epistaxis.pptx
- 2. Outline • DEFINITION • ANATOMY • PATHOPHYSIOLOGY • ETIOLOGY • CLINICAL PRESENTATION • INVESTIGATIONS • MANAGEMENT
- 3. Definition • Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx • Most nosebleeds are benign, self-limiting, and spontaneous, but some can be recurrent. • lifelong incidence of epistaxis in the general population is about 60%, with fewer than 10% seeking medical attention. • The age distribution is bimodal, with peaks in young children (2-10 y) and older individuals (50-80 y). • Prevalence: higher in males (58%) than in females (42%).
- 4. Anatomy
- 5. Pathophysiology • Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break. • More than 90% of bleeds occur anteriorly and arise from Little’s area, where the Kiesselbach plexus forms on the septum. The Kiesselbach plexus is where vessels from both the ICA (anterior and posterior ethmoidal arteries) and the ECA (sphenopalatine and branches of the internal maxillary arteries) converge. Anterior bleeding may also originate anterior to the inferior turbinate. • Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin (eg, from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx).
- 6. Etiology • Local vs systemic vs idiopathic • Trauma: self induced, Facial or nasal trauma, iatrogenic, foreign bodies • Dry weather: low humidity • Drugs: Topical nasal drugs such as antihistamines and corticosteroids,NSAIDs • Septal abnormality: Septal deviations and spurs • Inflammation: Bacterial, viral, and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis.
- 7. Etiology • Tumors: Benign and malignant tumors can manifest as epistaxis. present with signs and symptoms of nasal obstruction and rhino sinusitis, often unilateral. • Blood dyscrasias: Congenital vs acquired • Vascular abnormalities: Arteriosclerotic vascular disease, vascular neoplasms, aneurysms, and endometriosis. • Hypertension • Migraine :Children with migraine headaches have a higher incidence of recurrent epistaxis than children without the disease • Idiopathic: Approximately 10% of patients with epistaxis have no identifiable causes even after a thorough evaluation
- 8. Clinical presentation • Detailed history: • Examination preparation: Illumination, anesthesia, vasoconstrictors, suction, topical medication, cauterization, packing materials, Nasal speculum • Anterior epistaxis exhibit unilateral, steady, no massive bleeding. Just 10% of epistaxis are posterior, exhibiting massive bleeding that is initially bilateral. • General examination • vitals
- 9. Investigations • FBC/DC • Bleeding time • Coagulation profile • CT/MRI • Nasopharyngoscopy
- 10. Management • Acute management • ABCs • Manual Hemostasis :direct pressure +/-, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine • Humidification and Moisturization • Cauterization: Bleeding form Kiesselbach plexus treated with silver nitrate cauterization • Nasal Packing: adequate anesthesia and vasoconstriction are necessary.
- 11. • Anterior nasal packing : is indicated for overt or suspected epistaxis after direct pressure, topical agents, or silver nitrate cauterization • Soak cotton balls in a mix of 2% lidocaine and 1:1000 epinephrine prefabricated nasal tampons: The Merocel nasal tampon, The Rapid Rhino
- 12. • antibiotic as prophylaxis against sinusitis and staphylococcal toxic shock syndrome • Pack removal In 48hrs
- 13. • Posterior nasal packing • Failure of anterior packing, Reliable or high suspicion of posterior bleeding, bleeding diathesis • Contraindications: facial trauma that may include nasal bone and cribriform plate fractures, airway obstruction. • bleeding site is either posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity. • Double-Balloon Approach • Foley Catheter Approach • Pack removal in 72-96 hrs
- 15. • Admit all patients with posterior packing to the hospital for observation. Antibiotic cover • Complications: Sinusitis, Nasal septal pressure necrosis, Abscesses, Neurogenic syncope, Toxic shock syndrome, Persistent bleeding and restart of bleeding. • Arterial Ligation • Embolization
- 16. Prevention • Strenuous activities • Hot and dry environments – use of humidifiers, better thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area. • Avoid Hot and spicy foods • avoid Digital trauma . Nose blowing and excessive sneezing - Instruct patients to sneeze gently with the mouth open. • avoid drug abuse in adolescents.
- 17. References • Eric Goralnick, M. (2022, December 22). Anterior nasal packing for epistaxis. Overview, Technique, Preparation. https://emedicine.medscape.com/article/80526-overview • Ola Bamimore, M. (2021, July 12). Acute epistaxis. Overview, Clinical Presentation, Differential Diagnosis. https://emedicine.medscape.com/article/764719-overview • Quoc A Nguyen, M. (2022, December 22). Epistaxis. Practice Essentials, Anatomy, Pathophysiology. https://emedicine.medscape.com/article/863220-overview