endoscope is used to localize posterior bleeding ▫Superior optics ▫Allow endoscopic suction and cauterization Points suggesting posterior source: ▫Anterior surface cannot be visualized ▫Bilateral bleeding ▫Constant dripping of blood in the posterior pharynx ▫Bleeding in the pharynx with the anterior nasal packing in place

Control of Bleeding Topical vasoconstrictors ▫Otrivin (xylomethazoline) ▫Cocaine Chemical cauterization with silver nitrate stick ▫Rolled over mucosa until a grey eschar forms ▫Only one side should be cauterized to prevent septal necrosis or perforation Thermal cauterization with an electrocautery device for more aggressive bleeding under LA or GA

Anterior Nasal Packing Traditional petrolatum gauze filled with antibiotic ointment Success rate 85%

Expandable Merocel sponges (nasal tampons) which enlarge in the presence of moisture Coated with antibiotic and vasoconstrictor Success rate 85%

Rapid Rhino anterior balloon tampon

Posterior Nasal Packing Indications: ▫Failure of anterior packing ▫High suspicion of posterior bleeding ▫Older patient with atherosclerosis ▫Patient with bleeding diathesis Contraindications ▫Facial trauma ▫Shock ▫Altered mental status

Uncomfortable and difficulty in breathing Risk of hypoventilation and hypoxia Admission, bed rest, sedation Supplemental oxygen: ▫Elderly patients ▫Cardiac disorders ▫COPD Monitor blood pressure and hemoglobin level Control coexistent hypertension

Foley catheter

Double-balloon catheter

Gauze method

Surgical Intervention Indications: ▫Bleeding continues despite adequate packing and resuscitation ▫Nasal anomaly (septal deviation) ▫Patient’s refusal or intolerance to packing

Arterial ligation ▫External carotid artery ▫Internal maxillary artery transorally or transnasally ▫Ethmoidal arteries Angiography and vessel embolization

Prevention Control of hypertension Correction of bleeding disorders Humidifier or vaporizers Nasal saline sprays, ointment, vaseline Avoid hard nose blowing or sneezing Sneeze with mouth open Avoid nose picking Control the use of medications

Complications Rhinosinusitis Cardiovascular compromise Septal perforation Toxic shock syndrome Hypoxia Aspiration pneumonia CVA associated with embolization Recurrent epistaxis Re-bleeding on nasal pack removal

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