Epistaxis Flashcards
Describe the blood supply to the nasal septum
Blood supply to the nose can be divided into:
- Branches of the internal carotid
- Branches of the external carotid
What are the branches of the internal carotid?
- opthalmic artery
- anterior ethmoidal
- posterior ethmoidal
What are the branches of the external carotid?
-
Facial artery ->
- superior labial artery, angular artery
-
Maxillary artery ->
- sphenopalatine artery
- greater palatine artery
What is ‘Little’s area’?
- AKA Kiesselbach’s plexus
- region in the anterioinferior part of the nasal septum
- where 4 arteries anastamose to form a plexus:
- anterior ethmoidal artery
- sphenopalatine artery
- greater palatine artery
- septal branches of superior labial artery
- 90% of nosebleeds occur here
Epistaxis can be divided into anterior or posterior. What is anterior?
- 90%
- bleeding almost always occurs from Little’s area
- source of bleeding is obvious
What is posterior epistaxis?
usually arises in the posterior nasal cavity at the following sites:
- behind posterior part of middle turbinate
- posterior suprior part of the roof of nasal cavity
- involves branches of sphenopalatine artery and mayr esult in sudden massive bleeding
What are the local causes of epistaxis?
- idiopathic
- trauma (nose picking, fracture, foreign body, sneezing)
- nasal allergy
- infection eg. sinusitis
- tumours (angiofibroma, hemangioma, malignancy)
- hereditary telangiectasia
What are the systemic causes of epistaxis?
- hypertension
- cardiac -> CCF, mitral stenosis
- pulmonary -> COPD
- cirrhosis -> vit K def
- coagulopathies -> haemophilia, leukaemia, agranulocytosis
- exanthematous fevers
- hormonal -> vicarious menstruation, endometriosis
- drugs -> XS salicylates, anticoagulant therapy
Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of haemodynamic compromise.
When is it likely required?
- there is severe bleeding
- patient is older
- patient is unwell or frail
These patients need ABC approach, look out for symptoms of haemodynamic instability
What are the initial conservative measures for acute active bleeding?
- entire lower compressible cartilage of nose is pinched
- to apply pressure to possible anterior bleeding sites
- ice pack
- bed rest
For initial measures, what topical agent can be applied to help stop bleeding?
- liberal application of a topical vasoconstrictor (decongestant)
- oxymetazoline
- can be diagnostic + therepeautic
- help visualise epistaxis site and encourage haemostasis
- can then also apply topical anaesthetic
- if bleeding continues, can soak cotton wool in above agents and apply to nose
What should the patient do to remove possible blood clots?
- blows nose to clear blood + clots
- suction may be used
What can be done to stop any obvious, visible bleeding?
- silver nitrate cautery
- uncomfortable
- use petroleum jelly after for moisturisation
- important to avoid cautery at same location on both sides of septum -> can result in septal perforation
- electrocautery indicated for brisker bleeding resistant to silver nitrate cautery (done by ENT consultant)
If cautery fails to control bleeding, what can be done next, surgically?
-
anterior nasal packing
- traditional packing vs expanding nasal sponges
- anterior-posterior nasal packing if above fails
- posterior packing:
- double-balloon epistaxis device
- traditional gauze anterior pack w/ foley urinary catheter placed posteriorly
- endoscopic management of epistaxis sites
- angiography and embolisation w/ interventional radiology
- open surgical ligation
