epistaxis DEPARTMENT OF OTORHINOLARYNGOLOGY – HEAD&NECK SURGERY PADJADJARAN UNIVERSITY/ HASAN SADIKIN HOSPITAL BANDUNG

INTRODUCTION EPISTAXIS Haemostatic abnormality Any bleeding from the nose caused by haemostatic disturbance Haemostatic abnormality Mucous abnormality Vascular pathology Coagulation disorders

EPIDEMIOLOGY Prevalens: 7% - 14%. Recurrence 4%. Age : < 10 , > 35 Based on source of bleeding : Anterior epistaxis  esp. child – young adult Posterior epistaxis  old age Cold climate and low humidity >>  DRYNESS

ANATOMY A. Carotis Eksterna A. Maksilaris A. Fasialis A. Carotis Interna A. Oftalmika  A. Ethmoidales anterior & posterior

Adapted from : Netter Atlas

Anterior epistaxis : Posterior epistaxis : CLASSIFICATION occurs primarily in the Little’s area (Kiesselbah’s plexus) and more often venous in origin. Posterior epistaxis : primarily in the region of the posterior septum, posterior lateral nasal wall (Woodruff’s nasopharyngeal plexus) & posterior septum more often arterial in origin

ETIOLOGY SYStEMIC LOCAL Hypertension Vascular disorders Trauma: digital, fractures Nasal sprays Inflammatory reactions Anatomic deformities Foreign bodies Intranasal tumors Chemical inhalants Nasal prong O2, CPAP Surgery Hypertension Vascular disorders Blood dyscrasias Hematologic malignancies Allergies Malnutrition Alcohol Drugs (aspirin, etc) Liver / renal disease

EVALUATION INITIAL : COMPRESSION OF THE NOSTRIL (5-20 MIN) PLUGGING WITH GAUZE OR COTTON SOAKED IN TOPICAL ANESTHETIC – DECONGESTAN TILTING HEAD FORWARD  PREVENTS POOLING BLOOD TO POSTERIOR PHARYNX  AVOIDING NAUSEA & OBSTRUCTION SECURING HEMODYNAMIC STABILITY & AIRWAY PATENCY  FLUID RESUSCITATION

EVALUATION NO RESPOND LOCATE THE SOURCE OF BLEEDING : ANTERIOR RHINOSCOPY / NASOENDOSCOPY WITH PROPER LIGHT SOURCE & INSTRUMENT SELF PROTECTION REDUCE THE ANXIETY A THROUGH HISTORY SHOULD BE TAKEN WITH ATTENTION TO DURATION, FREQUENCY, SEVERITY  FAMILY HISTORY / BLEEDING DISORDER?

INSTRUMENT 11/7/2018

PHYSICAL EXAMINATION General status Local status Determine : - Anterior or posterior - Other stigmata

MANAGEMENT AIMED Stop the bleeding Avoid complication Avoid recurrence Most anterior epistaxis  self limited Controlled by pinching ala nasi 5 – 20 min

MANAGEMENT Minor Hemorrhage stop spontaneously  pediatric population, > 64% having experienced epistaxis Silver nitrat cautery Electric cautery Anterior nasal packing Removed after 20 men Antiseptic cream Barrier agent

Major Hemorrhage Emergency  active epistaxis & resuscitation Anterior bleeders ant nasal pack or cautery Posterior bleeders post nasal pack arterial ligation or embolization is performed Ensure adequate iv access & resuscitation Blood cloots out of his or her nose Explore with speculum or nasal endoscopy and suction

MANAGEMENT DIFFUSE / OOZING, MULTIPLE BLEEDING SITE OR RECURRENT BLLEDING  INDICATE SYSTEMIC PROCESS HEMATOLOGIC EVALUATION

NASAL PACKING anterior MANAGEMENT TRADITIONAL Ribbon gauze with vaselin / antibiotic oinment OTHERS Non absorbable Absorbable NASAL PACKING anterior

Anterior Nasal Packing 11/7/2018

11/7/2018

MANAGEMENT NASAL PACKING POSTERIOR BELLOCQ TAMPON FOLEY CATHETER BALLOON PACK

Posterior Nasal Packing (Bellocq tampon) 11/7/2018

Balloon Pack 11/7/2018

SURGERY LIGATION EMBOLIZATION SEPTAL DERMOPLASTY, SEPTOPLASTY A. ETHMOIDALES ANTERIOR A. MAXILLARIS A. SPHENOPALATINA A. CAROTID EXTERNA EMBOLIZATION SEPTAL DERMOPLASTY, SEPTOPLASTY

AVOID COMPLICATION HYPOVOLEMIC SHOCK APNEA, HYPOXIA SEPTAL PERFORATION AVOIDANCE HYPOVOLEMIC SHOCK APNEA, HYPOXIA SEPTAL PERFORATION ALAR RIM, COLUMELLA NECROSIS, LASERATION PALATUM MOLLE / LIPS ASPIRATION RECALCITRANT BLEEDING INFECTION IV FLUID MONITOR O2 LIMITED CAUTERY, PROPER PACK SIZE STABILIZATION PACKING WITHOUT CONTACT WITH ALAR / COLUMELLA ADEQUATE PLACEMENT & SECURING NASAL PACKS PROPHYLACTIC ANTIBIOTICS

AVOID RECURRENCE Patient education  Avoidance of digital manipulation,airborne irritants, dander, smoke Keep the nose moist Control of allergies Tappering amount of nasal spray Intranasal surgical technical refinements

SUMMARY GOOD EVALUATION & HISTORY  PREPARATION & PLANNING PROPER INSTRUMENTATION DON’T PANIC ! MANAGEMENT : CONSERVATIVE, COMFORTABLE, IF FAILED  SURGERY AVOID COMPLICATION FROM BLEEDING & OR MANAGMENT

ANTERIOR NASAL PACKING PROCEDURE

LEARNING GUIDE: ANTERIOR NASAL PACKING PROCEDURE   No Procedures Performance Scale 1 2 3 Preparation Greet the patient respect fully and with kindness introduce yourself.   The patient should be given adequate explanation about examinations. Explain the goals or the expected result examination. Check the instrument& material. 4 Hold the nasal speculum with one hand and then put in on the left or right nostril 5 Holt it with the thumb on the joint, the index finger free to steady it on the patient’s nose and the rest of the fingers on the stem proper to hold the speculum

6 Always try to open the stem or times in an upward action and not down into the floor or the nose. The good view of the nose anteriorly can be obtained simply by pressing on the tip of the nose   7 Topical anesthesia can be administered in order to decreasing discomfort, the risk of apnea, bradycardia, and hypotension by blocking the nasal-vagal reflex. A pledget or cotton swab soaked in 1 % pantocaine or lidocaine solution (with or without containing 1-2 drops of an epinephrine solution dilutes 1:1,000) is placed in the nose for 3-5 minutes 8 The traditional anterior pack petrolatum gauze (0.5 x 72 inch) coated with an antibacterial ointment is firmly packed into the nasal cavity

9 The packing is placed in a methodical (layering) fashion toward the posterior choana, starting at the nasal floor and packing up to about the level middle turbinate. It is possible to put a large amount into each side   10 Great care must be taken that : -      The pack does not rub on the columella, which is easily traumatized -      The free and of the packing should not be visible in the oropharynx behind the soft palate as this can lead to irritation, and also a danger that this portion might slip deeper into the aerodigestive tract and cause complication

11 Once the gauze is firmly packed properly into the nasal cavity: -      The patient should be admitted and kept under careful observation -      Give the patient humidifies oxygen and sedate with caution and only with reversible agents -      As the pack will be left in for at least 48 hours, put the patient on a board-spectrum antibiotic -      Establish an intravenous line, and cross-match the blood  

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