EPISTAXIS

Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist. Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground” A condition with a long history—Hippocrates to Henry Goodyear.

Anatomy/Physiology of Epistaxis Nasal cavity Vascular supply Physiology Vascular nature Mucosa

Why bleeding from the nose ? Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa (not squamous) Arterial to venous anastamoses ICA and ECA blood flow

Anatomy of the Lateral Nasal Wall SPF -class I (35%) -class II (56%) -class III (9%) Anatomy of the Lateral Nasal Wall

External Carotid Artery -Sphenopalatine artery -Greater palatine artery -Ascending pharyngeal artery -Posterior nasal artery -Superior Labial artery Internal Carotid Artery -Anterior Ethmoid artery -Posterior Ethmoid artery

Pterygopalatine Vasculature --Internal maxillary artery

Anatomy of the Nasal Cavity and Vasculature

Sphenopalatine AA Ethmoid AA Greater Palatine A

Kesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX) Woodruff’s Plexus: -Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

Anterior vs. Posterior Maxillary sinus ostium Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe Posterior: older population, usually from Woodruff’s plexus, more serious.

Etiology Local factors Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Dessication Foreign Bodies/other

Etiology Systemic factors Vascular Infection/Inflammation Coagulopathy

Local Factors -- Vascular ICA Aneurysms extradural cavernous sinus

Local Factors - Infection/Inflammation Rhinitis/Sinusitis Allergic Bacterial Fungal Viral

Local Factors - Trauma Nose picking Nose blowing/sneezing Nasal fracture Nasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle ear, base of skull Barotrauma

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal injury Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction

Local Factors - Neoplasm Juvenile nasopharyngeal angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Esthesioneuroblastoma Lymphoma

Local Factors – Dessication Cold, dry air—more common in wintertime Dry heat—Phoenix and Death valley Nasal oxygen Anatomic abnormalities Atrophic rhinitis

Local Factors - Other Self-inflicted (pedi) vs. traumatic foreign bodies Intranasal parasites Septal perforation Chemical (cocaine, nasal sprays, ammonia, etc.)

Systemic Factors -- Vascular Hypertension/Arteriosclerosis Hereditary Hemorrhagic Telangectasias (OWR)

Systemic Factors – Infection/Inflammation Tuberculosis Syphillis Wegener’s Granulomatosis Periarteritis nodosa SLE

Systemic Factors – Coagulopathies Thrombocytopenia Platelet dysfunction Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal supplements) Clotting Factor Deficiencies Hemophilia VonWillebrand’s disease Hepatic failure Hematologic malignancies

Etiology and Age Children—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o) Adults—trauma, idiopathic Middle age—tumors Old age--hypertension

Initial Management ABC’s Medical history/Medications Vital signs—need IV? Physical exam Anterior rhinoscopy Endoscopic rhinoscopy Laboratory exam Radiologic studies

bayonet forcepts vaseline gauze suction T.C.A. bacitracin gelfoam good light anesthetic Afrin epistat endoscopes silver nitrate merocels suction bovie/bipolar surgicel

Non-surgical treatments Control of hypertension Correction of coagulopathies/thrombocytopenia FFP or whole blood/reversal of anticoagulant/platelets Pressure/Expulsion of clots Topical decongestants/vasocontrictors Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie) Nasal packing (effective 80-90% of time) Greater palatine foramen block

Non-surgical treatments – on d/c Humidity/emolients Discontinue offending meds Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining/bedrest

Nasal packs Anterior nasal packs Posterior nasal packs Traditional Recent modifications Posterior nasal packs Ant/Post nasal packing

Pick a Pack, any pack

Pick a pack to pack with

TSS—Nugauze vs. Merocel Electron microscopy

Posterior Packs – Admission Elderly and those with other chronic diseases may need to be admitted to the ICU Continuous cardiopulmonary monitoring Antibiotics Oxygen supplementation may be needed Mild sedation/analgesia IVF

Indications for surgery/embolization Continued bleeding despite nasal packing Pt requires transfusion/admit hct of <38% (barlow) Nasal anomaly precluding packing Patient refusal/intolerance of packing Posterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

Selective Angiography/embolization Helps identify location of bleeding Embolization most effective in patients who Still bleeding after surgical arterial ligation Bleeding site difficult to reach surgically Comorbidities prohibit general anesthetic Effective only when bleeding is >.5 ml/min 90+% success rate, complication rate of 0.1% Only able to embolize external carotid & branches Complications: minor (18-45%)/major (0-2%) Contraindicated in bad atherosclerosis, Ethmoid bleed

Surgical treatment Transmaxillary IMA ligation Intraoral IMA ligation Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation External carotid artery ligation Septodermoplasty/Laser ablation

Transmaxillary IMA ligation Waters view Caldwell-Luc Electrocautery of posterior wall before removal Microscopic dissection and ligation of IMA --descending palatine & sphenopalantine most important Recurrence rate (failure rate) of 10-15% Complication rate of 25-30% (oa fistula,dental, n)

Intraoral IMA ligation Posterior gingivobuccal incision beginning at second molar Temporalis mm split and partially dissected IMAX visualized, clipped and divided Advantages: children/facial fractures Disadvantages: more proximal ligation Complications: trismus, damage to infraorbital n

Ant./Post. Ethmoidal ligation Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear Lynch incision Fronto-ethmoid suture line 12-24-6 (14-18, 8-10, 4-6)

Transnasal Endoscopic Sphenopalatine Artery ligation Follow Middle Turbinate to posteriormost aspect Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs) Elevation of flap—ID neurovascular bundle at foramen Ligation with titanium clip Reapproximate flap Complications –few, Failures—0-13%

Transnasal Spheno-palatine Artery ligation

ECA ligation Effectiveness Anterior border of SCM ID ECA/ICA Ligation after clear that surrounding structures are safe.

Septodermoplasty/Laser Remove mucosa from anterior ½ septum, floor of nose, lateral wall STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease Still bleed, but not as bad Definitive treatment (severe disease)—closure of nose

Statistically speaking,…. Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs. Others compared all medical treatment to surgery and showed cost cut using medical management. Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28% Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equal Failure rates: PP-30%, Sx-17%, Emb-4%

Tips and Pearls Red rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more (not on both sides of septum) Antihistamines to prevent rebleeds Cautery does not work with no platelets/clotting Glove packing H2O2 Merocels (2 or more) injected with cortisporin otic Amicar spray

Tips and Pearls Hot water irrigation Cold water irrigation Salt Pork Don’t pack nose in unconscious person with suspected skull fractures. Antibiotic cream vs. silver nitrate Intranasal pressure Estrogen cream to nasal septum

Tips and Pearls Transnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed) Submucosal supraperichondrial dissection of nasal septum Not all hospitals have embolization-trained interventionalists No hard-set outline. Do what is best for your particular patient

CASE REPORT 45 yo Vietnamese fisherman--stable, but uncomfortable Profuse nasal bleeding since 0200 this a.m. History: No known medical problems. Drinks 6-12 beers/day. Takes no medications. No history of easy bleeding. No family history. Physical exam: Profuse bleeding from both nostrils L>R and bleeding down the back of his throat—coughing up clots. Unable to locate precise location of bleed—appears to be posterior/superior.

Case 1 – cont’d Hgb 12.5 Lactated Ringers IVF bolus Nasal packs – removed two days later in the clinic,…rebleeds. Requires transfusion for Hgb of 6.5 Angiography—no obvious bleed/Embolization Ant/Post Ethmoid Artery ligation