Epistaxis ashly
- 1. EPISTAXIS Dr.ASHLY ALEXANDER DEPT OF ENT GMC,BHOPAL
- 2. “ Acute Hemorrhage from the Nostril, Nasal Cavity or Nasopharynx”
- 3. Vascular anatomy of the nose External Carotid Artery FacialArtery Superior Labial Lateral Nasal Ascending Palatine Maxillary Artery Greater Palatine Sphenopalatine Lateral Nasal Posterior Septal Internal Carotid Artery Anterior Ethmoidal Posterior Ethmoidal
- 4. KIESSELBACH’S PLEXUS (Little’s area) • In anterior inferior part of nasal septum • Most common site for Epistaxis • Mainly anterior epistaxis 1. septal br. Of sphenopalatine 2. Anterior ethmoidal 3. Septal br. Of superior labial 4. greater palatine arteries
- 5. WOODRUFF’S PLEXUS • Posterior end of inferior Turbinate • Venous plexus • Most common site for posterior epistaxis
- 6. CLASSIFICATION • Primary – no proven causal factor • Secondary- proven causal factor present
- 7. CLASSIFICATION Adult Vs Childhood Epistaxis 1. Childhood Epistaxis <16yrs 2. Adult Epistaxis >16yrs • There is a pronounced bimodal distribution in onset of Epistaxis • More common in childhood, becomes less common in early adulthood and peaks again in 6th decade
- 8. CLASSIFICATION Anterior Posterior Incidence More common Less common Site Little’s Area or anterior part of nasal septum Posterosuperior part of nasal cavity Age Children and young Adults >40yrs Cause Traumatic Spontaneous Bleeding Mild Severe
- 9. LOCAL CAUSES 1. Congenital : unilateral choanal atresia, meningocoele, encephalocoele, hemangioma etc.. 2. Acquired : INFECTIONS- Acute – Viral, Bacterial, Fungal Chronic Specific – tuberculosis, Syphylis, Leprosy, Rhinoscleroma Chronic Non specific – Ozoaena • Inflammatory – Rhinosinusitis, Nasal Polyposis • Trauma/ Foreign Body(Living/Non-Living) • Idiopathic • Neoplastic – Juvenile angiofibroma, etc.. • Drug Induced – Rhinitis Medicamentosa • Inhalants- tobacco, cannabis, mercury, wood dust, heroin, chrome, phosphorus
- 10. SYSTEMIC CAUSES Hypertension- commonest Cardiac –CCF, Mitral stenosis Pulmonary –COPD Cirrhosis – Vitamin K deficiency Renal –Nephritis Drugs – Excessive use of salicylates , anticoagulants Hormonal – Vicarious Menstruation, Endometriosis,granuloma gravidarum Coagulopathies – • Clotting disorders • bleeding disorders • Agranulocytosis • Leukemia • Vitamin K deficiency • Exanthematous fevers Idiopathic Causes
- 11. PATIENT HISTORY • Previous bleeding episodes • Onset, duration, frequency, amount of blood loss • h/o trauma • Family history of bleeding • Hypertension • Hepatic diseases • Drug history • Any other medical ailment
- 12. MANAGEMENT • Locate the bleeding site • Anterior and Posterior rhinoscopy • Diagnostic Nasal Endoscopy • INVESTIGATIONS : Hematological investigations – Hb%, TLC, DLC, BT, CT, Platelet count, prothrombin time Blood urea, liver function tests Radiology – x-ray and CT scan of nose, PNS and Nasopharynx Other investigations depending upon the possible cause
- 13. Trotter’s method • Old fashioned method of controlling epistaxis • Pt is made to sit upright with cork between the teeth and allowing the pt to bleed till he becomes hypotensive • Complication – Coronary Artery Thrombosis
- 15. Direct & indirect therapies • Treatment may be divided into direct and indirect therapies • Direct treatment is logically and theoretically superior • Indirect therapy should be resorted when bleeding point cannot be identified or bleeding is uncontrolled/profuse
- 16. Direct therapy • Anterior Epistaxis can be easily controlled with identification of the bleeder and cauterizing it with silver nitrate cautery or cautery with Trichloraceticacid(TCA) • Posterior Epistaxis can be identified by nasal endoscopy and cauterized with bipolar cautery • Direct method is more cost-effective as it facilitates outpatient management and significantly reduce inpatient stay
- 17. Cauterization 1. Electrical – with bipolar, Unipolar is contraindicated as it can cause optic nerve damage 2. Chemical a) Silver Nitrate 10% b) Tricholoroacetic acid 40% c) Carbolic Acid 3. Thermal 4. Cryotherapy
- 18. Indirect therapy • Failure to find bleeding point is an indication Various methods are 1. Hot water irrigation – irrigation with water heated to 500C 2. Systemic medical therapy – Tranexamic Acid and Epsilon aminocaproic acid 3. Nasal Packing
- 20. • For this, a ribbon gauze soaked with liquid paraffin is used. • About 1 metre gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. • Pack can be removed after 24 hours if bleeding has stopped.
- 22. POSTERIOR NASAL PACKING • If bleeding does not stop after anterior packing-Posterior epistaxis
- 24. COMPLICATIONS OF NASAL PACKING • SEPTAL HAEMATOMA / ABSCESS • SINUSITIS • PRESSURE NECROSIS • TOXIC SHOCK SYNDROME
- 25. Other methods • Merocel – A sponge like material placed in nasal cavity. It helps stop bleeding by providing pressure against the mucosa and by providing a surface against which the blood can clot. Pack is introduced in dehydrated state and expanded by instilling normal saline. It has to be removed • Gel Foam – An absorbable material with pro-coagulant properties. Contrary to Merocel it shrinks when it gets wet and dissolves in matter of weeks. It helps prevent the bleeding site from desiccation. • Kaltostat – Sodium-Calcium Alginate containing material (80:20 ratio). It swells up on absorbing water and it has to be removed. It controls bleed by providing pressure • Bivona – double balloon nasal catheter. Provides the effect of both anterior and posterior packing. Disadvantage – Balloons tend to inflate towards the path of least resistance and may fail to provide tamponade at the affected site.
- 26. Ligation methods Ligation is reserved for intractable bleeding where the source cannot be located or controlled by techniques mentioned above. Ligation should be performed as close to the bleeding point as possible. Thus the heirarchy of ligation is • Sphenopalatine artery- ESPAL • Internal maxillary artery- IMAL • External carotid artery- ECAL • Anterior/Posterior Ethmoidal artery
- 27. Elevation of Mucoperichondrial flap & SMR operation • In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. • SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.
- 28. Resuscitation Initial Examination Vessel NOT located Endoscopy Indirect Therapy Eg : Anterior Packs Continued Bleeding Posterior Pack Septal Surgery Ligation (ESPAL) Continued Bleeding - Angiography and embolization - Repeat above steps Check for secondary factors Vessel Located Direct Therapy Eg: BipolarBleeding Controlled -packs 48hrs minimum - Direct, same day discharge
- 29. QUESTIONS ??? ARTERY OF EPISTAXIS ??? MC ARTERY TO BLEED IN ENDOSCOPIC SURGERIES ??? MCC OF EPISTAXIS IN CHILDREN ??? MCC OF EPISTAXIS IN ELDERLY
- 30. ??? U/L EPISTAXIS IN ELDERLY MAY BE THE FIRST SYMPTOM OF-- ??? MAIN D/D OF EPISTAXIS IN ADOLESCENT MALE ??? ARTERY NOT TAKING PART IN KEISSELBACH’S PLEXUS ??? DIVIDING LINE BETWEEN ANT & POST BLEED
- 31. ??? MC SITE OF BLEEDING IN NASAL CAVITY