EPISTAXIS

Morgan Yost DONRMC – Kirksville, MO

OGME-411/27/2012

Introduction and History5-10% 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.

Anatomy/Physiology of EpistaxisAnatomy

Nasal cavityVascular supply

PhysiologyVascular natureMucosa

Anatomy of the Lateral Nasal Wall

Anatomy of the Nasal Cavity and Vasculature

External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Posterior nasal artery

-Superior labial artery

Internal Carotid Artery

-Anterior ethmoid artery

-Posterior ethmoid artery

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 A of Sphenopalatine A (IMAX)

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

EtiologyLocal factors

VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDesiccationForeign Bodies/other

Local Factors - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction

Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma

Local Factors – Desiccation

Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis

Systemic Factors – Coagulopathies Thrombocytopenia

Platelet dysfunctionSystemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure

Hematologic malignancies

Etiology and AgeChildren—foreign body, nose pickingAdults—trauma, idiopathicMiddle age—tumorsOld age--hypertension

Initial ManagementABC’s

Medical history/Medications

Vital signs—need IV?

Physical examAnterior rhinoscopy

Endoscopic rhinoscopy

Laboratory exam

Radiological studies

suction

good lightanesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

surgicel

epistat

bayonet forcepts

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. Bipolar vs. Bovie)

Nasal packing (effective 80-90% of time

Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest

Nasal packsAnterior nasal packs

Traditional

Posterior nasal packsTraditional

Ant/Post nasal packing

Pick a Pack, any pack

Indications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of <38%Nasal anomaly precluding packingPatient refusal/intolerance of packingFailed medical mgmt after >72hrs

Surgical treatment

Transmaxillary IMA ligation

Intraoral IMA ligation

Anterior/Posterior Ethmoidal ligation

Transnasal Sphenopalatine ligation

External carotid artery ligation

Tips and PearlsDon’t pack nose in unconscious person with suspected skull fractures.Oral antibiotics and pain meds while pack in placeAntibiotic cream, humidificationEstrogen cream to nasal septumSmoking cessation

Just for fun…