epistaxsis mh
TRANSCRIPT
EPISTAXISEPISTAXIS
ByBy
Mohammed HusseinMohammed Hussein
OverviewOverview
OverviewOverview
DefinitionDefinition:: Bleeding from inside the noseBleeding from inside the nose
OverviewOverview 5-10% of the population experience an 5-10% of the population experience an
episode of epistaxis each year. 10% of those episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking will see a physician. 1% of those seeking medical care will need a specialist.medical care will need a specialist.
Epistaxis in children younger than 2 years of Epistaxis in children younger than 2 years of age is infrequent, while it peaks between age is infrequent, while it peaks between ages 3-8 years. ages 3-8 years.
Anterior Epistaxis is more common in Anterior Epistaxis is more common in children & young adults.children & young adults.
Posterior Epistaxis is more common in older Posterior Epistaxis is more common in older adults with hypertension & arteriosclerosis.adults with hypertension & arteriosclerosis.
Incidence is higher in winter months & hot Incidence is higher in winter months & hot dry climate with low humidity.dry climate with low humidity.
Anatomy
Arteries of the nasal septum. The arterial supply of the nasal septum arises from branches of the external carotid artery (black) and the internal carotid artery (blue). Kiesselbach’s plexus is formed by the sphenopalatine artery, greater palatine artery, superior labial artery, and anterior ethmoid arteries.
Arteries of the lateral nasal wall. The arterial supply of the lateral nasal wall arises from branches of the external carotid artery (black) and the internal carotid artery (blue).
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)
Little’s area or Kiesselbach’s plexus is the commonest site of nose bleeds
EtiologyEtiology Local causesLocal causes:: Idiopathic:Idiopathic: 90% 90% Traumatic:Traumatic: foreign body, blow to the nose, fracture foreign body, blow to the nose, fracture
nasal bone, fracture anterior cranial fossa, after nasal bone, fracture anterior cranial fossa, after operationsoperations
Inflammatory:Inflammatory: rhinitis, sinusitis rhinitis, sinusitis Neoplastic:Neoplastic: Benign: Benign: Papiloma ,Angiofibroma Papiloma ,Angiofibroma Malignant :Malignant :Squamous cell Ca, adeno Ca, adenoid Squamous cell Ca, adeno Ca, adenoid
cystic Ca, olfactory cystic Ca, olfactory neuroblastoma ,melanoma ,lymphomaneuroblastoma ,melanoma ,lymphoma
Hereditary haemorrhagic telangectasiaHereditary haemorrhagic telangectasia Nasal septal deviation, spurs, and perforations cause Nasal septal deviation, spurs, and perforations cause
turbulent airflow, which can lead to mucosal drying turbulent airflow, which can lead to mucosal drying and bleeding and bleeding
shows a foreign body of long standing on the right side of a patient’s nose. The black arrow points to a foreign body mass:
RhinolithRhinolith
Septal hemangioma. a A vascular sessile polyp is seen on the septum (hemangioma), which is the cause of severe, recurrent bleeds. Treatment is by excision, or cautery if the lesion is small
Hereditary nasal teleangiectasia
Squamous cell carcinoma ofthe nasal vestibule
Carcinoma of the nasal septum.
??????
A 16-year-old boy presents with nasal obstruction and heavy epistaxis. What rare condition must be excluded? How ?
AnswerAnswer • Nontraumatic, severe unilateral epistaxis
in a teenage boy is juvenile nasopharyngeal angiofibroma until proven otherwise.
• The epidemiologic profile, endoscopic appearance, and imaging findings should lead to a correct diagnosis.
• A routine biopsy should be avoided when this lesion is suspected due to the risk of severe hemorrhage.
The angiofibroma of male puberty is a rare vascular malformationin the postnasal space, which may become extremely large, presenting with nasal obstruction and epistaxis.
EtiologyEtiology General causes:General causes: Bleeding disorders.Bleeding disorders.
A.A. CoagulopathiesCoagulopathiesB.B. Platelet disordersPlatelet disordersC.C. Blood vessel disordersBlood vessel disordersD.D. Hyperfibrinolysis .Hyperfibrinolysis .
Drugs.Drugs.1.1. AspirinAspirin2.2. AnticoagulantsAnticoagulants3.3. ChloramphenicolChloramphenicol4.4. MethotrexateMethotrexate5.5. ImmunosuppressantImmunosuppressant6.6. AlcoholAlcohol
EtiologyEtiology Cardio vascular:Cardio vascular: HypertensionHypertension Mitral stenosisMitral stenosis Hepatic :Hepatic : Liver cirrhosisLiver cirrhosis Liver failureLiver failure Fevers :Fevers :
EtiologyEtiology
Epistaxis may be the first sign of:Epistaxis may be the first sign of: Wegener's granulomatosis, Wegener's granulomatosis, Sarcoidosis, Sarcoidosis, Lupus erythematosus, Lupus erythematosus, Malignancy, Malignancy, Syphilis, Syphilis, Leprosy, tuberculosis, Leprosy, tuberculosis, and Occupational irritants. and Occupational irritants.
InvestigationsInvestigations
1.1. Complete blood counts: Complete blood counts: Hb ,TLC, ESR ,platelet Hb ,TLC, ESR ,platelet count ,BT,CTcount ,BT,CT
2.2. Blood grouping & cross Blood grouping & cross matchingmatching
3.3. Renal function test: blood urea, Renal function test: blood urea, serum creatinine.serum creatinine.
4.4. Blood sugarBlood sugar
5.5. Liver functionLiver function
6.6. Peripheral blood filmPeripheral blood film
Investigations
InvestigationsInvestigations
7.7. Screening for coagulation disorders:-Screening for coagulation disorders:-
PT,APTT,INR, Platelet count, serum PT,APTT,INR, Platelet count, serum fibrinogen ,Fibrin breakdown fibrinogen ,Fibrin breakdown product ,von willebrand factor antigen.product ,von willebrand factor antigen.
8.8. Nasal endoscopyNasal endoscopy
9.9. CT scanCT scan
10.10. MRIMRI
11.11. Angiography.Angiography.
ExaminationExamination
For the examination, you For the examination, you needneed
• A dequate lighting, • A nasal speculum,• Frazier and • Bayonet forceps, • gloves, face mask, and eye
protection. • A 0° to 30° telescope
Treatment
Different phases of Different phases of management :management :
1.1. To asses the general To asses the general condition of the patient.condition of the patient.
2.2. To arrest the hemorrhageTo arrest the hemorrhage3.3. To treat the underlying causeTo treat the underlying cause..
Treatment
TreatmentTreatment
Asses the general conditionAsses the general condition
Asses the amount of blood lossAsses the amount of blood loss
Record the vitals :BP, pulseRecord the vitals :BP, pulse
Estimate Hb .Estimate Hb .
Treat shock or hypovolaemia.Treat shock or hypovolaemia.
TreatmentTreatment
To arrest the hemorrhage.To arrest the hemorrhage.
Pressure on the nose.Pressure on the nose.
Topical decongestants,Topical decongestants,
CauterizationCauterization
Nasal packingNasal packing
EmbolizationEmbolization
Ligation of blood vessels.Ligation of blood vessels.
????????????????????????
• Incorrect technique for controlling epistaxis. The pressure is over the nasal bones and ineffective.
Control of epistaxis. Firm pressure with the finger or thumb on thelateral wall of the nose opposite Little’s area on the side of the
bleeding
Cautery. If epistaxis is recurrent, cautery (which is painless with local anesthetic) to the bleeding point is necessary, either with galvanocautery or with a chemical
Correct direction for Correct direction for placement of nasal placement of nasal
packingpacking
Transnasal Spheno-palatine Artery ligation
Transnasal Spheno-palatine Artery ligation
This picture shows the anterior ethmoid artery after a clip is applied. The black arrow shows the surgical clip and the white arrow points to a retractor holding the eye to allow access