Epistaxis

PRE-OPERATIVE( October 3, 2013 )

PGI Josh Matthew Rosales

General Data

• H.C.• 59 years old• Male• Married• Farmer• Brgy. Minoyan, Murcia, Negros Occidental

Chief Complaint

• Epistaxis

HISTORY OF PRESENT ILLNESS

• 47 years PTA, noted 1st episode of epistaxis • 9 years PTA, recurrence of epistaxis

episodes(1-2 episodes yearly)

HISTORY OF PRESENT ILLNESS• 1 month PTA, noted epistaxis(massive) with

hematemesis admitted as a case of UGIB

• 1 day PTA, noted sudden episode of epistaxis upon lifting a 5kg object

• On the day of admission, another episode of epistaxis, did not resolve opted consult admission

Past Medical History• (-) DM• (-) BA• (-) thyroid problems• (-) hypertension• (-) past hospitalizations; (-) trauma• (+) excision of cyst, supraauricular, Right• (+) food allergies: crustaceans, chicken,

egg, oily foods• (-)drug allergies

Family History

• (-) DM• (-) Hypertension• (-) Thyroid problems• (-) Blood dyscrasia• (-) epistaxis

Personal and Social History

• Married, with 4 children• Farmer• Nonsmoker• Nonalcoholic Beverage drinker

PHYSICAL EXAMINATION

Unremarkable

Unremarkable Unremarkable

ENT PHYSICAL EXAMINATION

Flexible Nasolaryngoscopy

CT SCAN

ASSESSMENT

Epistaxis, etiology to be determined

DISCUSSION

Preoperative

EPISTAXIS

Flint et al. Cummings Otolaryngology Head and Neck Surgery:5th Edition. Philadelphia: 2010

EPISTAXIS

• most common otolaryngologic emergency• etiology in the majority of patients is

idiopathic, followed by primary neoplasms and traumatic or iatrogenic causes

• management ranges from resuscitation, through direct visualization and cautery, nasal packing, and surgery to embolization.


ANATOMY

• The anterior nasal septum is the site of a plexus of vessels called Little’s or Kiesselbach’s area

Terminal branches of the external and internal carotid arteries supply the mucosa of the nasal cavitywith frequent anastomoses between these systems

ANATOMY

• External carotid artery supplies the nasal cavity via:• facial artery supplies the superior labial artery,

(supplies the anterior nasal septum)

• internal maxillary artery(courses within the pterygopalatine fossa) terminates in the sphenopalatine, descending palatine, pharyngeal, infraorbital, and posterior superior alveolar arteries

ANATOMY

•Sphenopalatine artery enters the nasal cavity through the sphenopalatine foramen and then divides into conchal (posterior-lateral) and septal (posteriormedial) branches.

•The internal carotid artery supplies the nasal mucosa via the ethmoidal branches of the ophthalmic artery.

Management

• The amount of blood loss should be estimated and over what period

• A clinical assessment of the patient’s cardiac status and circulating blood any of findings that would indicate significant hypovolemia)


Management• Obtaining intravenous access, checking for

and correcting any clotting abnormalities, and taking blood for “group and save” and/or crossmatching may be required.

• First aid measures: applying constant firm pressure over the lower (non-bony) part of the nose for 20 minutes; lean forward with the mouth open over a bowl so that further blood loss can be estimated.


Management

APPROACH1. Establish the site of bleeding.2. Stop the bleeding.3. Treat the cause.


Etiology—Selected Causes of EpistaxisLocal CausesIdiopathic—spontaneousTrauma: Nose picking Foreign body Nasal oxygen and continuous positive airway pressure Nasal fractureInflammatory/infectious: Common cold, viral rhinosinusitis Allergic rhinosinusitis Bacterial rhinosinusitis Granulomatous diseases (Wegener’s granulomatosis, sarcoid, tuberculosis) Environmental irritants (cigarette smoking, chemicals,pollution, altitude)Postoperative—iatrogenic: Nasal surgery Primary neoplasm: Hemangioma of the septum, turbinates Hemangiopericytoma

Nasal papilloma Pyogenic granuloma Angiofibroma Carcinoma and other nasal malignanciesStructural: Septal deformity, spurs Septal perforation Drugs: Topical nasal steroids Cocaine abuse Occupational substances

General Disorders, Systemic CausesHypertension (not more common, but more troublesome)ArteriosclerosisPlatelet deficiencies, dysfunction; coagulopathies (e.g., warfarin,liver disease)Leukemia, von Willebrand’s diseaseHereditary hemorrhagic telangiectasiaOrgan failure (liver, kidney)

Headlamp Examination Using Local Anesthesia

• The key to controlling most epistaxis is to find the site of the bleeding, and although chemical cautery with silver nitrate can be used, bipolar diathermy is more effective for stopping the bleeding.

• Once the clots have been sucked out, the nasal airway should be inspected, initially with a headlamp and then, if the bleeding point cannot be located, with an endoscope.


Epistaxis in Children• Young children usually bleed from a vessel

just inside the nose at the mucocutaneous junction on the septum, and the bleeding invariably stops spontaneously.

• Those who have leukemia or are undergoing chemotherapy often have epistaxis associated with thrombocytopenia.


Epistaxis in Adults

• The caudal end of the septum, where several branches of the external and internal carotid anastomose in Little’s area or Kiesselbach’s plexus, is the most common site of bleeding in adults.

• Less commonly bleeding,comes from further back on the septum, and a septal deviation may make it difficult to visualize


Epistaxis in Adults

• The association between hypertension and epistaxis is disputed

• Nosebleeds in patients with hypertension are more likely to lead to admission and to be associated with comorbidity

• A range of drugs has been linked with epistaxis: warfarin, aspirin, clopidogrel, and nonsteroidal antiinflammatory drugs


Epistaxis in Adults• In over-anticoagulated patients, fresh frozen

plasma, clotting factor extracts, and vitamin K help.

• In patients who do not have a history of a bleeding disorder or undergoing anticoagulant therapy, routine clotting studies do not add to the management


Topical Treatment

• A randomized controlled trial of silver nitrate cautery with topical antiseptic nasal carrier cream versus topical alone showed both to be effective.

• Collagen-derived particles with bovine-derived thrombin have been found to be better than nasal packs


Cautery• Most anterior epistaxis can be controlled

with identification of the bleeding point and cautery using a headlamp.

• The vast majority of posterior bleeding sites can be identified by endoscopy without the use of general anesthesia.

• The majority of posterior idiopathic bleeds are from the septum, usually from the septal branch of the sphenopalatine artery


Cautery• When the site of bleeding cannot clearly be

identified with a headlamp, the use of a rigid nasal endoscope by an experienced endoscopist is best.

• The key is to identify the site of the bleeding and gain control using silver nitrate cautery or bipolar suction diathermy.

• After cautery the patient should be advised against blowing the nose for about 10 days to allow the area to heal


Cautery

• Packing of the nose before endoscopy can complicate detection of the exact site of bleeding, because packing often causes mucosal trauma and misleads

• Rarely, nasal tumors can manifest as epistaxis, so it is important to check for a nasal mass, especially beyond a septal deviation.


Nasal Packing• If a bleeding point cannot be found, ideally

the nose is packed with an absorbable hemostatic agent that produces minimal mucosal trauma

• If an anterior pack fails and there is no access to an experienced surgeon , more packing to tamponade the bleeding point may be required.

• The role of prophylactic systemic antibiotics in patients who have nasal packs is not well establishedFlint et al. Cummings Otolaryngology Head and Neck Surgery:5th Edition. Philadelphia: 2010

Nasal Packing

• If the patient does not experience rebleeding within 12 to 24 hours, the packs should be removed.

• The nose should be inspected with a rigid endoscope to exclude any disease that may have been responsible for the bleeding.


Maxillary Artery Ligation• Another technique to control posterior

epistaxis is ligation of the internal maxillary artery in the pterygopalatine fossa.

• Reported success rate of approximately 90%.• Treatment failures are due to the difficulty in

finding the artery and its branches. • Complications: sinusitis, facial pain, oroantral

fistula, and facial, dental paresthesia


Endoscopic sphenopalatine artery ligation(ESPAL)

• If bleeding cannot be controlled after endoscopic examination and cautery and/or nasal packing, examination with use of either a general anesthetic or a local anesthetic with sedation is indicated.

• diathermy of any bleeding points or ESPAL is the treatment of choice

• Clipping or diathermy of the sphenopalatine artery is now the accepted treatment for management of persistent posterior epistaxis


Endoscopic sphenopalatine artery ligation(ESPAL)

• Various reports have claimed success rates for ESPAL between 92% and 100% in controlling epistaxis.

• Failure to clip all the branches of the sphenopalatine artery may be the reason for continued epistaxis after the procedure.


Embolization• Arterial embolization has been shown to be

effective in the treatment of intractable epistaxis.

• Complications: cerebrovascular accident, hemiplegia, ophthalmoplegia, facial nerve palsy, seizures, and soft tissue necrosis.

• Embolization technique is effective mainly for the external carotid artery supply and very dangerous for the internal carotid supply


Hot Water Irrigation • Hot water irrigation as a noninvasive

treatment for posterior epistaxis has received some renewed attention

• Experiments showed that irrigating the nose at 40° to 46°C does not lead to any histologic changes of the mucosa and those higher than 46°C result in vasodilatation and, in particular, edema of the mucosa. local compression of blood vessel and propagate cascade for hemostasis


Summary• The role of rigid nasal endoscopy as part of

the initial assessment of epistaxis, with direct visualization and control of the bleeding point, is effective in the majority of patients and reduces the need for nasal packing.

• Endoscopic sphenopalatine artery ligation is well established as the treatment of choice when cautery and nasal packing fail.


THANK YOU.

Epistaxis

Documents

Transcript of Epistaxis