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

medicine

Epistaxis

Arterialsupply 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

branches) (IMAX)

-Posterior ethmoid (ICA)

Classification:

Anterior epistaxis (90%) Bleeding from Little’s area. Controlled by an anterior pack Younger patients

Posterior epistaxis (10%) Occurs in the area of Woodruff’s plexus Older patients Epistaxis not controlled by anterior nasal

packing.

Local Factors - Inflammation

URI allergic rhinitis Sinusitis

Increased vascularity and greater friability of vessels in inflamed mucosa

Etiology :

-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/Inflammatio

n

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:

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

Rhinoscopy

Initial Management:

Exam and treatment options

Non-surgical treatments

Topical decongestants/vc. Cautery (AgNo3) 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 >72hrs

:Surgical treatment

Transmaxillary IMA ligation Transnasal Sphenopalatine ligation External carotid artery ligation Anterior/Posterior Ethmoidal A.

ligation

Last one

The end www.zahrawi.ly