ENT Case 4 - Epistaxis

Question 1

What questions should you ask in an epistaxis history?

Answer 1

• Frequency
• Duration
• Side - which side is affected or is it both sides?
• Is the blood dripping out of the nose or down the back of the throat or both?
• What does the patient do when the nosebleeds begin - i.e do they apply pressure?
• How much blood (teaspoons) do you bleed?
• Does anything seem to trigger / precipitate the nosebleed?
• Hx of previous bleeds?
• What previous treatment have they had?

PMH:

• HTN
• Chronic granulomatous diseases (e.g granulomatosis with polyangitis)
• Bleeding disorders (e.g HHT, haemophilia)
• Rhinitis

Drugs:

• Antiplatelet medication e.g. aspirin or clopidogrel
• Anticoagulation e.g. warfarin

Question 2

How would you conduct a nasal exam?

Answer 2

3 stages for completion:

• Inspection of the external nose – any obvious trauma, scarring, deformity etc.
  
  • look at the nostrils (nares) for discharge
• Anterior rhinoscopy - using Thudichum speculum
• Posterior rhinoscopy - using nasal endoscope (comes in flexible and rigid forms)

Question 3

Describe the following areas inside the nose:

• Woodruf’s plexus
• Kiesselbach’s plexus
• Little’s area

Answer 3

Woodruf’s plexus:
- area located over posterior end of middle turbinate - causes posterior epistaxis

Kiesselbach’s plexus:
- source of ~85% of all epistaxis

plexus of vessels in Little’s area - formed by 3 arteries:

• anterior ethmoid artery
• sphenopalatine artery
• greater palatine artery

Little’s area:

• area on the anterior portion of the nasal septum - well vascularised
• where ~ 85% of all epistaxis come from

Question 4

What is the managemnet of recurrent epistaxis with prominent vessels in Little’s area?

Answer 4

Epistaxis advice:

• do NOT clean the nose
• do NOT blow nose for 1-2 weeks
• no strenuous exercise for 1-2 weeks
• for 72 hours avoid hot baths, showers, let food cool down, don’t drink hot drinks

Naseptin ointment:

• prescribed for 1-2 weeks to keep nasal cavity free of crusts
• contains peanuts - check allergy

Silver nitrate cautery to the affected area:

• apply local anaesthetic
• area around vessel cauterised using silver nitrate stick in each position for 15 secs
• then cauterise the vessel itself
• antiseptic cream e.g. Naspetin - BD, 2 weeks (treats staphylococcal colonization)

Question 5

What should a patient do when they have a nosebleed?

Answer 5

Stand up / sit upright

Apply firm pressure to the end of the nostrils (not the bridge of the nose)

Tilt head forwards

Question 6

How do you manage severe epistaxis acutely?

Answer 6

ABCDE

• Ensure their airway is clear and they can breath i.e. blood not going down throat
• Insert IV line
• Assess cap refill, HR, BP and listen to heart
• FBC, coagulation profile and blood group
• If firm pressure and tilting head forward don’t stop bleeding:
  
  • Anterior nasal packing
  • Admit to ENT ward
• If patient continues to bleed:
  
  • Posterior packing
• If patient continues to bleed:
  
  • Surgery - artery ligation (sphenopalatine / anterior ethmoidal artery)

Question 7

If a pt is bleeding through anterior nasal packs and coughing up clots, where is the bleed and what should you do?

Answer 7

The bleed is a posterior nasal bleed

• Contact ENT SpR minimum
• Insert posterior pack i.e. foley catheter passed into nose and balloon inflated in post-nasal space then pulled forward to apply pressure to back of nose –> then clipped at front to stop it moving
• Then insert anterior nasal packs
• If in for > 48hrs –> prophylactic oral Abx

Question 8

What can cause epistaxis?

Answer 8

• Idiopathic - > 85% cases
• Trauma - blunt trauma / nose picking (i.e. digital trauma)
• Inflammatory
  
  • granulomatosis with polyangitis (GPA), sarcoidosis
• Acute or chronic rhinosinusitis
• Drugs:
  
  • Aspirin, Clopidogrel, Warfarin, LMW heparins (e.g Clexane)
• Haematological
  
  • DIC, ITP
• Neoplasia of the nasal cavity
  
  • SCC, adenocarcinoma, inverted papilloma, juvenile angiofibroma
• Iatrogenic e.g. recent nasal surgery