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

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