epistaxis from an ent resident perspective
DESCRIPTION
Recent PPT of a lecture on epistaxis and some recent facial trauma cases.TRANSCRIPT
EPISTAXIS
Morgan Yost DONRMC – Kirksville, MO
OGME-411/27/2012
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.
Anatomy/Physiology of EpistaxisAnatomy
Nasal cavityVascular supply
PhysiologyVascular natureMucosa
Anatomy of the Lateral Nasal Wall
Anatomy of the Nasal Cavity and Vasculature
External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
-Posterior nasal artery
-Superior labial artery
Internal Carotid Artery
-Anterior ethmoid artery
-Posterior ethmoid artery
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)
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.
EtiologyLocal factors
VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDesiccationForeign Bodies/other
Local Factors - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma
Local Factors - Iatrogenic nasal injury
Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction
Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma
Local Factors – Desiccation
Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis
Systemic Factors – Coagulopathies Thrombocytopenia
Platelet dysfunctionSystemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)
Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure
Hematologic malignancies
Etiology and AgeChildren—foreign body, nose pickingAdults—trauma, idiopathicMiddle age—tumorsOld age--hypertension
Initial ManagementABC’s
Medical history/Medications
Vital signs—need IV?
Physical examAnterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiological studies
suction
good lightanesthetic
silver nitrate
merocels
gelfoam
bacitracin
endoscopes
suction bovie/bipolar
Afrin
surgicel
epistat
bayonet forcepts
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
Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest
Nasal packsAnterior nasal packs
Traditional
Posterior nasal packsTraditional
Ant/Post nasal packing
Pick a Pack, any pack
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
Surgical treatment
Transmaxillary IMA ligation
Intraoral IMA ligation
Anterior/Posterior Ethmoidal ligation
Transnasal Sphenopalatine ligation
External carotid artery ligation
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
Just for fun…