ENT - Epistaxis Flashcards
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?
- 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
How would you conduct a nasal exam?
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)
Describe the following areas inside the nose:
- Woodruf’s plexus
- Kiesselbach’s plexus
- Little’s area
-
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
What is the management of recurrent epistaxis with prominent vessels in Little’s area?
-
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
-
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
What should a patient due when they get a nosebleed?
Stand up or sit upright, apply firm pressure to end of nostrils (not bridge of nose) and tilt head forward!!
How do you manage a profuse epistaxis acutely?
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 a pt is bleeding through anterior nasal packs and coughing up clots, where is the bleed and what should you do?
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
What can cause epistaxis?
- 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