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Respiratory 4 > Epistaxis > Flashcards

Epistaxis Flashcards

1
Q

Epistaxis is the what of otolaryngology?

A

Epistaxis has been referred to as the albatross of otolaryngology

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2
Q

Epistaxis general information?

A

5-15% of the population suffers an episode of epistaxis each year. Up to 60% of the population will suffer an episode some time in their lives. 6-10% will require medical attention, only 1% of these patients will require a specialist.

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3
Q

Pathophysiology of epistaxis?

A
  • Nose is a very vascular organ which allows for proper heating and humidification of air.
  • Vasculature runs under mucosa, not squamous epithelial tissue
  • There are numerous arterial-venous anastamoses
  • Arterial system is high pressure – internal and external carotid artery
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4
Q

Branches of the maxillary branch of the external carotid feed what part of the nose?

A

Branches of maxillary branch of external carotid artery:

– Sphenopalatine

– Pharyngeal

– Descending palatine

– Posterior nasal

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5
Q

Branches of the internal carotid artery feed what part of the nose?

A

Branches of internal carotid artery:

– Anterior ethmoid

– Posterior ethmoid

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6
Q

Explain Kiesselbach’s Plexus (Little’s Area)?

A

– Area of the nasal septum where branches of sphenopalatine, anterior ethmoid, superior labial, and greater palatine arteries anastamose.

– Most Common location of anterior epistaxis • Most pediatric epistaxis is related to picking the nose in this area.

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7
Q

Explain Woodruff’s plexus?

A

– Posterior nasal – Ant. and posterior ethmoids – Pharyngeal branches of maxillary – Common site of posterior

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8
Q

Anterior vs posterior nosebleeds?

A
  • Maxillary sinus ostium separates one from the other
  • Anterior is most common (>90% of cases), occurs in younger patient, and is often less severe
  • Posterior is usually older patient and can be more serious
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9
Q

Explain local etiologies for nosebleeds?

A

Trauma (fracture or digital)– most common cause Iatrogenic– nasal prongs for O2, nasal steroids

Anatomic– septal deviation

Neoplasm

Desiccation– winter months

Foreign bodies

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10
Q

Explain systemic causes of nosebleeds?

A

Inflammation/Infection (rhinitis, sinusitis)

Coagulopathy

Vascular abnormalities

Hypertension

Drugs

Alcohol

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11
Q

Neoplasms that could cause nosebleeds?

A
  • Adenocarcinoma
  • Melanoma
  • Lymphoma
  • Juvenile nasopharyngeal angiofibroma
  • Inverted papilloma
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12
Q

inflammation/infections that can lead to nosebleeds?

A
  • SLE
  • Wegener’s Granulomatosis
  • Polyarteritis Nodosa
  • Syphilis
  • Tuberculosis
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13
Q

Coagulopathies that can lead to nosebleeds?

A
  • Platelet dysfunction – systemic disease (uremia) vs. drug induced (NSAIDS)
  • Thrombocytopenia
  • Hemophilia – A and B
  • Von Willebrand’s disease
  • Liver Failure
  • Hematologic Malignancy
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14
Q

How does age play a role in the likely etiology of nose bleeds?

A
  • Children – often digital trauma or foreign body. Of those with chronic epistaxis, 33% have a coagulopathy • Age: Epistaxis usually occurs in children aged 2-10 years. Occurrence is unusual in infants in the absence of a coagulopathy or nasal pathology (eg, choanal atresia, neoplasm). Local trauma (eg, nose picking) does not occur until later in the toddler years. Older children and adolescents also have a less frequent incidence. Consider cocaine abuse in adolescent patients.
  • Middle Age – trauma, idiopathic, neoplasm
  • Old Age - hypertension
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15
Q

Explain Osler, Weber, Rendu syndrome?

A
  • Also known as hereditary hemorrhagic telangiectasias
  • Causes arterialvenous fistulas on mucosal surfaces
  • 90% present with epistaxis
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16
Q

initial management of epistaxis?

A
  • ABC’s
  • History – HTN, Coumadin?
  • May need IV fluids if tachy or hypotensive
  • Labs – cbc, Pt/INR, PTT, activated thromboplastin
  • Radiologic studies – X-ray, Ct (for trauma)
17
Q

Physical exam of the nasal cavity?

A
  • Use of a large-sized, otologic, handheld speculum can be helpful
  • Begin the examination with inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or cautery.
  • Anterior bleeds from the nasal septum are most common, and the site frequently can be identified if bleeding is active.
  • Carefully remove by suction any large amount of clot.
18
Q

Examination of the pharynx?

A
  • Observe the posterior pharynx for constant dripping of blood that may signify a posterior rather than an anterior bleed.
  • After placement of an anterior pack, reassess this area and, if bleeding is noted in the pharynx with an anterior pack in place, strongly consider a posterior bleed
19
Q

Skin examination for epistaxis?

A

• Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality

20
Q

Management of Exsanguinating epistaxis?

A

Often related to trauma

  • Due to severe mid-face trauma
  • Laceration of the maxillary artery
  • Anterior and posterior packs
  • May require ligation of the external carotid artery under local anesthetic
21
Q

Management of Anterior and Posterior expistaxis?

A
  • Get control of HTN
  • Correct coagulopathies
  • Topical decongestants/vasoconstrictors
  • Cautery – chemical vs. electric
  • Nasal Packing (80-90% effective)
22
Q

Explain managment of epistaxis with vasoconstrictors?

A
  • First step after other conservative treatments have failed (squeezing nose shut for at least 10 minutes)
  • Should first try to visualize bleeding site so you know where it is
  • Use Afrin (or similar product) and spray liberally around bleeding area
  • May need to spray Afrin onto cotton ball and place directly onto bleeding site
23
Q

Management of chemical cautery to control epistaxis?

A

–First apply topical lidocaine

–Apply directly to bleeding site in a circular direction for at least 30 seconds

–Neutralize with saline

–May need to cover site with Oxycel or similar absorbable type gauze

24
Q

Management of electrocautery for control of epistaxis?

A
  • Use if Afrin and Silver Nitrate unsuccessful
  • May go directly to nasal packing
  • Again use lidocaine first
  • Monopolar or bipolar
  • Cover site with vaseline gauze
  • May require ENT consult for posterior bleeds
25
Q

Explain traditional anterior packs?

A
  • Use vaseline gauze
  • Left in for 3-4 days
  • Must be put on antibiotic prophylaxis
26
Q

Explain traditional posterior packs?

A
  • Used when anterior pack fails or if source is known to be posterior
  • Requires IV sedation for placement
  • Again need antibiotics
  • Requires monitored hospital bed and telemetry (risk of arrhythmias)
  • Remove in 3-5 days
27
Q

Explain newer packing methods?

A

Expandable Packs – Nugauze, Merogel Place along floor of nasal passage Expands as it absorbs water/blood Will hopefully cover bleeding site

28
Q

Balloons to help stop epistaxis?

A
  • Come in anterior and anterior/posterior style packs • Fill with saline, not air
  • Risk of pressure necrosis if over inflated
29
Q

Indications for surgery for epistaxis?

A
  • Persistent bleeding after proper packing
  • Massive bleed requiring multiple transfusions
  • Nasal anomaly that precludes packing (septal spur)
  • Failed medical management after 72 hrs.
30
Q

What is a septoplasy?

A

Septoplasty – Used to correct nasal deformities preventing packing or visualization of bleeding source

31
Q

Where does a maxillary artery ligation occur? failure rate?

A

• Ligate the maxillary artery in pterygopalatine fossa • Failure rate of 10-15%

32
Q

Anterior / Posterior Ethmoid Artery Ligation is used for? what incision? beware of?

A

Anterior / Posterior Ethmoid Artery Ligation

  • For posterior bleeds
  • Uses a Lynch incision
  • Must beware of optic nerve (4-7mm beyond posterior ethmoid)
33
Q

Two approaches to sphenoplalatine artery ligation? Failure rate?

A

Sphenopalatine Artery Ligation

  • Transantral (Caldwell-Luc) vs. Endoscopic (Transnasal)
  • Endoscopic approach utilizes an incision near the middle turbinate
  • Failure rate 0-13%
34
Q

When is Angiography/Embolization effective? sucess rate? complications?

A
  • Most effective in the following: – patients still bleeding after surgical ligation, – bleeding site difficult to reach surgically, – those with significant comorbidities that prohibit general anesthesia
  • Greater than 90% success rate
  • Minor complications 18-45% of the time
  • Major complications 0-2% of the time

Respiratory 4 (18 decks)

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