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EPISTAXIS
Morgan Yost DONRMC – Kirksville, MO
OGME-411/27/2012
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Introduction and History5-10% 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.
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Anatomy/Physiology of EpistaxisAnatomy
Nasal cavityVascular supply
PhysiologyVascular natureMucosa
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Anatomy of the Lateral Nasal Wall
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Anatomy of the Nasal Cavity and Vasculature
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External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
-Posterior nasal artery
-Superior labial artery
Internal Carotid Artery
-Anterior ethmoid artery
-Posterior ethmoid artery
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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 A of Sphenopalatine A (IMAX)
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Anterior vs. PosteriorMaxillary sinus ostiumAnterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severePosterior: older population, usually from Woodruff’s plexus, more serious.
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EtiologyLocal factors
VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDesiccationForeign Bodies/other
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Local Factors - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma
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Local Factors - Iatrogenic nasal injury
Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction
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Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma
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Local Factors – Desiccation
Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis
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Systemic Factors – Coagulopathies Thrombocytopenia
Platelet dysfunctionSystemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)
Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure
Hematologic malignancies
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Etiology and AgeChildren—foreign body, nose pickingAdults—trauma, idiopathicMiddle age—tumorsOld age--hypertension
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Initial ManagementABC’s
Medical history/Medications
Vital signs—need IV?
Physical examAnterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiological studies
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suction
good lightanesthetic
silver nitrate
merocels
gelfoam
bacitracin
endoscopes
suction bovie/bipolar
Afrin
surgicel
epistat
bayonet forcepts
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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. Bipolar vs. Bovie)
Nasal packing (effective 80-90% of time
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Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest
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Nasal packsAnterior nasal packs
Traditional
Posterior nasal packsTraditional
Ant/Post nasal packing
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Pick a Pack, any pack
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Indications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of <38%Nasal anomaly precluding packingPatient refusal/intolerance of packingFailed medical mgmt after >72hrs
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Surgical treatment
Transmaxillary IMA ligation
Intraoral IMA ligation
Anterior/Posterior Ethmoidal ligation
Transnasal Sphenopalatine ligation
External carotid artery ligation
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Tips and PearlsDon’t pack nose in unconscious person with suspected skull fractures.Oral antibiotics and pain meds while pack in placeAntibiotic cream, humidificationEstrogen cream to nasal septumSmoking cessation
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Just for fun…
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