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KAU Rabigh Medical School Department of Otolaryngology, Head and Neck Surgery Tutorial 7.

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Presentation on theme: "KAU Rabigh Medical School Department of Otolaryngology, Head and Neck Surgery Tutorial 7."— Presentation transcript:

1 KAU Rabigh Medical School Department of Otolaryngology, Head and Neck Surgery Tutorial 7

2 Epistaxis By Razan A. Basonbul, MBBS

3 Epidemiology  Epistaxis is the most common bleeding disorder of the head and neck.  It is estimated to occur in about 60% of the population.  Most cases require no medical intervention.  The majority of cases occur in children 50 years old.  More common in Males than Females.

4 Anatomy  Blood Supply of the nose is through branches of both :  Internal Carotid Artery.  External carotid Artery.  Epistaxis based on the location of bleeding is described as  Anterior.  Posterior.  About 90% of cases occur in the region of the Kiesselbach’s plexus ( Little’s area) along the anterior septum.  It is Susceptible to bleeding due to fragile mucosa and tight adherence to underlying mucosa affording little resistance to mechanical stress.  The usual location of posterior bleeding is the Woodruff’s plexus on the lateral wall posterior to inferior/ middle turbinate.


6 Little’s area ( Kiesselbach’s plexus) Most common site of bleeding (90%) Contributing arteries: 1.IC  Ophthalmic  Anterior ethmoid 2.EC  Facial  Superior Labial 3.EC  Maxillary  Desending palatine  Greater palatine 4.EC  Maxillary  Sphenopalatine ( terminal branches)

7 Etiology 80% idiopathic  Local:  Trauma/nose picking  Dry nasal mucosa/ Irritants  Tumors  Medications (nasal steroids)  Foreign body  Allergic rhinitis/sinusitis  Systemic:  Osler-weber-rendu Disease  Coagulopathies  Hemophilia  Thrombocytopenia  Medications (anticoagulants/antihistamin es/antihypertensives/anti- inflammatories)  Hypertension / Aspirin!  Systemic infection  Recreational drugs  Alcohol  smoking

8 Evaluation  Initial Assessment  History  Examination  Investigation  Management

9 Initial Assessment  ABCs ( Airway, Breathing, IV access)  Pulse Oxymetry placed prior to the physical exam and record vitals.  Unstable patients should have Intravenous ( IV ) catheters and fluids started.  Ask the patient to blow the nose to allow clots to move out decreasing the bleeding.  Sit up the patient with body tilted forward to prevent blood from going down the pharynx.  Apply continuous pressure to anterior cartilaginous portion the nose for 5-10 min.  If stable take a quick history.

10 History  Make Sure the patient is stable !  Duration of current episode,  Amount of bleeding,  Location of bleeding,  Intermittent VS continuous,  recent trauma,  prior history and treatment,  chronic medical conditions ( Hypertension, Liver or Kidney Disease, on regular oxygen and ventilators),  known bleeding disorders,  Medications,  recent illnesses,  recreational drug use,  prior surgeries,  herbal medicines,

11 Examination  Instruments necessary:  nasal speculum,  light source,  suction, and irrigator.  Inspect the turbinates and septum to identify the general condition of the mucosa and location of bleeding.  Examine Oropharynx for clots ( risk of aspiration)  Nasal Endoscopy for chronic, recurrent epistaxis without obvious bleeding source.  Systemic examination for other causes including Neck exam and signs of bruises.

12 Investigations  For:  Patients with significant bleeding,  known liver or renal disease,  or on anticoagulation therapy.  Do:  complete blood count (CBC),  Type and cross match,  Prothrombin (PT)/partial thromboplastin time (PTT)/ bleeding time,  Liver function tests and Creatinine.  Patients with recurrent, unexplained epistaxis should be evaluated for a hereditary bleeding disorder. The most common one associated with epistaxis is von Willebrand factor (vWF).

13 Management  Correct hypovolemia ( 3:1 role: for every loss of 100ml blood replace by 300ml crystalloid fluid)  If hypertensive control with antihypertensive carefully.  If known bleeding disorder, replace by appropriate blood component.

14  Apply vasoconstrictive ( Phenylephrine, oxymetazoline [ Afrin ] ) and if necessary, Local anesthetic agents ( Lidocaine ) either directly or on a nasal pledge.  If minor Bleeding and stopped afterwards, Chemichal Cauterization ( silver nitrate) can be used for localized bleeding.  Topical hemostatic agents as Gelfoam, surgicel, floseal can be placed that provides procoagulant effect after cauterization attempts. ( nasal spray is needed for several days to allow resorption).

15  If bleeding is still active, Nasal Packing is preformed.  Anterior Nasal Packing:  Nasal Tampons and extendable sponges; provide pressure against nasal mucosa  Vaseline Strep-Gauze; placed to posterior choanae, controls most posterior bleeds, Placed for 3-5 days, provided with anti- staphylococcal antibiotics.  Posterior Nasal Packing:  Foley catheter, pneumatic nasal catheter or posterior packing is placed.  Nasal Balloons; ( 2 balloons one in nasopharynx and other in nasal cavity) is advisable  Packing of both sides or posterior packing is an indication for Hospital admission!!

16  If bleeding persists; 1.Posterior packing. 2.Endoscopic cautery. 3.Endoscopic clipping of the sphenopalatine artery. 4.Transantral ligation of internal maxillary artery. 5.Angiograpgy with embolization.  In Summery: Squeeze - Look & Cauterize - Anterior Pack - Balloon - Posterior pack - Surgery or Embolization.

17 Typical contents of an epistaxis tray. Top row: nasal decongestant sprays and local anesthetic, silver nitrate cautery sticks, bayonet forceps, nasal speculum, Frazier suction tip, posterior double balloon system and syringe for balloon inflation. Bottom row: Packing materials, including nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform), Merocel, Gelfoam, and suction cautery.

18 Anterior Nasal packing

19 Posterior Nasal Packing

20 Nasal Balloon Packing

21 Complications Complications may occur as a result of any treatment intervention and include:  Infection (localized or spread into surrounding tissues),  Abscess formation,  Septal Necrosis,  Septal hematoma,  Septal perforation.

22 Questions ?

23 Take Home Messages  Most common (90%) site of bleeding is Anterior bleeds from Little’s area ( Kiesselbach’s plexus)  Most common cause of epistaxis in children is nasal picking (trauma) and dry mucosa and viral URTIs with frequent nose blowing.  Systemic illness and medications are important causes of nose bleeding in Adults.  Check ABCs and Stabilize the patient first!  “Blow your nose”, “Sit up and tilt forward” and apply CONTINOUS pressure for 5-10 min.

24  Tips to prevent a nosebleed :  Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime.  Keep children’s fingernails short to discourage nose- picking.  Counteract the effects of dry air by using a humidifier.  Use a saline nasal spray to moisten dry nasal membranes.  Quit smoking. Smoking dries out the nose and irritates it.  Tips to prevent rebleeding after initial bleeding has stopped:  Do not pick or blow nose.  Do not strain or bend down to lift anything heavy.  Keep head higher than the heart.

25  Admit the person to hospital if:  Epistaxis continues despite efforts to stop the bleeding.  Bleeding from the posterior area of the nose is suspected.  A nasal pack has been inserted in primary care.  Consider admission to hospital if the person is elderly or has a comorbid condition (such as coronary artery disease, severe hypertension, clotting disorder, or significant anemia).

26  Consider referral to ORL specialist if the person has recurrent episodes and is at high risk of having a serious underlying cause,  Use clinical judgment and consider referral in the following groups:  Males 12–20 years of age — angiofibroma is possible (but rare).  People with any symptoms suggestive of cancer — such as nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), or palpable neck glands.  People with a family history of hereditary haemorrhagic telangiectasia and suggestive features upon examination — telangiectasia on the lips, mucous membranes, and fingers.  People with occupational exposure to wood dust or chemicals as they are prone to nasopharyngeal cancer.

27 Thank you  References:  Books:  Primary care otolaryngology.  Taylor’s Manual of family Medicine.  Otolaryngology head and neck surgery by Raza Pasha,MD  Websites:   rent_epistaxis/referral rent_epistaxis/referral

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