Epistaxis
- 1. Done by Dr. Nawras Mahir Farhan
- 2. Epistaxis - Introduction • One of the most frequent causes of bleeding. About 5-10% of population experience an episode of epistaxis each year • Epistaxis : is bleeding from nose , through Ant. Or Post. Nares • The origin of blood : from nose, nasopharynx, paranasal sinuses or Ant. Cranial fossa .
- 3. Local Causes of Epistaxis • Idiopathic 85% • Nasal trauma (nose picking, foreign bodies, fracture nasal bone • inflammatory : Allergic, chronic or infectious rhinitis Or sinusitis • Iatrogenic : surgery or Medications (topical) • Neoplasms of the nose or sinuses • Tumors of the nasopharynx especially Nasopharyngeal Angiofibroma • Vascular malformation
- 4. Systemic Causes of Epistaxis • Anticoagulants : Aspirin , Warfrin • Systemic arterial hypertension • Hereditary hemorrhagic telangectasias • Blood diseases and coagulopathies : Thrombocytopenia, ITP, Leukemia, Hemophilia OR Platelet dysfunction • Hepatorenal diseases
- 5. Nasal Blood Supply * A. INTERNAL carotid a. system via opthalmic a. (ant.&post. Ethmoidal a.) Supply the roof of nasal cavity * B. EXTERNAL carotid a. system -Via internal maxillary branches) -Sphenopalatine a. is the major a. of nasal cavity . Supply the rest of the nasal (terminal cavity
- 6. Nasal Blood Supply LITTLE`S AREA: •Is higly vascularized area at anteroinferior aspect of septum (confluence of arteries) : •Supplied by : -Shenoplalatine a. - superior labial a. - ant. Ethmoidal a. - greater palatine a.
- 7. LOCATION of Epistaxis •ANTERIOR : account for 70% of epistaxis and primarily at LITTLE`S AREA •POSTERIOR : Less common and may be associated more with hypertension & atherosclerosis …. Most often occur post. To the middle turbinate (sphenopalatine a. branch )
- 8. CLINICAL APPROACH History & Assessment •Make sure that the patient is not in shock • Remember ABC • Determine : -Duration - quantity - hypovolemia symptoms - previous Hx. Of epistaxis - predisposing medical condition - potentially contributing medication
- 9. Physical Exam - Equipment • Protective equipment - gloves, safety goggles , headlight if available, Nasal Speculum • Vasoconstricting agent (such as oxymetazoline) • Topical anesthetic • Apply decongestant • Identify bleeder site by ant. Rhinoscopy • Consider cautry with silver nitrate or suction cautry • most epistaxis respond to Ant. Packing
- 10. NASAL PACKING ANTERIOR PACKING *Formed expandable sponges are very effective &Available in many shapes, sizes and some are soaked with antibacterial properties * Traditional Ant. Pack : by applying 1/2 inch Gauze which is. Coated with •topical antibiotic ointment prior to placement
- 11. NASAL PACKING POSTERIOR PACKING * Balloon-type episaxis devices often easiest by filling balloons” with water, not air and Oriented in direction as shown *Traditional post. Nasal packing -Note : it need admission + oxygen
- 12. GENERAL NOTES - Pack remain in place 3-5days - pain medication is essential - patient should receive AB covering staph. Aureus (toxic shock) - ELDERLY patient necessitate ICU observation , oximetry & oxygen - if no site found so x-ray and CT to rule out occuled malignancy
- 13. Surgical managment •Submucosal resection • A nt. & post. Ethmoidal a. ligation • Internal maxillary a. ligation • External carotid a. ligation
- 14. Complication • **** of post. Packing • Must be careful after placement of a posterior pack to avoid necrosis of the nasal ala • Sinusitis • Abscesses • Neurogenic syncope • Toxic shock syndrome • Persistent bleeding and restart of bleeding, in spite of above interventions • **** bilateral silver nitrate cautary cause septal necrosis
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