epistaxis

Question 1

definition of epistaxis

Answer 1

nose bleed
(kiesselback plexus of vessels)
posterior nosebleeds occur in older people - more profuse

Question 2

causes of episataxis

Answer 2

blood vessels in nose are superficial and easily damaged
in Little’s area - vessels anastomose to form Keisselbach’s plexus
* trauma
* inflammation - infection/polyps
* topical drugs - decongestants, cocaine
* vascular - wegener’s
* post-op
* tumour
* nasal oxygen - because dries mucosa
* systemic causes of bleeding/bad clot formation

Question 3

epidemiology of epistaxis

Answer 3

common in children 2-10yrs
adults >45yr
posterior - more common in older
recurrent - 15yo and older

Question 4

px of epistaxis

Answer 4

self-limiting
mortality if complications -
* hypovolaemia
* toxic shock syndrome - from prolonged nasal packing
* co-morbidities - coronary artery disease, HTN, clotting disorder, sig anaemia

Question 5

complications of epistaxis

Answer 5

Hypovolaemia.
Anaemia.
Aspiration from dislodgement or malpositioning (especially with posterior epistaxis).
Death.

Question 6

complications of nasal packing

Answer 6

Sinusitis.
Septal haematoma or abscess (due to traumatic packing).
Pressure necrosis (secondary to excessively tight packing).
Toxic shock syndrome (from prolonged packing).
Apnoeic episodes (associated with bilateral anterior or posterior nasal packs).

Question 7

complication of nasal cautery treatment

Answer 7

septal perforation - direct effect of silver nitrate stick

Question 8

assessment of epistaxis

Answer 8

A-E
hx
* when did it start, which nostril
* blood loss
* whether temporary pack has been used before seeking medical help eg cotton wool
* previous episodesn

exam
* get pt to blow nose to remove clots
* look for bleeding point - small red dot
* signs of bleeding disorder - telangiectasia

determine if underlying cause
consider NAI in less than 2 yo

Question 9

when to suspect a posterior bleed in epistaxis

Answer 9

bleeding is profuse
both nostrils
site cannot be identified
if bleeding started first down throat

Question 10

sx suggestive of tumour in epistaxis

Answer 10

• nasal obstruction
• rhinorrhoea
• facial pain
• hearing loss
• persistent lymphadenopathy
• cranial neuropathy - facial numbness/double vision

Question 11

ix for epistaxis

Answer 11

clinical unless underlying cause suspected (FBC, clotting)

Question 12

mx of acute epistaxis

Answer 12

A-E
1. sit with upper body forward and mouth open
2. pinch cartilage 10-15mins - breath through mouth
3. if first aid works - give antiseptic cream for 10days
4. if not
* nasal cautery - if bleeding point can be seen, only do one side to avoid septal perforation
* nasal packing - if cautery is ineffective / bleeding point cant be seen - admit

Question 13

recommendations after acute epistaxis

Answer 13

avoid following for 24hrs
* blowing or picking nose
* heavy lifting
* strenuous exercise
* lying flat
* alcohol/hot drinks

Question 14

secondary care treatment for epistaxis

Answer 14

• Resuscitation — this may include transfusion to replace blood volume and provide coagulation factors.
• Formal packing (may be under general anaesthetic).
• Endoscopic assessment and electrocautery.
• Examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment).
• Radiological arterial embolization.
• Intravenous or oral tranexamic acid.

Question 15

mx of recurrent epistaxis

Answer 15

1. advise on first aid measures
2. determine underlying cause
3. refer tio ENT if sx of angiofibroma / cancer / telangiectasia
4. refer to paeds if less than 2 - consider NAI and underlying cause
5. topical antiseptic / cautery if no underlying cause

Question 16

when to suspect angiofibroma

Answer 16

males 12-20yrs
nasal obstruction
severe epistaxis