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Dr Deborah Amott ENT Surgeon

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1 Dr Deborah Amott ENT Surgeon dhamott@hotmail.com
Epistaxis Dr Deborah Amott ENT Surgeon

2 Core Presentations By the end of this year, you should be able to perform a competent medical interview, physical examination and suggest a basic investigational plan for a patient presenting with this symptom.

3 Function of the Nose 5

4 Airway Filtration Humidification Warming Smell
Function of the Nose Airway Filtration Humidification Warming Smell

5 What are the symptoms patients will complain of?
6

6 What are the symptoms patients will complain of?
Block: congestion vs. total obstruction uni vs. bilateral Run (‘rhinorrhoea’) React to irritation: itching, sneezing, pain Change in smell (+taste): decreased/absent, foul Facial pressure/pain Bleed (‘epistaxis’)

7 Each of these can be fixed or variable over time…

8 Epistaxis: Vascular Anatomy

9 Anterior vs. Posterior Epistaxis
History Examination Investigations

10 Causes Local Systemic Hypertension?

11 Causes Local Systemic Hypertension? Mucosal trauma: micro vs. macro
Vessels: Increased blood flow vs. abnormal vessels Systemic Atherosclerosis Coagulopathies: Primary: platelets vs. clotting factors Secondary: platelets vs. clotting factors Hypertension?

12 General Pathological Processes
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid-base imbalance/auto-immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic: too much vs. too little of an otherwise good thing

13 Ask 4 Questions… What is the most likely diagnosis?
What is the most IMPORTANT diagnosis? Could this be life-threatening? What information do I need to confirm my diagnosis? What’s my time frame?

14 Examination General Vital Signs System specific Anterior Rhinoscopy
Nasendoscopy

15 Examination External view: gross deviation Nasal obstruction Tilt tip
Block each nostril separately, ‘sniff in’ Tilt tip Look in: thudicum speculum and pen torch

16 Let’s come back to this one….
Investigations Let’s come back to this one….

17 Treatment Is the patient unstable?
Are they at risk of becoming unstable? Patient factors Bleeding

18 Stages of Shock

19 Stages of Shock

20 What’s the Cost vs. Benefit?
Treatment Behavioural: avoid triggers, diet, exercise, sleep, environmental modification, mood management Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements etc Pharmacologic: topical, enteral, transcutaneous, injections Interventional Minimal: endoscopic, angiography, etc Maximal: open surgery, radiation etc What’s the Cost vs. Benefit?

21 Not stable? Initiate Resuscitation
A: airway ( + cervical spine) B: breathing C: circulation D: disability E: everything else

22 Stable? Ladder of Intervention
First Aid: local pressure, calm down, sit down Modify risk factors Modify triggers OK, still bleeding…

23 Stable? Ladder of Intervention
OK, still bleeding… Local pressure Get the blood pressure down Vasoconstrictors Cautery Anterior packing Posterior packing Surgical miracles: endoscopic, open, angiography

24 Phenylephrine Oxymetazoline
Vasoconstrictors Adrenaline Cocaine Phenylephrine Oxymetazoline

25 Vasoconstrictors Adrenaline Cocaine Phenylephrine Oxymetazoline
α & β nonselective adrenergic agonist – local vasoconstriction. Cocaine LA: Sodium channel block NorAdr reuptake inhibition Phenylephrine Oxymetazoline α- adrenergic agonists

26 Anterior Packing

27 Posterior Pack

28 Surgical Miracles: endoscopic clipping

29 ‘Surgical’ miracles: angiography

30 Causes Local Systemic Hypertension? Trauma: micro vs. macro
Vessels: Increased blood flow vs. abnormal vessels Systemic Atherosclerosis Coagulopathies: Primary: platelets vs. clotting factors Secondary: platelets vs. clotting factors Hypertension?

31 But what about this coagulation stuff?

32 Platelets

33

34

35 Von Willebrand Disease
Binds platelets to each other, and to the damaged endothelial wall Co-factor for Factor VIII. vWD – quantitative or qualitative deficit 8

36 Coagulopathy: Typical Features

37 Coagulopathy: Typical Features

38 Investigations Know the question you want to answer.
Only order an investigation if the result will affect your management A proper initial clinical assessment and then repeated thorough clinical assessment is always much better than multiple non-targeted tests. Recruit help

39 ?

40 Learn ENT


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