Epistaxis Dr Abdussalam M jahan ENT depart Misurata

Epistaxis Dr. Abdussalam M jahan ENT depart, Misurata university, faculty of medicine

Arterial supply of the septum

Kiesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (ICA) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX) Woodruff’s Plexus: - Sphenopalatine A (Pharyngeal & Post. Nasal (IMAX) branches) -Posterior ethmoid (ICA)

Classification: Anterior epistaxis (90%) Bleeding from Little’s area. Controlled by an anterior pack Younger patients Posterior Occurs epistaxis (10%) in the area of Woodruff’s plexus Older patients Epistaxis not controlled by anterior nasal packing.

Etiology: Local Factors - Inflammation URI allergic rhinitis Sinusitis Increased vascularity and greater friability of vessels in inflamed mucosa

-Trauma Nose picking Nose blowing/sneezing Nasal fracture Nasogastric/nasotracheal intubation Trauma to sinuses, orbits, middle ear, base of skull Barotrauma

-Iatrogenic nasal injury Functional endoscopic sinus surgery Septoplasty or Rhinoplasty Nasal reconstruction

-Neoplasm Juvenile angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Lymphoma

-Others: Cold, dry air—more common in wintertime Dry heat. Anatomic abnormalities (ie: nasal septal deformity turbulent flow (dry mucosa leading to crusting) Atrophic rhinitis

foreign bodies Intranasal parasites Septal perforation Chemical (cocaine, nasal sprays, ammonia)

Systemic factors Vascular. Infection/Inflammation. Coagulopathy.

- Vascular: Hypertension Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) subepidermal vessels lacking elastic tissue in capillary wall and deficiency of smooth muscle

– Infection/Inflammation Tuberculosis Syphillis Wegener’s Granulomatosis Periarteritis nodosa SLE

– Coagulopathies Primary coagulopathies (hemophilia, von Willebrand’s disease, thrombocytopenia and polycythemia vera). Secondary coagulopathies (uremia, alcoholism, chronic liver disease, leukemia, myeloma, aplastic anemia, idiopathic thrombocytopenis purpura or hypovitaminosis). Iatrogenic coagulopathies (heparin)

Etiology and Age Children - foreign body, nose picking Adults - trauma, idiopathic Middle age - tumors Old age - hypertension

Management: ØInitial Management: ABC’s. Vital signs—need IV. Medical history/Medications. Labs. Physical exam – Rhinoscopy

Exam and treatment options

ØNon-surgical treatments Topical decongestants/vc. Cautery (Ag. No 3) Nasal packing. Control of hypertension Correction of: coagulopathies/thrombocytopenia

Nasal packing: Anterior nasal packs Traditional Recent modifications Posterior nasal packs Traditional Recent modifications

Packing

Posterior Packs – Admission Elderly and those with other chronic diseases may need to be admitted to the ICU Continuous cardiopulmonary monitoring Antibiotics Oxygen supplementation may be needed Mild sedation/analgesia IVF

Discharge instructions Humidity/emolients Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining Avoid hot/spicy food

Indications for surgery: Continued bleeding despite nasal packing Nasal anomaly interfering with packing Patient refuse/intolerance of packing Posterior bleeding with failed non surgical treatment after >72 hrs

Surgical treatment: Transmaxillary IMA ligation Transnasal Sphenopalatine ligation External carotid artery ligation Anterior/Posterior Ethmoidal A. ligation Last one

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