By Stacey Singer-Leshinsky R-PAC Epistaxis By Stacey Singer-Leshinsky R-PAC

Function of the Nose Vasculature just under the mucosa. Vasculature supply originates from the ethmoid branches of the internal carotid arteries and the facial and internal maxillary divisions of the external carotid arteries. Nose bleeds are very common

Epistaxis Acute hemorrhage from the nostril, nasal cavity, or nasopharynx. Etiology includes: infection, trauma, allergic rhinitis, renal failure, nasal defects, hypertension, tumors, use of blood thinners, aspirin. History:

Epistaxis Classified by the location Can be either anterior or posterior.

Anterior Epistaxis Kiesselbach’s plexus most common. Clinical Manifestations: History Unilateral bleeding No sensation of post nasal drip Blood is bright red

Anterior Epistaxis Diagnostics Hemoglobin/Hematocrit CBC Bleeding time

Anterior Epistaxis Management: ABC Direct pressure. Pinch nostrils sit forward. Cautery- chemical, electric, thermal. Silver nitrate sticks Use of vasoconstrictors sprays. / anesthetic agents. Anterior packing Merocel: compressed sponge. Remove any clots visualized Anterior epistaxis balloons.

Anterior Epistaxis Complications of nasal packing: Septal hematomas/abscess Sinusitis Pressure necrosis

Posterior Epistaxis Usual source is the branches of the sphenopalatine artery. Bleeding occurs behind the posterior portion of the middle turbinate or posterior superior roof of the nasal cavity.

Posterior Epistaxis Clinical Manifestations: Nausea, hematemesis, anemia, hemoptysis or melena. No visualized anterior source of bleeding Post nasal drip of blood Blood is dark red Brisk arterial bleed

Posterior Epistaxis Diagnostics: Hemoglobin/ Hematocrit History of bleeding disorder

Posterior Epistaxis Management: Attempt to locate the source Vasoconstrictive/ anesthetic agents Posterior nasal packing Immediate otolaryngologist referral Prophylactic antibiotics Hospitalization and monitoring

Posterior Epistaxis Packing

Posterior Epistaxis Indications for surgery/ embolization Continued bleeding with packing Required transfusion Nasal anomaly precluding packing Patient intolerance to packing

Epistaxis Differential Diagnosis Local irritation Occupational exposure Allergies Malignancy due to systemic disease such as granulomatous disease(Wegener’s sarcoidosis) Hereditary hemorrhagic telangiectasia(Osler-Weber-Rendu syndrome) Bleeding disorders hypertension

Epistaxis Complications Sinusitis Possibility of airway obstruction Toxic shock syndrome Septal hematoma or abscess Septal perforation

Osler-Weber-Rendu syndrome Disorder of blood vessels Etiology: Genetic: Clinical manifestations: telangiectases on the lips, tongue and nasal mucosa Complications include hemorrhage