[1] Epistaxis Flashcards
What is epistaxis more commonly known as?
A nosebleed
What is epistaxis?
Bleeding from the nasal cavity and/or nasopharynx
What sort of age distribution does epistaxis have?
Bimodal
When are nosebleeds most common?
In the young and the old
Why does the nasal cavity bleed profusely?
The mucosa has a rich blood supply that can easily be ruptured
What is blood supply rupture associated with?
Trauma or can be spontaneous
What are the two types of nosebleeds?
- Anterior
- Posterior
Which type of nosebleed is most common?
Anterior
What area of the nasal cavity to anterior nosebleeds start in?
Little’s area
What is found within Little’s area?
Kiesselbach’s plexus
What is Kiesselbach’s plexus?
A richly vascular area
Bleeding from what causes posterior nosebleeds?
Woodruff’s plexus
What is Woodruff’s plexus?
A venous plexus
Where is Woodruff’s plexus found?
In the posterior part of the inferior meatus
How are posterior nosebleeds different from anterior nosebleeds in presentation?
- Prolonged
- Both nostrils
- More blood in the mouth
Which type of nosebleed is more difficult to control?
Posterior
What are the most common causes of nose bleeding?
- Nose picking
- Blunt trauma
- Insertion of foreign body
When is bleeding more likely?
When there is inflammation and thinning of the nasal tissues
What factors can cause thinning and inflammation?
- Relative humidity
- Respiratory tract infection
- Chronic sinusitis
- Rhinitis
- Environmental irritants
- Nasal oxygen
When should investigation of epistaxis causes be considered?
When they are recurrent and do not respond to home therapies
What are the categories of rare underlying causes of epistaxis?
- Coagulopathy
- Inflammatory
- Medications/drugs
- Neoplasia
- Trauma
- Vascular malformation
What coagulopathies can cause epistaxis?
- Thrombocytopenia
- Leukaemia
- Haemophilia
- HIV
- Chronic liver disease
What inflammatory causes lead to epistaxis?
- Granulomatosis with polyangiitis
- SLE
What medication can cause nosebleeds?
Anticoagulation
What other drugs can cause nosebleeds?
Insufflation (sniffed) drugs
What insufflation drug can particularly cause epistaxis?
Cocaine
What neoplastic conditions can cause epistaxis?
- Squamous cell carcinoma
- Nasopharyngeal angiofibroma
What are the rarer traumatic causes of epistaxis?
- Anatomical deformities e.g. septal spurs
- Nasal bone fracture
What vascular malformations can cause epistaxis?
- Hereditary haemorrhagic telangiectasis
- Aneurysm of carotid artery
Where can blood commonly come out from in epistaxis?
One or both nostrils
Where may blood travel in more severe cases?
Thought the nasolacrimal duct and come out of the eye
What worrying symptoms can nose bleed cause?
Nausea, vomiting and apparent haematemesis
How can nose bleed cause apparent haematemesis?
Back flow of blood into the stomach causing vomiting
How is epistaxis typically diagnosed?
Clinically
In nosebleeds requiring investigations, what may be useful?
- FBC
- Coagulation
- Urea and creatinine
- LFT
- Nasal endoscopy and nasopharnygoscopy
- Other specific investigations
What are the differentials for epistaxis?
- Haemoptysis
- Haematemesis
How are most cases of epistaxis managed?
Self-limiting with home management
How can nose bleeds be managed at home?
- Sit or stand upright
- Pinch nose just above nostrils for 10 - 15 minutes
- Lean forwards
- Breath through mouth
- Ice pack on top of the nose
How can a patient who is hospitalised with epistaxis be treated?
- Anterior septal pressure
- Liberal topical vasoconstrictor
What is an example of a topical vasoconstrictor?
Oxymetazoline 0.05%
What is rare in epistaxis?
Haemodynamic compromise
What is needed if haemodynamic compromise occurs in epistaxis?
- Urgent fluid resuscitation
- Possible blood transfusion
What happens if there is persistent bleeding despite initial treatment?
- Chemical cauterisation
- Packing
- Endoscopic evaluation and ligation or intra-arterial embolisation
- Open surgical ligation
What is chemical cauterisation?
Using silver nitrate to burn and seal off the bleeding
What is usually applied before chemical cauterisation?
Topical anaesthetic
What type of bleeds is chemical cauterisation best for?
Mild easily visible bleeds
What is nasal packing often accompanied with?
Antibiotics and analgesia
What are the types of nasal packing?
- Anterior packing
- Posterior packing
What are the types of anterior packing?
- Traditional packing
- Expanding nasal sponges
What is traditional anterior nasal packing?
Horizontal layering of 12mm cotton gauze saturated with petroleum jelly or antibiotic ointment
Why are expanding nasal sponges more convenient?
Easier to position
What are the difficulties with posterior nasal packing?
- Greater patient discomfort
- Consider IV analgesia and anti-emetics
How is endoscopic evaluation and ligation performed?
Under GA
How is intra-arterial embolisation performed?
Using a catheter inserted in the groin and passed up the aorta to the vessel
What are the potential complications of epistaxis?
- Sinusitis
- Septal haematoma/perforation
- Mucosal pressure necrosis
- Vasovagal episode
- Aspiration
