Epistaxis Flashcards
What are key questions to ask with a hx of frequent nosebleeds?
- Frequency and duration
- 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 they start i.e. do they apply pressure/does it stop on its own
- History of previous bleeds
- What previous treatment have they had
- PMH: HTN, chronic granulomatous diseases e.g. GPA, bleeding disorders e.g. HHT, haemophilia, rhinitis
- DH: check if they are on any blood thinning medication e.g. warfarin
What investigations can you do in frequent nosebleeds?
- Posterior rhinoscopy (back of nasal cavity and post nasal space): done with endoscope passed into nose under local anaesthesia - ENT surgeon
- Anterior rhinoscopy: use Thleddicum’s speculum, if unavailable use otoscope
- Inspection of external nose: any previous/recent history of trauma
What are the types of endoscope used to look at the nose?
- Flexible endoscope: image quality not as good but can view pharynx and larynx
- Rigid endoscope: good image quality, can control with 1 hand and do procedure with other hand like suction of blood or nasal cautery but can’t examine the rest of pharynx and larynx
What is the most common place of epistaxis in the nose?
Anterior aspect of septum, called Little’s area, due to prominent exposure. The plexus of vessels in Little’s area is Kiessekbach’s plexus.
Woodruff’s plexus is at the posterior end of the middle turbinate - it causes posterior bleeds.
What is the treatment for after recurrent epistaxis?
- Epistaxis advice (most for around 2 weeks)
- Silver nitrate cautery for affected area: apply LA over area to be cauterised then area around vessel cauterised then cauterise the vessel
- Naseptin ointment: prescribed for 1-2 weeks after cauterisation to keep nasal cavity lining crust free, contains peanuts so check patient isn’t allergic. Apply twice daily for 2 weeks.
What is the epistaxis advice for recurrent epistaxis?
- Don’t blow your nose for 1 week
- Don’t clean nose or pick nose
- Avoid hot bathes and showers
- Let food cool down (also avoid very spicy foods)
- Don’t drink hot tea and coffee for first 72hrs
- No strenuous exercise for 1 week
- When sneezing, sneeze with mouth open to avoid rush of air through the nose
- Avoid blowing nose to clear any clots for around 2 weeks after epistaxis
What is a nasal septal haematoma?
Haematoma (blood collects) between septal cartilage and overlying perichondrium. If untreated irreversible septal necrosis may develop within 3-4 days. Thought to be due to pressure-related ischaemia of cartilafe resulting in necrosis (may result in saddle nose deformity). Treatment is surgical drainage and IV antibiotics.
What is the management of a patient bleeding profusely from both nostrils and spitting large clots?
- A-E
- Make sure IV access available: get cannula in due to blood loss
- Examining nose in this situation is hard. Wear apron and eyewear to protect against blood, coughing and sneezing.
- Blood may need to be sucked out of the nose in order to see where it is bleeding from but the aim is still to try and find a bleeding point
- Use a headlight and Thuddicum’s speculum, if you can see a vessel that’s causing the problem then cauterise it. If not apply direct pressure and packing.
How do you pack a bleeding nose?
- Admit to ENT ward
- Anterior nasal packing: packs should go in the nose backwards
- Posterior nasal bleed: posterior pack, usually a foley catheter passed into the nose so the balloon is the postnasal space, this is blown up and pulled forward to apply pressure to back of nose and then clipped at front to stop it from falling backwards. Stay in for 48 hours, if >48hrs prescribe oral prophylactic antibiotics
- If bleeding continues after posterior pack, ligate artery that is bleeding - commonly ligated arteries are the sphenopalatine artery and anterior ethmoidal artery.
How do you stop epistaxis in children?
Bleeding usually comes from Little’s area and is often precipitated by digital trauma. In most cases it is possible to prevent further bleeding by using a cream such as naseptin or bactroban. These have anti-bacterial properties and treat any staphylococcal colonisation that may be causing inflammation of the nasal vestibule but also have a protective effect. The cream should first be applied in the nostrils then careful posterior massage of nasal alar so it is worked backwards into the nasal cavity.
What are the causes of epistaxis?
- Idiopathic
- Trauma: blunt or digital trauma
- Inflammatory: chronic granulomatous disease e.g. GPA, sarcoidosis
- Acute or chronic rhinosinusitis (inflammation of lining of nasal cavity)
- Drugs: aspirin, clopidogrel, warfarin, LMWH e.g. clexane
- Haematological e.g. DIC, ITP
- Neoplasia of nasal cavity: squamous cell carcinoma, adenocarcinoma, inverted papilloma, juvenile angiofibroma
- Iatrogenic: recent nasal surgery
What medication is sometimes used to stop epistaxis?
Tranexamic acid, an anti-fibrinolytic agent. Contraindicated for:
- blood clots
- bleeding in the brain or urine
- heart valve problems
- visual problems secondary to bleeding
- irregular heartbeat
- irregular unexplained menstrual bleeds
- using birth control medication or devices
- taking medication such as clotting factors and tretinoin.
What is the main area of blood vessels called in the nose?
Little’s area/Kisselbach plexus
What is the treatment for epistaxis?
- A-E
- Conservative (pinch nose and head forward - constant pressure for 20 mins, ice)
- Nasal cautery
- Nasal packing
- If still bleeding then surgery (probably posterior bleed so ligate sphenopalatine artery)
