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EPISTAXIS

Glen Porter, MD

Faculty Advisor: Francis B. Quinn, MD, FACS

The University of Texas Medical Branch

Department of Otolaryngology

Galveston, Texas

Grand Rounds Presentation

April 10, 2002

Introduction and History

5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.

Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”

A condition with a long history—Hippocrates to Henry Goodyear.

Anatomy/Physiology of Epistaxis

Anatomy

Nasal cavity

Vascular supply

Physiology

Vascular nature

Mucosa

Why bleeding from the nose ?

Vascular organ secondary to incredible

heating/humidification requirements

Vasculature runs just under mucosa (not

squamous)

Arterial to venous anastamoses

ICA and ECA blood flow

Anatomy of the Lateral Nasal Wall

SPF

-class I (35%)

-class II (56%)

-class III (9%)

External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

Internal Carotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery

Pterygopalatine Vasculature

--Internal maxillary artery

Anatomy of the Nasal Cavity

and Vasculature

Sphenopalatine AA

Ethmoid AA

Greater Palatine A

Kesselbach’s

Plexus/Little’s Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus:

-Pharyngeal & Post. Nasal

AA of Sphenopalatine A

(IMAX)

Anterior vs. Posterior

Maxillary sinus ostium

Anterior: younger, usually septal vs. anterior

ethmoid, most common (>90%), typically less

severe

Posterior: older population, usually from

Woodruff’s plexus, more serious.

Etiology

Local factors

Vascular

Infectious/Inflammatory

Trauma (most common)

Iatrogenic

Neoplasm

Dessication

Foreign Bodies/other

Etiology

Systemic factors

Vascular

Infection/Inflammation

Coagulopathy

Local Factors -- Vascular

ICA Aneurysms

extradural

cavernous sinus

Local Factors - Infection/Inflammation

Rhinitis/Sinusitis

Allergic

Bacterial

Fungal

Viral

Local Factors - Trauma

Nose picking

Nose blowing/sneezing

Nasal fracture

Nasogastric/nasotracheal intubation

Trauma to sinuses, orbits, middle ear, base of

skull

Barotrauma

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgery

Rhinoplasty

Nasal reconstruction

Local Factors - Neoplasm

Juvenile nasopharyngeal angiofibroma

Inverted papilloma

SCCA

Adenocarcinoma

Melanoma

Esthesioneuroblastoma

Lymphoma

Local Factors –

Dessication

Cold, dry air—more common in wintertime

Dry heat—Phoenix and Death valley

Nasal oxygen

Anatomic abnormalities

Atrophic rhinitis

Local Factors - Other

Self-inflicted (pedi) vs. traumatic foreign bodies

Intranasal parasites

Septal perforation

Chemical (cocaine, nasal sprays, ammonia, etc.)

Systemic Factors -- Vascular

Hypertension/Arteriosclerosis

Hereditary Hemorrhagic Telangectasias (OWR)

Systemic Factors –

Infection/Inflammation

Tuberculosis

Syphillis

Wegener’s Granulomatosis

Periarteritis nodosa

SLE

Systemic Factors – Coagulopathies

Thrombocytopenia

Platelet dysfunction Systemic disease (Uremia)

drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor Deficiencies Hemophilia

VonWillebrand’s disease

Hepatic failure

Hematologic malignancies

Etiology and Age

Children—foreign body, nose picking, nasal

diptheria (1/3 with chronic bleeds have

coagulation d/o)

Adults—trauma, idiopathic

Middle age—tumors

Old age--hypertension

Initial Management

ABC’s

Medical history/Medications

Vital signs—need IV?

Physical exam

Anterior rhinoscopy

Endoscopic rhinoscopy

Laboratory exam

Radiologic studies

suction

good light anesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

T.C.A.

surgicel

epistat

bayonet forcepts vaseline gauze

Non-surgical treatments

Control of hypertension

Correction of coagulopathies/thrombocytopenia

FFP or whole blood/reversal of anticoagulant/platelets

Pressure/Expulsion of clots

Topical decongestants/vasocontrictors

Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)

Nasal packing (effective 80-90% of time)

Greater palatine foramen block

Non-surgical treatments – on d/c

Humidity/emolients

Discontinue offending meds

Nasal saline sprays

Avoidance of nose picking/blowing

Sneeze with mouth open

Avoid straining/bedrest

Nasal packs

Anterior nasal packs

Traditional

Recent modifications

Posterior nasal packs

Traditional

Recent modifications

Ant/Post nasal packing

Pick a Pack, any pack

Pick a pack to pack with

TSS—Nugauze vs. Merocel

Electron microscopy

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

Indications for surgery/embolization

Continued bleeding despite nasal packing

Pt requires transfusion/admit hct of <38%

(barlow)

Nasal anomaly precluding packing

Patient refusal/intolerance of packing

Posterior bleed vs. failed medical mgmt after

>72hrs (wang vs. schaitkin)

Selective Angiography/embolization

Helps identify location of bleeding

Embolization most effective in patients who Still bleeding after surgical arterial ligation

Bleeding site difficult to reach surgically

Comorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min

90+% success rate, complication rate of 0.1%

Only able to embolize external carotid & branches

Complications: minor (18-45%)/major (0-2%)

Contraindicated in bad atherosclerosis, Ethmoid bleed

Surgical treatment

Transmaxillary IMA ligation

Intraoral IMA ligation

Anterior/Posterior Ethmoidal ligation

Transnasal Sphenopalatine ligation

External carotid artery ligation

Septodermoplasty/Laser ablation

Transmaxillary IMA ligation

Waters view

Caldwell-Luc

Electrocautery of posterior wall before removal

Microscopic dissection and ligation of IMA --descending palatine & sphenopalantine most important

Recurrence rate (failure rate) of 10-15%

Complication rate of 25-30% (oa fistula,dental, n)

Intraoral IMA ligation

Posterior gingivobuccal incision beginning at

second molar

Temporalis mm split and partially dissected

IMAX visualized, clipped and divided

Advantages: children/facial fractures

Disadvantages: more proximal ligation

Complications: trismus, damage to infraorbital n

Ant./Post. Ethmoidal ligation

Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear

Lynch incision

Fronto-ethmoid

suture line

12-24-6

(14-18, 8-10, 4-6)

Transnasal Endoscopic

Sphenopalatine Artery ligation

Follow Middle Turbinate to posteriormost aspect

Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs)

Elevation of flap—ID neurovascular bundle at foramen

Ligation with titanium clip

Reapproximate flap

Complications –few, Failures—0-13%

Transnasal Spheno-

palatine Artery ligation

ECA ligation

Effectiveness

Anterior border of SCM

ID ECA/ICA

Ligation after clear that surrounding structures

are safe.

Septodermoplasty/Laser

Remove mucosa from anterior ½ septum, floor of nose, lateral wall

STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts

Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease

Still bleed, but not as bad

Definitive treatment (severe disease)—closure of nose

Statistically speaking,….

Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.

Others compared all medical treatment to surgery and showed cost cut using medical management.

Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%

Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equal

Failure rates: PP-30%, Sx-17%, Emb-4%

Tips and Pearls

Red rubber on suction in contralateral nasal cavity

AgNO3 x 30seconds or more (not on both sides of septum)

Antihistamines to prevent rebleeds

Cautery does not work with no platelets/clotting

Glove packing

H2O2

Merocels (2 or more) injected with cortisporin otic

Amicar spray

Tips and Pearls

Hot water irrigation

Cold water irrigation

Salt Pork

Don’t pack nose in unconscious person with suspected

skull fractures.

Antibiotic cream vs. silver nitrate

Intranasal pressure

Estrogen cream to nasal septum

Tips and Pearls

Transnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed)

Submucosal supraperichondrial dissection of nasal septum

Not all hospitals have embolization-trained interventionalists

No hard-set outline. Do what is best for your particular patient

CASE REPORT

45 yo Vietnamese fisherman--stable, but uncomfortable

Profuse nasal bleeding since 0200 this a.m.

History: No known medical problems. Drinks 6-12 beers/day. Takes no medications. No history of easy bleeding. No family history.

Physical exam: Profuse bleeding from both nostrils L>R and bleeding down the back of his throat—coughing up clots. Unable to locate precise location of bleed—appears to be posterior/superior.

Case 1 – cont’d

Hgb 12.5

Lactated Ringers IVF bolus

Nasal packs – removed two days later in the

clinic,…rebleeds.

Requires transfusion for Hgb of 6.5

Angiography—no obvious bleed/Embolization

Ant/Post Ethmoid Artery ligation