Common causes of epistaxis Child: nose picking, foreign body, exanthematous fever Adolescent: nasopharyngeal angiofibroma, trauma, sinusitis Adults: sinusitis, trauma Elderly: hypertension, malignancy
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.
Common sites of epistaxis
Anterior Epistaxis Posterior Epistaxis IncidenceMore commonLess common LocalizationEasyDifficult Common siteLittles areaWoodruff plexus Age< 18 yr> 40 yr Common CauseTraumaHypertension TreatmentAnterior packPosterior pack
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
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
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
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
Trotters method Elderly pt in sitting position, leaning forward, mouth open allowing bleeding to continue till hypotension develops. May lead to coronary thrombosis + death.
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.
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each nostril & their ends brought out via mouth 2 ends of gauze strips attached to nasal pack tied to catheter tips & withdrawn from nose
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.
Antero-Posterior Nasal Packing with Foleys catheter
Catheter tip in nasopharynx
Anterior nasal packing
Brightons nasal balloon
Epistat nasal balloon
Bivona triple lumen catheter
Surgical intervention for refractory epistaxis
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)
External Carotid ligation
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