Chapter 23 - Epistaxis

Question 1

Things to consider with recurrent epistaxis and unidentifiable cause

Answer 1

coagulopathy
vascular abnormality
drug use
hereditary disorders
inflammatory and autoimmune conditions

Question 2

4 ways to address posterior epistaxis

Answer 2

SPA ligation (most efficacious, cost-effective)
posterior packing
embolization
cautery

Question 3

3 ways GPA can present to ENT

Answer 3

epistaxis
subglottic stenosis
hearing loss

Question 4

Conditions to consider with refractory epistaxis, thrombocytopenia

Answer 4

DIC (underlying issue, sepsis)
Massive hemorrhage
thrombotic microangiopathy
HIT
ITP
Bone Marrow Suppression

Question 5

Next steps after posterior packing

Answer 5

Admit

Telemetry, pulse ox

Question 6

Where does a JNA originate?

Answer 6

Medial PPF

Question 7

General blood supply to nose

Answer 7

Ant Ethmoid - superior, septum
SPA- posterolateral wall, nasal cavity
Facial- anterior nasal cavity

Question 8

4 initial steps to control mild epistaxis

Answer 8

1- gently blow nose (remove clots)
2- oxymetazoline
3- pinch alae against septum, hold for 10-15 minutes
4- cold compress on bridge of nose
Lean forward (to decrease blood down throat –> GI irritate/emesis/aspirate, to quantify better)

Question 9

Signs of shock

Answer 9

anxiety
cool/clammy skin
oliguria/anuria
weak
pallor
diaphoresis
altered mentation

Question 10

When to do endoscopy for eval of epistaxis

Answer 10

can’t see source on anterior rhin, suspect posterior on history, conservative not successful, suspect tumor/lesion

Question 11

Two symptoms of blood loss

Answer 11

light head

SOB

Question 12

When to obtain CBC for epistaxis eval

Answer 12

significant loss
repeated large episodes
coagulopathy
on anticoag

Question 13

Causes of secondary epistaxis

Answer 13

Liver disease
Heme dz
Anticoag
Trauma
Neoplasm
Recent Surgery
Hereditary
Illicit drugs
Chronic medical issue
Cancer

Question 14

Materials you can use for anterior packing

Answer 14

Nasal tampon (with abx oint), then saline
Balloon/merocel
petroleum-impregnated gauze
Gelatin sponge wrapped in oxydized cellulose

Question 15

How to apply silver nitrate

Answer 15

decongestant, pressure (slow bleeding, dry is better)
apply against mucosa at origin of blled until becomes gray (<10 sec)
periphery to center of bleed site
Finally, apply topical saline/decongestant to halt chemical reaction

Question 16

How to place posterior pack

Answer 16

Red rubber tube into nose, through OP, retrieve with ring forceps
Attach cotton pack with silk ties to oral end, pull until rests in NP
May pack anterior as well
Fasten tube externally
Telemetry (risk arrythmia, syncope), pulse ox (may need supp O2), ABx

Question 17

Possible complications of posterior packing

Answer 17

pain, respiratory difficulty
TSS, sinusitis
alar/septal necrosis
pharyngeal fibrosis/stenosis

Question 18

Broad DDX new-onset nasal bleeding

Answer 18

Cold/dry air
Trauma/Surgery
URI, sinusitis, drugs, autoimmune
Meds
aneurysm
septal deviation/perforation
HHT
Arteriosclerosis, HTN, blood dyscrasia, paraneoplastic, liver dz, platelets

Question 19

Meds that may contribute to epistaxis

Answer 19

Aspirin/Anti Coag
intranasal steroids
nasal cannula O2
chemo
Fish oil
Evening primrose
garlic
cranberry juice
vitamin E
echinacea
ginseng
St. John's wort
ginkgo biloba
ginger
kava
saw palmetto

Question 20

What to do if you suspect autoimmune cause of bleed

Answer 20

Look for signs of vasculitis
Test c-ANCA, ACE
If above negative, don’t need Bx