EPISTAXISEPISTAXIS

ByBy

Mohammed HusseinMohammed Hussein

OverviewOverview

OverviewOverview

DefinitionDefinition:: Bleeding from inside the noseBleeding from inside the nose

OverviewOverview 5-10% of the population experience an 5-10% of the population experience an

episode of epistaxis each year. 10% of those episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking will see a physician. 1% of those seeking medical care will need a specialist.medical care will need a specialist.

Epistaxis in children younger than 2 years of Epistaxis in children younger than 2 years of age is infrequent, while it peaks between age is infrequent, while it peaks between ages 3-8 years. ages 3-8 years.

Anterior Epistaxis is more common in Anterior Epistaxis is more common in children & young adults.children & young adults.

Posterior Epistaxis is more common in older Posterior Epistaxis is more common in older adults with hypertension & arteriosclerosis.adults with hypertension & arteriosclerosis.

Incidence is higher in winter months & hot Incidence is higher in winter months & hot dry climate with low humidity.dry climate with low humidity.

Anatomy

Arteries of the nasal septum. The arterial supply of the nasal septum arises from branches of the external carotid artery (black) and the internal carotid artery (blue). Kiesselbach’s plexus is formed by the sphenopalatine artery, greater palatine artery, superior labial artery, and anterior ethmoid arteries.

Arteries of the lateral nasal wall. The arterial supply of the lateral nasal wall arises from branches of the external carotid artery (black) and the internal carotid artery (blue).

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)

Little’s area or Kiesselbach’s plexus is the commonest site of nose bleeds

EtiologyEtiology Local causesLocal causes:: Idiopathic:Idiopathic: 90% 90% Traumatic:Traumatic: foreign body, blow to the nose, fracture foreign body, blow to the nose, fracture

nasal bone, fracture anterior cranial fossa, after nasal bone, fracture anterior cranial fossa, after operationsoperations

Inflammatory:Inflammatory: rhinitis, sinusitis rhinitis, sinusitis Neoplastic:Neoplastic: Benign: Benign: Papiloma ,Angiofibroma Papiloma ,Angiofibroma Malignant :Malignant :Squamous cell Ca, adeno Ca, adenoid Squamous cell Ca, adeno Ca, adenoid

cystic Ca, olfactory cystic Ca, olfactory neuroblastoma ,melanoma ,lymphomaneuroblastoma ,melanoma ,lymphoma

Hereditary haemorrhagic telangectasiaHereditary haemorrhagic telangectasia Nasal septal deviation, spurs, and perforations cause Nasal septal deviation, spurs, and perforations cause

turbulent airflow, which can lead to mucosal drying turbulent airflow, which can lead to mucosal drying and bleeding and bleeding

shows a foreign body of long standing on the right side of a patient’s nose.  The black arrow points to a foreign body mass:

RhinolithRhinolith

Septal hemangioma. a A vascular sessile polyp is seen on the septum (hemangioma), which is the cause of severe, recurrent bleeds. Treatment is by excision, or cautery if the lesion is small

Hereditary nasal teleangiectasia

Squamous cell carcinoma ofthe nasal vestibule

Carcinoma of the nasal septum.

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A 16-year-old boy presents with nasal obstruction and heavy epistaxis. What rare condition must be excluded? How ?

AnswerAnswer • Nontraumatic, severe unilateral epistaxis

in a teenage boy is juvenile nasopharyngeal angiofibroma until proven otherwise.

• The epidemiologic profile, endoscopic appearance, and imaging findings should lead to a correct diagnosis.

• A routine biopsy should be avoided when this lesion is suspected due to the risk of severe hemorrhage.

The angiofibroma of male puberty is a rare vascular malformationin the postnasal space, which may become extremely large, presenting with nasal obstruction and epistaxis.

EtiologyEtiology General causes:General causes: Bleeding disorders.Bleeding disorders.

A.A. CoagulopathiesCoagulopathiesB.B. Platelet disordersPlatelet disordersC.C. Blood vessel disordersBlood vessel disordersD.D. Hyperfibrinolysis .Hyperfibrinolysis .

Drugs.Drugs.1.1. AspirinAspirin2.2. AnticoagulantsAnticoagulants3.3. ChloramphenicolChloramphenicol4.4. MethotrexateMethotrexate5.5. ImmunosuppressantImmunosuppressant6.6. AlcoholAlcohol

EtiologyEtiology Cardio vascular:Cardio vascular: HypertensionHypertension Mitral stenosisMitral stenosis Hepatic :Hepatic : Liver cirrhosisLiver cirrhosis Liver failureLiver failure Fevers :Fevers :

EtiologyEtiology

Epistaxis may be the first sign of:Epistaxis may be the first sign of: Wegener's granulomatosis, Wegener's granulomatosis, Sarcoidosis, Sarcoidosis, Lupus erythematosus, Lupus erythematosus, Malignancy, Malignancy, Syphilis, Syphilis, Leprosy, tuberculosis, Leprosy, tuberculosis, and Occupational irritants. and Occupational irritants.

InvestigationsInvestigations

1.1. Complete blood counts: Complete blood counts: Hb ,TLC, ESR ,platelet Hb ,TLC, ESR ,platelet count ,BT,CTcount ,BT,CT

2.2. Blood grouping & cross Blood grouping & cross matchingmatching

3.3. Renal function test: blood urea, Renal function test: blood urea, serum creatinine.serum creatinine.

4.4. Blood sugarBlood sugar

5.5. Liver functionLiver function

6.6. Peripheral blood filmPeripheral blood film

Investigations

InvestigationsInvestigations

7.7. Screening for coagulation disorders:-Screening for coagulation disorders:-

PT,APTT,INR, Platelet count, serum PT,APTT,INR, Platelet count, serum fibrinogen ,Fibrin breakdown fibrinogen ,Fibrin breakdown product ,von willebrand factor antigen.product ,von willebrand factor antigen.

8.8. Nasal endoscopyNasal endoscopy

9.9. CT scanCT scan

10.10. MRIMRI

11.11. Angiography.Angiography.

ExaminationExamination

For the examination, you For the examination, you needneed

• A dequate lighting, • A nasal speculum,• Frazier and • Bayonet forceps, • gloves, face mask, and eye

protection. • A 0° to 30° telescope

Treatment

Different phases of Different phases of management :management :

1.1. To asses the general To asses the general condition of the patient.condition of the patient.

2.2. To arrest the hemorrhageTo arrest the hemorrhage3.3. To treat the underlying causeTo treat the underlying cause..

Treatment

TreatmentTreatment

Asses the general conditionAsses the general condition

Asses the amount of blood lossAsses the amount of blood loss

Record the vitals :BP, pulseRecord the vitals :BP, pulse

Estimate Hb .Estimate Hb .

Treat shock or hypovolaemia.Treat shock or hypovolaemia.

TreatmentTreatment

To arrest the hemorrhage.To arrest the hemorrhage.

Pressure on the nose.Pressure on the nose.

Topical decongestants,Topical decongestants,

CauterizationCauterization

Nasal packingNasal packing

EmbolizationEmbolization

Ligation of blood vessels.Ligation of blood vessels.

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• Incorrect technique for controlling epistaxis. The pressure is over the nasal bones and ineffective.

Control of epistaxis. Firm pressure with the finger or thumb on thelateral wall of the nose opposite Little’s area on the side of the

bleeding

Cautery. If epistaxis is recurrent, cautery (which is painless with local anesthetic) to the bleeding point is necessary, either with galvanocautery or with a chemical

Correct direction for Correct direction for placement of nasal placement of nasal

packingpacking

Transnasal Spheno-palatine Artery ligation

Transnasal Spheno-palatine Artery ligation

This picture shows the anterior ethmoid artery after a clip is applied.  The black arrow shows the surgical clip and the white arrow points to a retractor holding the eye to allow access