Epistaxis Flashcards
Epistaxis is the what of otolaryngology?
Epistaxis has been referred to as the albatross of otolaryngology
Epistaxis general information?
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.
Pathophysiology of epistaxis?
- 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
Branches of the maxillary branch of the external carotid feed what part of the nose?
Branches of maxillary branch of external carotid artery:
– Sphenopalatine
– Pharyngeal
– Descending palatine
– Posterior nasal
Branches of the internal carotid artery feed what part of the nose?
Branches of internal carotid artery:
– Anterior ethmoid
– Posterior ethmoid
Explain Kiesselbach’s Plexus (Little’s Area)?
– 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.
Explain Woodruff’s plexus?
– Posterior nasal – Ant. and posterior ethmoids – Pharyngeal branches of maxillary – Common site of posterior
Anterior vs posterior nosebleeds?
- 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
Explain local etiologies for nosebleeds?
Trauma (fracture or digital)– most common cause Iatrogenic– nasal prongs for O2, nasal steroids
Anatomic– septal deviation
Neoplasm
Desiccation– winter months
Foreign bodies
Explain systemic causes of nosebleeds?
Inflammation/Infection (rhinitis, sinusitis)
Coagulopathy
Vascular abnormalities
Hypertension
Drugs
Alcohol
Neoplasms that could cause nosebleeds?
- Adenocarcinoma
- Melanoma
- Lymphoma
- Juvenile nasopharyngeal angiofibroma
- Inverted papilloma
inflammation/infections that can lead to nosebleeds?
- SLE
- Wegener’s Granulomatosis
- Polyarteritis Nodosa
- Syphilis
- Tuberculosis
Coagulopathies that can lead to nosebleeds?
- Platelet dysfunction – systemic disease (uremia) vs. drug induced (NSAIDS)
- Thrombocytopenia
- Hemophilia – A and B
- Von Willebrand’s disease
- Liver Failure
- Hematologic Malignancy
How does age play a role in the likely etiology of nose bleeds?
- 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
Explain Osler, Weber, Rendu syndrome?
- Also known as hereditary hemorrhagic telangiectasias
- Causes arterialvenous fistulas on mucosal surfaces
- 90% present with epistaxis
initial management of epistaxis?
- 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)
Physical exam of the nasal cavity?
- 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.
Examination of the pharynx?
- 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
Skin examination for epistaxis?
• Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality
Management of Exsanguinating epistaxis?
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
Management of Anterior and Posterior expistaxis?
- Get control of HTN
- Correct coagulopathies
- Topical decongestants/vasoconstrictors
- Cautery – chemical vs. electric
- Nasal Packing (80-90% effective)
Explain managment of epistaxis with vasoconstrictors?
- 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
Management of chemical cautery to control epistaxis?
–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
Management of electrocautery for control of epistaxis?
- 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
Explain traditional anterior packs?
- Use vaseline gauze
- Left in for 3-4 days
- Must be put on antibiotic prophylaxis
Explain traditional posterior packs?
- 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
Explain newer packing methods?
Expandable Packs – Nugauze, Merogel Place along floor of nasal passage Expands as it absorbs water/blood Will hopefully cover bleeding site
Balloons to help stop epistaxis?
- Come in anterior and anterior/posterior style packs • Fill with saline, not air
- Risk of pressure necrosis if over inflated
Indications for surgery for epistaxis?
- Persistent bleeding after proper packing
- Massive bleed requiring multiple transfusions
- Nasal anomaly that precludes packing (septal spur)
- Failed medical management after 72 hrs.
What is a septoplasy?
Septoplasty – Used to correct nasal deformities preventing packing or visualization of bleeding source
Where does a maxillary artery ligation occur? failure rate?
• Ligate the maxillary artery in pterygopalatine fossa • Failure rate of 10-15%
Anterior / Posterior Ethmoid Artery Ligation is used for? what incision? beware of?
Anterior / Posterior Ethmoid Artery Ligation
- For posterior bleeds
- Uses a Lynch incision
- Must beware of optic nerve (4-7mm beyond posterior ethmoid)
Two approaches to sphenoplalatine artery ligation? Failure rate?
Sphenopalatine Artery Ligation
- Transantral (Caldwell-Luc) vs. Endoscopic (Transnasal)
- Endoscopic approach utilizes an incision near the middle turbinate
- Failure rate 0-13%
When is Angiography/Embolization effective? sucess rate? complications?
- 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
