epistaxis Flashcards
what are local causes of epistaxis?
Local causes :
1- Idiopathic : - Bleeding from little area. - The commonest cause of epistaxis 90%. - Occurs spontaneously, may be initiated by slight trauma or change of
atmosphere. - Occurs mainly in children and adolescents.
2- Congenital : hereditary haemorrhagic telengiectasia.
3- Traumatic : - Accidental : nose picking, foreign body, fracture nasal bones and fracture
skull base. - Post nasal operations.
4- Inflammatory : acute rhinitis and sinusitis.
5- Neoplastic : - Benign (haemangioma) and malignant (carcinoma). - Nasopharyngeal angiofibroma (severe epistaxis). - Nasopharyngeal carcinoma.
6- Septal deviation.
what are the general causes of epistaxis?
General causes :
1- High arterial blood pressure (hypertension) :
ff-
Mostly from the posterior part of the nose.
gg- The commonest cause of epistaxis in elderly patients. - 325 -
2- High venous blood pressure due to heart failure and mediastinal
tumours.
3- Fevers e.g. rheumatic fever and exanthemata due to toxic capillarities
(vasculitis).
4- Haemorrhagic blood diseases e.g. purpura, haemophilia, leukaemia and
vit. C or K deficiency.
5- Drugs as anti-coagulants, non steroidal anti-inflammatory drugs and
salicylate.
6- Hormonal: during menses.
what are sites of bleeding in nose?
1- Little’s area: is the commonest site.
2- Above the middle turbinate (upper part of the nasal cavity). From the
anterior and posterior ethmoidal arteries.
3- Below the middle turbinate (posterior part of the nasal cavity): from the
sphenopalatine artery (artery of epistaxis).
4- The middle meatus, the inferior turbinate and floor: are rare sites.
clinical picture of epistaxis
Clinical picture :
1) Bleeding may be anterior (nasal) or posterior (post-nasal) or with
both.
2) Unilateral or bilateral.
3) Mild or severe.
what are investigations of epistaxis?
Investigations :
1- Blood pictures (anemia, leukemia).
2- Coagulation profile for bleeding tendency.
3- Liver function tests.
4- CT scan (nose and nasopharynx).
5- Biopsy : if tumor is seen.
how to control bleeding in mild and moderate attack?
i- First aid :
The patient sites with the head leant forwards (to prevent swallowing of
blood), the nostrils are compressed by the fingers (to compress little’s area),
apply cold compresses over forehead and nasal bridge (to induce reflex
vasoconstriction), packing nasal fossae using piece of cotton soaked with
vasoconstrictor solution.
ii- Cautery : Under local anesthesia
kk- Chemical using chronic acid or silver nitrate crystals.
ll- Electrical (diathermy).
iii- Anterior nasal pack :
When above lines fails using Vaseline gauze, inflatable tampons or merocel
sponges for 24-48 hours under antibiotic cover.
How to control bleeding in severe cases?
If the patient is shocked, treatment of shock should start immediately.
i- Treatment of shock :
mm- Patient head down (elevation of foot of bed) to increase blood
flow to the brain.
- I.V fluids and blood transfusion according to Hb %.
- Sedative as diazepam, avoide morphia (to avoid respiratory
center depression).
- I.V corticosteroids.
- Monitoring vital signs e.g. pulse, blood pressure, temperature and
urinary output.
ii- Anterior nasal pack.
iii- Posterior nasal pack :
- Used if anterior pack fail or if the bleeding is posterior – using
Vaseline pack (under general anesthesia), inflatable balloon or
fooly’s catheter.
iv- Surgical control :
When nasal packing fails to control bleeding.
ss- Ligation of anterior ethmoidal artery via the orbit if bleeding is
coming from above the middle turbinate.
tt- Ligation of internal maxillary artery in pterygopalatine fossa through
radical antrostomy if bleeding comes from below the middle
turbinate.
uu- Endoscopic ligation of sphenopalatine artery.
N.B. Ligation of external carotid artery in the neck is less effective due to
cross anastmosis.
v- Emoblization : Angiography to detect the bleeding vessel then injection of
embolus (e.g. Gelatin sponge) to occlude it.
