EPISTAXISEPISTAXIS

BYBY

IntroductionIntroduction

Epistaxis is a greek word meaning nose bleed. Epistaxis is a greek word meaning nose bleed. has been a part of the human experience from has been a part of the human experience from earliest times earliest times

Hippocrates commented that holding pressure Hippocrates commented that holding pressure on the nose helped to abate bleeding. on the nose helped to abate bleeding. Kiesselbach and Little(1879) were the first to Kiesselbach and Little(1879) were the first to identify the nasal septum’s anterior plexus as a identify the nasal septum’s anterior plexus as a source of nasal bleeding. source of nasal bleeding.

Pilz(1869) was the first to surgically treat Pilz(1869) was the first to surgically treat epistaxis with arterial ligationepistaxis with arterial ligation

IncidenceIncidence

EEpistaxis, has been reported to occur in up to 60 pistaxis, has been reported to occur in up to 60 percent of the general population. It has a bimodal percent of the general population. It has a bimodal distribution, with peaks at ages younger than 10 distribution, with peaks at ages younger than 10 years and older than 50 years. years and older than 50 years.

Affected persons usually do not seek medical Affected persons usually do not seek medical attention, particularly if the bleeding is minor or self-attention, particularly if the bleeding is minor or self-limited. In rare cases, however, massive nasal limited. In rare cases, however, massive nasal bleeding can lead to death.bleeding can lead to death.

The incidence increases with advancing age, The incidence increases with advancing age, during the winter months, and is more common in during the winter months, and is more common in malesmales

AnatomyAnatomy

The rich vascular supply of the nose The rich vascular supply of the nose originates from the ethmoidal branches of originates from the ethmoidal branches of the the internal carotid arteriesinternal carotid arteries and the facial and the facial and internal maxillary divisions of the and internal maxillary divisions of the external carotid arteriesexternal carotid arteries. Although nasal . Although nasal circulation is complex epistaxis usually is circulation is complex epistaxis usually is described as either anterior or posterior described as either anterior or posterior bleeding. This simple distinction provides bleeding. This simple distinction provides a useful basis for management.a useful basis for management.

Blood supply of noseBlood supply of nose

Common bleeding SitesCommon bleeding Sites

Kiesselbachs plexus Kiesselbachs plexus Littles areaLittles area

Woodruffs AreaWoodruffs Area Retrocolumellar vein Retrocolumellar vein Middle turbinateMiddle turbinate

Local causesLocal causes

Epistaxis digitorum (nose picking) &TraumaEpistaxis digitorum (nose picking) &Trauma Foreign bodiesForeign bodies Intranasal neoplasm or polypsIntranasal neoplasm or polyps Irritants (e.g., cigarette smoke)Irritants (e.g., cigarette smoke) Medications (e.g., topical corticosteroids)Medications (e.g., topical corticosteroids) Rhinitis, Sinusitis acute and chronicRhinitis, Sinusitis acute and chronic Septal deviation , Septal perforationSeptal deviation , Septal perforation Adenoids Adenoids Vascular malformation or telangiectasiaVascular malformation or telangiectasia

Systemic causesSystemic causes

HaemophiliaHaemophilia HypertensionHypertension LeukemiaLeukemia Liver disease Liver disease (e.g., cirrhosis,Factor defeciency)(e.g., cirrhosis,Factor defeciency)

Medications Medications e.g., aspirin, anticoagulants, nonsteroidal anti-e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugsinflammatory drugs

Platelet dysfunction & ThrombocytopeniaPlatelet dysfunction & Thrombocytopenia OthersOthers Diffuse oozing, multiple bleeding sites, or recurrent bleeding Diffuse oozing, multiple bleeding sites, or recurrent bleeding

may indicate a systemic processmay indicate a systemic process

IdiopathicIdiopathic

Vast majority of cases come under this Vast majority of cases come under this categorycategory

Bleeding patternsBleeding patterns

Septum littles areaSeptum littles area Above the middle turb ethmoidal vesselsAbove the middle turb ethmoidal vessels Below the middle turb sphenopalatine ABelow the middle turb sphenopalatine A Posterior woodruffs areaPosterior woodruffs area Generalized bleeding disorderGeneralized bleeding disorder

Site and age relationshipSite and age relationship

Anterior 1/3 bleeds in adultsAnterior 1/3 bleeds in adults

Commonest from littles areaCommonest from littles area

Posterior 2/3 bleeds in old age Posterior 2/3 bleeds in old age

At the juntion of floor and lateral wallAt the juntion of floor and lateral wall

ExaminationExamination Every attempt should be made to locate the Every attempt should be made to locate the

source of bleeding that does not respond to source of bleeding that does not respond to simple compression and nasal plugging. simple compression and nasal plugging.

The examination should be performed in a well-The examination should be performed in a well-lighted room, with the patient seated and lighted room, with the patient seated and clothing protected by a sheet or gown. clothing protected by a sheet or gown.

The doctor should wear gloves and other The doctor should wear gloves and other appropriate protective equipment (e.g., surgical appropriate protective equipment (e.g., surgical mask, safety glasses). mask, safety glasses).

A headlamp /head mirror and a nasal speculum A headlamp /head mirror and a nasal speculum should be used for optimal visualization should be used for optimal visualization

Examination Examination contdcontd

Clots and foreign bodies in the anterior Clots and foreign bodies in the anterior nasal cavity can be removed with a small nasal cavity can be removed with a small suction tip, irrigation, forceps, and cotton-suction tip, irrigation, forceps, and cotton-tipped applicators.tipped applicators.

Initial ManagementInitial Management Application of direct pressure to the septal area Application of direct pressure to the septal area

and plugging of the affected cavity with gauze and plugging of the affected cavity with gauze or cotton that has been soaked in a topical or cotton that has been soaked in a topical decongestant. decongestant.

Direct pressure should be applied continuously Direct pressure should be applied continuously for at least five minutes, and for up to 20 for at least five minutes, and for up to 20 minutes. minutes.

Tilting the head forward prevents blood from Tilting the head forward prevents blood from pooling in the posterior pharynx, thereby pooling in the posterior pharynx, thereby avoiding nausea and airway obstruction. avoiding nausea and airway obstruction.

Hemodynamic stability and airway patency Hemodynamic stability and airway patency

Management PrinciplesManagement Principles

Although most patients with epistaxis can Although most patients with epistaxis can be treated as out patients, hospital be treated as out patients, hospital admission and close observation should admission and close observation should be considered for elderly and patients with be considered for elderly and patients with posterior bleeding or coagulopathy. posterior bleeding or coagulopathy. Admission also may be prudent for Admission also may be prudent for patients with complicating comorbid patients with complicating comorbid conditions such as IHD, severe conditions such as IHD, severe hypertension or significant anemia hypertension or significant anemia

ANTERIOR EPISTAXISANTERIOR EPISTAXIS

If a single anterior bleeding site is found, If a single anterior bleeding site is found, vasoconstriction should be attempted with vasoconstriction should be attempted with topical application of oxymetazoline or topical application of oxymetazoline or phenylephrine solution. For bleeding that phenylephrine solution. For bleeding that is likely to require more aggressive is likely to require more aggressive treatment, a local anesthetic, such as a treatment, a local anesthetic, such as a

4% Xylocaine solution, should be used. 4% Xylocaine solution, should be used. Adequate anesthesia should be obtained Adequate anesthesia should be obtained before treatment proceeds.before treatment proceeds.

CautrizationCautrization

Larger vessels generally respond more readily Larger vessels generally respond more readily to electrocautery. However, it must be performed to electrocautery. However, it must be performed cautiously to avoid excessive destruction of cautiously to avoid excessive destruction of healthy surrounding tissues. healthy surrounding tissues.

Use of electrocautery on both sides of the Use of electrocautery on both sides of the septum may increase the risk of septal septum may increase the risk of septal perforation.perforation.

Some studies found no difference in efficacy or Some studies found no difference in efficacy or complication rate between chemical cautery complication rate between chemical cautery (silver nitrate ) and electrocautery (silver nitrate ) and electrocautery

Anterior nasal packingAnterior nasal packing anterior nasal cavity should be packed, from posterior to anterior nasal cavity should be packed, from posterior to

anterior, with ribbon gauze impregnated with petroleum anterior, with ribbon gauze impregnated with petroleum jelly or polymyxin B-bacitracin zinc-neomycin . jelly or polymyxin B-bacitracin zinc-neomycin . Nonadherent gauze impregnated with petroleum jelly Nonadherent gauze impregnated with petroleum jelly and Bipp also works well .Bayonet forceps and a nasal and Bipp also works well .Bayonet forceps and a nasal speculum are used to approximate the layers of the speculum are used to approximate the layers of the gauze, which should extend as far back into the nose as gauze, which should extend as far back into the nose as possible. Each layer should be pressed down firmly possible. Each layer should be pressed down firmly before the next layer is inserted .Once the cavity has before the next layer is inserted .Once the cavity has been packed as completely as possible, a gauze "drip been packed as completely as possible, a gauze "drip pad” may be taped over the nostrils and changed pad” may be taped over the nostrils and changed periodically. periodically.

Anterior nasal packingAnterior nasal packing

Complications of nasal packingComplications of nasal packing

Procedures include septal hematomas and Procedures include septal hematomas and abscesses from traumatic packing, abscesses from traumatic packing, sinusitis, syncope during packing, and sinusitis, syncope during packing, and pressure necrosis secondary to pressure necrosis secondary to excessively tight packing.excessively tight packing.

possibility of toxic shock syndrome with possibility of toxic shock syndrome with prolonged nasal packingprolonged nasal packing

POSTERIOR EPISTAXISPOSTERIOR EPISTAXIS

Much less common than anterior bleeding . Posterior Much less common than anterior bleeding . Posterior packing may be accomplished by passing a catheter packing may be accomplished by passing a catheter through one nostril (or both nostrils), through the through one nostril (or both nostrils), through the nasopharynx, and out the mouth . A gauze pack then is nasopharynx, and out the mouth . A gauze pack then is secured to the end of the catheter and positioned in the secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior choana, sealing until the pack is seated in the posterior choana, sealing the posterior nasal passage and applying pressure to the the posterior nasal passage and applying pressure to the site of the posterior bleeding. site of the posterior bleeding.

It requires special training and usually is performed by It requires special training and usually is performed by an otolaryngologist an otolaryngologist

Post nasal packingPost nasal packing

Foleys catheterFoleys catheter A Foley catheter (10 to 14 French) with a 30-mL balloon A Foley catheter (10 to 14 French) with a 30-mL balloon

may be used. The catheter is inserted through the bleeding may be used. The catheter is inserted through the bleeding nostril and visualized in the oropharynx before inflation of nostril and visualized in the oropharynx before inflation of the balloon. The balloon then is inflated with approximately the balloon. The balloon then is inflated with approximately 10 mL of saline, and the catheter is withdrawn gently 10 mL of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and forward. The through the nostril, pulling the balloon up and forward. The balloon should seat in the posterior nasal cavity and balloon should seat in the posterior nasal cavity and tamponade a posterior bleed. With traction maintained on tamponade a posterior bleed. With traction maintained on the catheter, the anterior nasal cavity then is packed as the catheter, the anterior nasal cavity then is packed as previously described. Traction is maintained by placing an previously described. Traction is maintained by placing an clamp on the catheter beyond the nostrils, which should be clamp on the catheter beyond the nostrils, which should be padded to prevent soft tissue damage. As with anterior padded to prevent soft tissue damage. As with anterior epistaxis, topical antistaphylococcal antibiotic ointment may epistaxis, topical antistaphylococcal antibiotic ointment may be used to prevent toxic shock syndrome. However, use of be used to prevent toxic shock syndrome. However, use of oral or intravenous antibiotics for posterior nasal packing is oral or intravenous antibiotics for posterior nasal packing is documenteddocumented

PERSISTENT BLEEDINGPERSISTENT BLEEDING

Patients with anterior or posterior bleeding that Patients with anterior or posterior bleeding that continues despite packing or balloon procedures continues despite packing or balloon procedures may require treatment by an otolaryngologist. may require treatment by an otolaryngologist. Endoscopy may be used to locate the exact site Endoscopy may be used to locate the exact site of bleeding for direct cauterization.of bleeding for direct cauterization.

Hot water irrigation, a technique described more Hot water irrigation, a technique described more than 100 years ago, has been reexamined than 100 years ago, has been reexamined recently. This technique has shown promise in recently. This technique has shown promise in reducing discomfort and length of hospitalization reducing discomfort and length of hospitalization in patients with posterior epistaxis. in patients with posterior epistaxis.

Danger signals in a severe nosebleedDanger signals in a severe nosebleed

Heavy bleeding.Heavy bleeding.

Palpitation, shortness of breath and turning pale.Palpitation, shortness of breath and turning pale.

Swallowing large amounts of blood, which will Swallowing large amounts of blood, which will cause you to vomit.cause you to vomit.

Indications for surgical interventionIndications for surgical intervention

have been widely debated, but usually include have been widely debated, but usually include failure of medical treatment after 72 hours, failure of medical treatment after 72 hours,

nasal anatomy that precludes local treatments, nasal anatomy that precludes local treatments, patient refusal of medical management, patient refusal of medical management,

initial hematocrit of <38% (males), initial hematocrit of <38% (males), and the need for transfusion. and the need for transfusion. Many authors have argued that a posterior Many authors have argued that a posterior

bleed that will necessitate a posterior pack is bleed that will necessitate a posterior pack is indication enough to pursue surgical treatment. indication enough to pursue surgical treatment.

Surgical measuresSurgical measures

Arterial ligationArterial ligation maxillary arterymaxillary artery anterior ethmoidal arteryanterior ethmoidal artery posterior ethmoidal arteryposterior ethmoidal artery external carotid arteryexternal carotid artery EmbolizationEmbolization Septal surgerySeptal surgery laserslasers

How to avoid nosebleedsHow to avoid nosebleeds

Avoid damaging the nose and excessive nose-picking.Avoid damaging the nose and excessive nose-picking.

Seek medical treatment for any disease causing the Seek medical treatment for any disease causing the nosebleeds.nosebleeds.

Get a humidifier if you live in a dry climate or at high Get a humidifier if you live in a dry climate or at high altitude.altitude.

summarysummary

The medical community’s understanding The medical community’s understanding of epistaxis has increased dramatically. of epistaxis has increased dramatically. Our treatment, though somewhat modified Our treatment, though somewhat modified over the years, has continued to include over the years, has continued to include techniques first noted several thousand techniques first noted several thousand years ago. years ago.

SummarySummary Epistaxis is the manifestation of many different Epistaxis is the manifestation of many different

disease processes.disease processes. Its treatment is as varied as its etiologies. Its treatment is as varied as its etiologies.

Treatment will be most effective when underlying Treatment will be most effective when underlying medical problems are understood, nasal medical problems are understood, nasal anatomy is appreciated, and the patient’s anatomy is appreciated, and the patient’s response to treatment and general medical response to treatment and general medical status are taken into account. status are taken into account.

The otolaryngologist should be familiar with The otolaryngologist should be familiar with treatment options and be able to offer surgical treatment options and be able to offer surgical intervention, if necessary.intervention, if necessary.