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Epistaxis Dr. Vishal Sharma. Definition & Causes Bleeding from within the nasal cavity. Causes: 1. Idiopathic (55 %) 2. Local 3. General.

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Presentation on theme: "Epistaxis Dr. Vishal Sharma. Definition & Causes Bleeding from within the nasal cavity. Causes: 1. Idiopathic (55 %) 2. Local 3. General."— Presentation transcript:

1 Epistaxis Dr. Vishal Sharma

2 Definition & Causes Bleeding from within the nasal cavity. Causes: 1. Idiopathic (55 %) 2. Local 3. General

3 Local causes (nose & P.N.S.) Congenital: hereditary telengiectasia Trauma: nose picking, injury to nose / face / skull base, nasal surgery, foreign body Infection: vestibulitis, sinusitis, atrophic rhinitis, rhinosporodiosis, rhinoscleroma Neoplasms: angiofibroma, hemangioma, inverted papilloma, malignancy Deviated nasal septum (spur)

4 General causes Hypertension Bleeding disorders: haemophilia, thrombocytopenia, leukemia Drugs: aspirin, anticoagulants Physiological: cold + dry climate, high altitude, vicarious menstruation, violent exertion, barotrauma Liver failure Exanthematous fevers

5 Common causes of epistaxis Child: nose picking, foreign body, exanthematous fever Adolescent: nasopharyngeal angiofibroma, trauma, sinusitis Adults: sinusitis, trauma Elderly: hypertension, malignancy

6 Common sites of epistaxis Littles area (80-90 %): Kiesselbachs arterial plexus at antero-inferior part of septal cartilage. Common in children. Woodruffs venous (?) plexus: near posterior end of middle turbinate. Common in elderly, hypertensives. Retro-columellar vein: common in adults.

7 Common sites of epistaxis


9 Anterior Epistaxis Posterior Epistaxis IncidenceMore commonLess common LocalizationEasyDifficult Common siteLittles areaWoodruff plexus Age< 18 yr> 40 yr Common CauseTraumaHypertension TreatmentAnterior packPosterior pack

10 Evaluation of pt. with epistaxis mode of onset, duration, frequency, amount, side, site, previous bleeding nasal trauma, purulent nasal discharge hypertension, hepatic diseases, family history of bleeding, bleeding from other sites, use of anticoagulants, aspirin measurement of pulse & blood pressure

11 Investigations Hemoglobin, Packed Cell Volume Blood grouping & cross-matching Bleeding Time, Clotting Time Activated Partial Thromboplastin Time Prothrombin Time Platelet count Diagnostic Nasal Endoscopy (D.N.E.) C.T. scan paranasal sinus

12 General treatment Record pulse & blood pressure Reassurance + bed rest in sitting posture with back rest Adequate sedation (Diazepam) Inj. Ethamsylate 500 mg IV Q8H Amlodipine / Nifedipine for hypertension IV fluids / blood transfusion for shock

13 Anterior epistaxis Pinch nostrils + ice pack Bleeding continues Insert cotton pledgets soaked in 1: 1000 adrenaline in nasal cavity Bleeding continues Chemical cautery with AgNO 3 or electrical cautery (if bleeder is localized) or anterior nasal packing

14 Trotters method Elderly pt in sitting position, leaning forward, mouth open allowing bleeding to continue till hypotension develops. May lead to coronary thrombosis + death.

15 Adrenaline soaked pledget

16 Chemical cautery

17 Anterior nasal packing Anterior nasal packing for hrs antibiotic cover with: Liquid paraffin + antibiotic cream gauze Vaseline gauze Bismuth Iodoform Paraffin Paste gauze Merocel tampoon Simpson balloon

18 Anterior nasal gauze packing


20 Ribbon gauze soaked with liquid paraffin + antibiotic cream used. Both nasal cavities packed tightly by layering from floor to roof. Pack removed after 48 hrs. Systemic antibiotics given to prevent sinus infection & toxic shock syndrome.

21 Merocel nasal tampoon

22 Simpsons nasal balloon

23 Posterior epistaxis Posterior + anterior nasal packing for hrs antibiotic cover with: Post nasal gauze pack Foleys catheter Brighton balloon (double lumen) Epistat balloon (double lumen) Bivona balloon (triple lumen)

24 Antero-Posterior Nasal Packing with gauze pack

25 Posterior nasal gauze pack

26 Catheter introduction

27 Tying of pack to catheter tip

28 Guiding pack into nasopharynx

29 Tying of anterior strips

30 Anterior nasal packing

31 Outer nasal packing

32 Posterior nasal packing Post nasal pack prepared by tying 3 ribbon gauze strips to piece of gauze roll 2 Foleys catheters passed through each nostril & their ends brought out via mouth 2 ends of gauze strips attached to nasal pack tied to catheter tips & withdrawn from nose

33 Posterior nasal packing Pack that follows ribbon gauze strips, is guided into nasopharynx with index finger. Anterior nasal packing done. 2 ribbon gauze strips tied over a gauze piece on columella. 3 rd gauze strip brought out from mouth & taped to cheek. Pack removed after hr.

34 Antero-Posterior Nasal Packing with Foleys catheter

35 Foleys catheter

36 Catheter introduction

37 Catheter tip in nasopharynx

38 Anterior nasal packing

39 Brightons nasal balloon

40 Epistat nasal balloon

41 Bivona triple lumen catheter

42 Epistaxis set

43 Surgical intervention for refractory epistaxis

44 1. Arterial ligation by external approach external carotid artery: ligated in neck, distal to superior thyroid artery internal maxillary artery: ligated in pterygo- palatine fossa (Caldwell-Luc opn) anterior or posterior ethmoidal artery: ligated in orbit (Lynch-Howarth incision)


46 External Carotid ligation


48 2. Angiography and embolization 3. Submucosal Resection of septum 4. Septo-dermoplasty: for hereditary telengiectasia 5. Endoscopic cautery & clipping: Sphenopalatine artery Anterior or posterior ethmoidal artery

49 Angiography + embolization

50 Endoscopic clipping

51 Thank You

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