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

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

3. 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

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

5. Adapted from : Netter Atlas

6. 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

9. 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

10. 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

11. 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?

12. INSTRUMENT
11/7/2018

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

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

15. 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

16. 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

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

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

19. Anterior Nasal Packing
11/7/2018

21. 11/7/2018

22. MANAGEMENT NASAL PACKING POSTERIOR BELLOCQ TAMPON FOLEY CATHETER
BALLOON PACK

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

25. Balloon Pack
11/7/2018

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

27. 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

28. 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

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

31. ANTERIOR NASAL PACKING PROCEDURE

32. LEARNING GUIDE: ANTERIOR NASAL PACKING PROCEDURENo
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

33. 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

34. 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

35. 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

36. Thank you