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Nose > Epistaxis > Flashcards

Epistaxis Flashcards

1
Q

Epistaxis defn

A

Bleeding from inside the nose is called epistaxis

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2
Q

Epistaxis is
A. Sign
B. Disease

A

A. Sign

Therefore an attempt should always be made to find any local or constitutional cause

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3
Q

Blood supply of nasal septum

A

INTERNAL CAROTID SYSTEM
1. Anterior ethmoidal artery
2. Posterior ethmoidal artery
-Branches of ophthalmic artery
EXTERNAL CAROTID SYSTEM
1. Sphenopalatine artery (branch of maxillary artery) gives nasopalatine and posterior medial nasal branches
2. Septal branch of greater palatine artery (branch of max- illary artery).
3. Septal branch of superior labial artery (branch of facial artery).

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4
Q

Blood supply of lateral wall of nose

A

INTERNAL CAROTID SYSTEM

  1. Anterior ethmoidal artery 2. Posterior ethmoidal artery
    - Branches of ophthalmic artery

EXTERNAL CAROTID SYSTEM

  1. Posterior lateral nasal branches → From sphenopalatine artery
  2. Greater palatine artery → From maxillary artery
  3. Nasal branch of anterior superior dental → From infraorbital branch of maxillary artery
  4. Branches of facial artery to nasal vestibule
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5
Q

Location of little area

A

anterior inferior part of nasal septum

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6
Q

Arteries forming little area

A

anterior eth- moidal, septal branch of superior labial, septal branch of sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called “Kiesselbach’s plexus”

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7
Q

Little area is also called as

A

Kiesselbach’s plexus

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8
Q

common site of venous bleeding in young people

A

Retrocolumellar vein runs vertically downwards just behind the columella, crosses the floor of nose and joins venous plexus on the lateral nasal wall

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9
Q

WOODRUFF’S PLEXUS

A

plexus of veins situated inferior to posterior end of inferior turbinate. It is a site of posterior epistaxis in adults.

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10
Q

Local causes of epistaxis in nose

A 
Trauma
Infections 
Foreign bodies 
Neoplasms of nose and paranasal sinuses Atmospheric changes 
Deviated nasal septum
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11
Q

Local cause of epistaxis in nasopharyx

A
  1. Adenoiditis.
  2. Juvenile angiofibroma.
  3. Malignant tumours.
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12
Q

Cvs cause of epistaxis

A

Hypertension, arterioscle- rosis, mitral stenosis, pregnancy (hypertension and hormonal).

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13
Q

Disorders of blood and blood vessels causes of epistaxis

A

Aplastic anaemia, leukaemia, thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K defi- ciency and hereditary haemorrhagic telangectasia.

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14
Q

Liver causes of epistaxis

A

Hepatic cirrhosis (deficiency of factor II, VII, IX and X).

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15
Q

Kidney causes of epistaxis

A

Chronic nephritis.

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16
Q

Drugs causing epistaxis

A

-Excessive use of salicylates and other analgesics
(as for joint pains or headaches),
-anticoagulant therapy(for heart disease).

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17
Q

Mediastinal compression causes of epistaxis

A

Tumours of mediastinum

raised venous pressure in the nose

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18
Q

Acute general infection causes of epistaxis

A

Influenza, measles, chick-

enpox, whooping cough, rheumatic fever, infectious mononucleosis, typhoid, pneumonia, malaria and den- gue fever.

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19
Q

epistaxis occurring at the time of menstruation

A

Vicarious menstruation

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20
Q

Many times the cause of epistaxis is due to

A

IDIOPATHIC

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21
Q

Site of epistaxis

A
  • Little’s area.
  • Above the level of middle turbinate
  • Below the level of middle turbinate
  • Posterior part of nasal cavity.
  • Diffuse
  • Nasopharynx.
22
Q

Vessels involved in Above the level of middle turbinate in epistaxis

A

anterior and posterior ethmoidal vessels (internal carotid system).

23
Q

Vessels involved in Below the level of middle turbinate in epistaxis

A

branches of sphenopalatine artery. It may be hidden, lying lateral to middle or inferior turbinate

24
Q

Diffuse SITES OF EPISTAXIS means

A

Both from septum and lateral nasal wall. This is often seen in general systemic disorders and blood dyscrasias.

25
Q

Classification OF EPISTAXIS

A

ANTERIOR EPISTAXIS

POSTERIOR EPISTAXIS

26
Q

ANTERIOR EPISTAXIS

A

When blood flows out from the front of nose with the patient in sitting position.

27
Q

POSTERIOR EPISTAXIS

A

Mainly the blood flows back into the throat. Patient may swallow it and later have a “coffee-coloured” vomitus. This may erroneously be diagnosed as haematemesis.

28
Q

FIRST AID in epistaxis

A

Little’s area - pinching the nose with thumb and index finger for about 5 min ➡️compresses the vessels of the Little’s area

29
Q

Trotter’s method FIRST AID in epistaxis

A

patient is made to sit, leaning a little forward over a basin to spit any blood and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflex vasoconstriction.

30
Q

CAUTERIZATION

A

useful in anterior epistaxis when bleeding point has been located. The area is first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or coagulated with electrocautery.

31
Q

CAUTERIZATION is done with

A

bead of silver nitrate or coagulated with electrocautery.

32
Q

ANTERIOR NASAL PACKING is done only when

A

bleeding is profuse and/or the site of bleeding is difficult to localize

33
Q

ANTERIOR NASAL PACKING

A

use a ribbon gauze soaked with liquid paraffin. About 1 m gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front (Figure 33.3). One or both cavities may need to be packed. Pack can be removed after 24 h, if bleeding has stopped. Sometimes, it has to be kept for 2–3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.

34
Q

POSTERIOR NASAL PACKING indication

A

patients bleeding posteriorly into the throat

35
Q

POSTERIOR NASAL PACKING procedure

A

A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rub- ber catheter is passed through the nose and its end brought out from the mouth (Figure 33.4). Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed to hang in the oropharynx. It helps in easy removal of the pack later. Patients requiring post- nasal pack should always be hospitalized. Instead of postna- sal pack, a Foley’s catheter size 12–14 F can also be used. After insertion balloon is inflated with 5–10 mL of saline. The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal pack is kept in the usual manner. These days nasal balloons are also avail- able (Figure 33.5). A nasal balloon has two bulbs, one for the postnasal space and the other for nasal cavity.

36
Q

ENDOSCOPIC CAUTERIZATION

A

Using topical or general anaesthesia, bleeding point is local- ized with a rigid endoscope. It is then cauterized with a mal- leable unipolar suction cautery or a bipolar cautery. The procedure is effective with less morbidity and decreased hospital stay.

37
Q

limitation of ENDOSCOPIC CAUTERIZATION

A

profuse bleeding does not permit localization of the bleeding point.

38
Q

ELEVATION OF MUCOPERICHONDRIAL FLAP

AND SUBMUCOUS RESECTION (SMR) OPERATION indication

A

persistent or recurrent bleeds from the septum

39
Q

ELEVATION OF MUCOPERICHONDRIAL FLAP

AND SUBMUCOUS RESECTION (SMR) OPERATION procedure

A

elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels.
SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.

40
Q

LIGATION Is performed in which VESSELS

A

External carotid
Maxillary artery
Ethmoidal arteries

41
Q

LIGATION OF VESSELS of External carotid

A

When bleeding is from the exter- nal carotid system and the conservative measures have failed, ligation of external carotid artery above the origin of superior thyroid artery should be done

42
Q

Ligation of Maxillary artery’s indication

A

uncontrollable posterior epistaxis.

43
Q

Maxillary artery Ligation procedure

A

Caldwell–Luc operation

Posterior wall of maxillary sinus is removed and the maxillary artery or its branches are blocked by applying clips.

44
Q

Caldwell–Luc operation is superceded by

A

transnasal endoscopic sphenopalatine artery ligation

45
Q

Indication for ligation of Ethmoidal arteries

A

nterosuperior bleeding above the middle turbinate, not controlled by packing

46
Q

Incision made in ligation of Ethmoidal arteries

A

Lynch incision -The vessels are exposed in the medial wall of the orbit by an external ethmoid incision

47
Q

What is TESPAL

A

TRANSNASAL ENDOSCOPIC SPHENOPALATINE ARTERY LIGATION

48
Q

Procedure for TESPAL

A

The procedure can be done with rigid endoscopes under topical anaesthesia with sedation or under a general anaes- thesia. A mucosal flap is lifted in posterior part of lateral nasal wall, sphenopalatine artery (SPA)is localized as it exits the foramen and closed with a vascular clip. Distal branches of the artery can be additionally cauterized and the flap then reposited. Anterior ethmoidal artery can also be ligated by Lynch incision as an adjunctive procedure. SPA ligation gives high success in control of refractory posterior bleed

49
Q

EMBOLIZATION procedure

A

It is done by an interventional radiologist through femoral artery catheterization. Internal maxillary artery is localized and the embolization is performed with absorbable gelfoam and/ or polyvinyl alcohol or coils. Both ipsilateral or bilateral emboli- zations may be required for unilateral epistaxis because of cross circulation. Embolization is generally a safe procedure but may have potential risks like cerebral thromboembolism, haema- toma at local site. Ethmoidal arteries cannot be embolized.

50
Q

GENERAL MEASURES IN EPISTAXIS

A
  1. Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting.
  2. Reassure the patient. Mild sedation should be given.
  3. Keep check on pulse, BP and respiration.
  4. Maintain haemodynamics. Blood transfusion may be required.
  5. Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 h.
  6. Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex.
  7. Investigate and treat the patient for any underlying local or general cause.
51
Q

Hereditary haemorrhagic telangiectasia

A

It occurs on the anterior part of nasal septum and is the cause of recurrent bleeding

52
Q

Rx for Hereditary haemorrhagic telangiectasia

A
  • Argon, KTP or Nd: YAG laser

- septodermoplasty - where anterior part of septal mucosa is excised and replaced by a split-skin graft

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