epistaxis

EPISTAXIS

DEPARTMENT OF OTORHINOLARYNGOLOGY

– HEAD&NECK SURGERYPADJADJARAN

UNIVERSITY/ HASAN SADIKIN HOSPITAL

BANDUNG

INTRODUCTIONEPISTAXIS Any bleeding from the nose caused

by haemostatic disturbance

Haemostatic abnormality•Mucous abnormality•Vascular pathology•Coagulation disorders

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EPIDEMIOLOGY Prevalens: 7% - 14%. Recurrence

4%. Age : < 10 , > 35Based on source of bleeding :

Anterior epistaxis esp. child – young adult

Posterior epistaxis old ageCold climate and low humidity >>

DRYNESS

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ANATOMY A. Carotis Eksterna

A. MaksilarisA. Fasialis

A. Carotis InternaA. Oftalmika A. Ethmoidales

anterior & posterior

5Adapted from : Netter Atlas

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CLASSIFICATION

Anterior epistaxis : occurs primarily in the Little’s area

(Kiesselbah’s plexus) and more often venous in origin.

Posterior epistaxis : primarily in the region of the posterior septum, posterior lateral nasal wall (Woodruff’s

nasopharyngeal plexus) & posterior septum more often arterial in origin

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ETIOLOGYLOCAL

Trauma: digital, fractures

Nasal sprays Inflammatory

reactions Anatomic

deformities Foreign bodies Intranasal tumors Chemical inhalants Nasal prong O2,

CPAP Surgery

SYSTEMIC Hypertension Vascular

disorders Blood dyscrasias Hematologic

malignancies Allergies Malnutrition Alcohol Drugs (aspirin,

etc) Liver / renal

disease

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EVALUATION

INITIAL : COMPRESSION OF THE NOSTRIL (5-20 MIN)

PLUGGING WITH GAUZE OR COTTON SOAKED IN TOPICAL ANESTHETIC – DECONGESTAN

TILTING HEAD FORWARD PREVENTS POOLING BLOOD TO POSTERIOR PHARYNX AVOIDING NAUSEA & OBSTRUCTION

SECURING HEMODYNAMIC STABILITY & AIRWAY PATENCY FLUID RESUSCITATION

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EVALUATION NO RESPOND LOCATE THE SOURCE OF BLEEDING : ANTERIOR RHINOSCOPY / NASOENDOSCOPY

WITH PROPER LIGHT SOURCE & INSTRUMENT

SELF PROTECTION

REDUCE THE ANXIETY

A THROUGH HISTORY SHOULD BE TAKEN WITH ATTENTION TO DURATION, FREQUENCY, SEVERITY FAMILY HISTORY / BLEEDING DISORDER?

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INSTRUMENT

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PHYSICALEXAMINATION• General status• Local status

Determine : - Anterior or

posterior - Other stigmata

MANAGEMENT AIMED

Stop the bleedingAvoid complicationAvoid recurrence

Most anterior epistaxis self limitedControlled by pinching ala nasi 5 – 20

min

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Minor Hemorrhagestop spontaneously pediatric population, > 64% having experienced epistaxis

Antiseptic creamBarrier agent

Anterior nasalpackingRemoved after 20 men

Silver nitrat cauteryElectric cautery

MANAGEMENT

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Major Hemorrhage Emergency active epistaxis

Ensure adequate iv access & resuscitation

•Blood cloots out of his or her nose•Explore with speculum or nasal endoscopy and suction

• Anterior bleeders ant nasal pack or cautery

•Posterior bleeders post nasal pack arterial ligation or embolization is performed

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MANAGEMENT

DIFFUSE / OOZING, MULTIPLE BLEEDING SITE OR RECURRENT BLLEDING INDICATE SYSTEMIC PROCESS

HEMATOLOGIC EVALUATION

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MANAGEMENT•TRADITIONAL•Ribbon gauze with

vaselin / antibiotic oinment

•OTHERS•Non absorbable•Absorbable

NASAL PACKIN

Ganterior

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Anterior Nasal Packing

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MANAGEMENT

NASALPACKING

POSTERIOR

BELLOCQ TAMPONFOLEY CATHETERBALLOON PACK

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Posterior Nasal Packing (Bellocq tampon)

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Balloon Pack

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SURGERY

LIGATION A. ETHMOIDALES ANTERIOR A. MAXILLARIS A. SPHENOPALATINA A. CAROTID EXTERNA

EMBOLIZATIONSEPTAL DERMOPLASTY,

SEPTOPLASTY

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AVOID COMPLICATIONCOMPLICATION

HYPOVOLEMIC SHOCK APNEA, HYPOXIA SEPTAL PERFORATION

ALAR RIM, COLUMELLA NECROSIS, LASERATION PALATUM MOLLE / LIPS

ASPIRATION RECALCITRANT

BLEEDING INFECTION

AVOIDANCE IV FLUID MONITOR O2 LIMITED CAUTERY,

PROPER PACK SIZE STABILIZATION PACKING

WITHOUT CONTACT WITH ALAR / COLUMELLA

ADEQUATE PLACEMENT & SECURING NASAL PACKS

PROPHYLACTIC ANTIBIOTICS

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AVOID RECURRENCE

Patient education Avoidance of digital manipulation,airborne irritants, dander, smoke

Keep the nose moistControl of allergies Tappering amount of nasal spray Intranasal surgical technical

refinements

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SUMMARY GOOD EVALUATION & HISTORY PREPARATION &

PLANNING

PROPER INSTRUMENTATION

DON’T PANIC !

MANAGEMENT : CONSERVATIVE, COMFORTABLE, IF FAILED SURGERY

AVOID COMPLICATION FROM BLEEDING & OR MANAGMENT

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ANTERIOR NASAL PACKING PROCEDURE

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LEARNING GUIDE: ANTERIOR NASAL PACKING PROCEDURE 

No Procedures

Performance Scale

0 1 2 3

Preparation

1 Greet the patient respect fully and with kindness introduce yourself.

2 The patient should be given adequate explanation about examinations.

3 Explain the goals or the expected result examination.Check the instrument& material.

Procedures

4 Hold the nasal speculum with one hand and then put in on the left or right nostril

5 Holt it with the thumb on the joint, the index finger free to steady it on the patient’s nose and the rest of the fingers on the stem proper to hold the speculum

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6 Always try to open the stem or times in an upward action and not down into the floor or the nose. The good view of the nose anteriorly can be obtained simply by pressing on the tip of the nose

7 Topical anesthesia can be administered in order to decreasing discomfort, the risk of apnea, bradycardia, and hypotension by blocking the nasal-vagal reflex. A pledget or cotton swab soaked in 1 % pantocaine or lidocaine solution (with or without containing 1-2 drops of an epinephrine solution dilutes 1:1,000) is placed in the nose for 3-5 minutes

8 The traditional anterior pack petrolatum gauze (0.5 x 72 inch) coated with an antibacterial ointment is firmly packed into the nasal cavity

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9 The packing is placed in a methodical (layering) fashion toward the posterior choana, starting at the nasal floor and packing up to about the level middle turbinate. It is possible to put a large amount into each side

10 Great care must be taken that :-      The pack does not rub on the columella, which is easily traumatized-      The free and of the packing should not be visible in the oropharynx behind the soft palate as this can lead to irritation, and also a danger that this portion might slip deeper into the aerodigestive tract and cause complication

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11 Once the gauze is firmly packed properly into the nasal cavity:-      The patient should be admitted and kept under careful observation -      Give the patient humidifies oxygen and sedate with caution and only with reversible agents-      As the pack will be left in for at least 48 hours, put the patient on a board-spectrum antibiotic-      Establish an intravenous line, and cross-match the blood

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