ENT - Epistaxis Flashcards

1
Q

Edward Jones, a 72 year old s complaining that he is suffering from frequent nosebleeds (epistaxis).

What are the key questions you ask in a nose-bleed history?

A
  • 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 haemophilia)
  • Rhinitis

Drugs:

  • Antiplatelet medication e.g. aspirin or clopidogrel
  • Anticoagulation e.g. warfarin
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2
Q

How would you conduct a nasal exam?

A

3 stages for completion:

  1. Inspection of the external nose – any obvious trauma, scarring, deformity etc.
    1. look at the nostrils (nares) for discharge
  2. Anterior rhinoscopy - using Thudichum speculum
  3. Posterior rhinoscopy - using nasal endoscope (comes in flexible and rigid forms)
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3
Q

Describe the following areas inside the nose:

  • Woodruf’s plexus
  • Kiesselbach’s plexus
  • Little’s area
A
  • 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
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4
Q

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

A
  1. Epistaxis advice
    • do NOT clean the nose
    • do NOT blow nose for 1-2 weeks
    • no stenuous exercise for 1-2 weeks
    • for 72 hours avoid hot baths, showers, let food cool down, don’t drink hot drinks
  2. Naseptin ointment
    • prescribed for 1-2 weeks to keep nasal cavity free of crusts
    • contains peanuts - check allergy
  3. 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
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5
Q

What should a patient due when they get a nosebleed?

A

Stand up or sit upright, apply firm pressure to end of nostrils (not bridge of nose) and tilt head forward!!

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6
Q

How do you manage a profuse epistaxis acutely?

A

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
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7
Q

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

A

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
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8
Q

What can cause epistaxis?

A
  • 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
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