Epistaxis(nosebleed)

Classification I. According to site

• Anterior• Superior; Anterior ethmoid ( bleeding is

from above ant. half of middle turbinate)• Inferior; Greater palatine,• Posterior; Sphenopalatine (Bleeding is

from below anterior half of middle turbinate

II. Primary & secondary

Ⅲ. According to Age• Children:

– Foreign body, nose picking ,nasal diphtheria.

• Adults: – Trauma, idiopathic.

• Middle age:– tumors.

• Old age: – hypertension.

etiological factor of nose bleed

1 local cause:• trauma• inflammation• tumor• deviated nasal septum 2 systom reason

Aetiology Local Causes Trauma

– Nose picking, – Fractures (nasal bone, sinuses and/or skull base)– Nasal intubation– SurgeryInfections

● Fungal infection ● Suppurative sinusitis ● Influenza, Measles,Diphtheria,Tuberculosis ● Atrophic rhinitis

Local Causes• Septum disorder (deviated nasal septum )-

spur,perforation.

• Foreign body.

.

Local Causes• Neoplasms of

the nose, nasopharynx and sinuses

Carcinom of the Nasopharynx

Angiofibroma

Hemangioma

General Causes• Acute infectious disease - Influenza,measles,diphtheria,malaria, typhoid,et al.• Cardiovascular disease - Hypertension, - Atherosclerosis, - Osler-Weber-Rendu disease• Blood clotting problem - Haemophilia, purpura, leukemias, aregenerative anemia,et al.

General General CausesCauses

Osler-Weber-Rendau‘s syndrome

General Causes• Vitamin C ,P & K deficiencies.• Severe liver & kidney disease.• Drugs – prescribed - Anticoagulants - Warfarin / Heparin.

- Aspirin- platelet function inhibitor.

• Toxicosis • Vicarious menstruation -during the period.

Environmental reason

• High altitudes

(drier and lower atm. pressure)

• Air-conditioning

• Extreme changes in temperature

Idiopathic

• “Spontaneous” is a better description.

• Usually initiated by minor ‘digital’ trauma.

• Often associated with atmospheric drying.

AnatomyAnatomy

ICA (branches of ophthalmic)Anterior ethmoid – supplies lateral wall of nose, nasal septum, nasal tipPosterior ethmoid – posterior lateral wall of nose, superior turbinate and sup septum

ECA (branches of internal maxillary)sphenopalatine – supplies the posterior septum, poste-rior middle and superior turbinatesDescending palatine – lower midseptumSuperior labial (facial artery) anterior septum

Blood supply of nasal cavity

External carotid

Internal maxillary a.

Anterior & posterior ethmoidal a.

sphenopalatine a.

Great palatine a.

Vessels Involved

• Anterior ethmoid a.

• Posterior ethmoid a.

• Greater palatine a.

• Sphenopalatine a.

• Superior labial a.

Internal carotid

External carotid

Sites of bleeding

• Nasal Septum - Little’s Area 90% of epistaxis from this site.- Rest of septum

spurs,perforation ,etc

Little’s area

Confluence of :– Anterior Ethmoidal a.– Greater Palatine a.– Sphenopalatine a.– Sup. Labial a.

Sites of bleeding

• Posterior nasal cavity - Woodruff’s plexus - artery often due to hypertensionoften due to hypertension

severe

FIRST AID–Make the patient sit up, pinch or

press nose, open mouth and breath.

– Ice on forehead.

Management

5 minute pressure

correctIncorrect

CAUTERIZATION1) Chemicals• Silver Nitrate stick, • Chromic acid bead.2) Electrical• Apply ointment and advise against

blowing and nose picking.

Anterior Pack• For active anterior epistaxis.• Keep for 24-48 hours.• Antibiotics if for more than 24 hrs.

SEDATION

Anterior pack

Anterior Pack

PVA foam packs are usually packaged sterile. The foam is compressed to provide smaller packs for easier insertion into tiny areas without pain. The expansion of the compressed foam produces gentle pressure on the mucosa

and provides both active and passive absorption.

Posterior Pack

Posterior packing if bleed is posterior.

posterior pack

① ③② ④

packingpacking

OTHER TREATMENTS

• Ligation of vessels – Maxillary artery– Ethmoid arteries– External Carotid artery

• Embolization-DSA• Blood transfusion• Treatment of primary affection

Management protocolManagement protocol