EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each...

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EPISTAXIS

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Transcript of EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each...

Page 1: EPISTAXIS. 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.

EPISTAXIS

Page 2: EPISTAXIS. 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.

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.Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”A condition with a long history—Hippocrates to Henry Goodyear.

Page 3: EPISTAXIS. 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.

Anatomy/Physiology of EpistaxisAnatomy

Nasal cavityVascular supply

PhysiologyVascular natureMucosa

Page 4: EPISTAXIS. 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.

Why bleeding from the nose ? Vascular organ secondary to incredible

heating/humidification requirementsVasculature runs just under mucosa (not squamous)Arterial to venous anastamosesICA and ECA blood flow

Page 5: EPISTAXIS. 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.

Anatomy of the Lateral Nasal Wall

SPF

-class I (35%)

-class II (56%)

-class III (9%)

Page 6: EPISTAXIS. 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.

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

Page 7: EPISTAXIS. 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.

Pterygopalatine Vasculature

--Internal maxillary artery

Page 8: EPISTAXIS. 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.

Anatomy of the Nasal Cavity and Vasculature

Page 9: EPISTAXIS. 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.

Sphenopalatine AA

Ethmoid AA

Greater Palatine A

Page 10: EPISTAXIS. 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.
Page 11: EPISTAXIS. 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.
Page 12: EPISTAXIS. 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.

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)

Page 13: EPISTAXIS. 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.
Page 14: EPISTAXIS. 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.

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.

Page 15: EPISTAXIS. 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.

EtiologyLocal factors

VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDessicationForeign Bodies/other

Page 16: EPISTAXIS. 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.

EtiologySystemic factors

VascularInfection/InflammationCoagulopathy

Page 17: EPISTAXIS. 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.

Local Factors -- Vascular

ICA Aneurysms extradural cavernous sinus

Page 18: EPISTAXIS. 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.

Local Factors - Infection/Inflammation

Rhinitis/SinusitisAllergicBacterialFungalViral

Page 19: EPISTAXIS. 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.

Local Factors - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma

Page 20: EPISTAXIS. 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.

Nasal Fracture with Septal Hematoma

Page 21: EPISTAXIS. 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.

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction

Page 22: EPISTAXIS. 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.

Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma

Page 23: EPISTAXIS. 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.
Page 24: EPISTAXIS. 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.

Local Factors – Dessication

Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis

Page 25: EPISTAXIS. 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.

Local Factors - Other

Self-inflicted (pedi) vs. traumatic foreign bodiesIntranasal parasitesSeptal perforationChemical (cocaine, nasal sprays, ammonia, etc.)

Page 26: EPISTAXIS. 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.

Systemic Factors -- Vascular

Hypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias (OWR)

Page 27: EPISTAXIS. 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.

Systemic Factors – Infection/Inflammation

TuberculosisSyphillisWegener’s GranulomatosisPeriarteritis nodosaSLE

Page 28: EPISTAXIS. 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.

Systemic Factors – Coagulopathies Thrombocytopenia

Platelet dysfunctionSystemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure

Hematologic malignancies

Page 29: EPISTAXIS. 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.

Etiology and AgeChildren—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o)Adults—trauma, idiopathicMiddle age—tumorsOld age--hypertension

Page 30: EPISTAXIS. 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.

Initial ManagementABC’s

Medical history/Medications

Vital signs—need IV?

Physical examAnterior rhinoscopy

Endoscopic rhinoscopy

Laboratory exam

Radiologic studies

Page 31: EPISTAXIS. 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.

suction

good lightanesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

T.C.A.

surgicel

epistat

bayonet forceptsvaseline gauze

Page 32: EPISTAXIS. 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.

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

Page 33: EPISTAXIS. 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.

Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest

Page 34: EPISTAXIS. 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.

Nasal packsAnterior nasal packs

TraditionalRecent modifications

Posterior nasal packsTraditional Recent modifications

Ant/Post nasal packing

Page 35: EPISTAXIS. 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.

Pick a Pack, any pack

Page 36: EPISTAXIS. 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.

Pick a pack to pack with

Page 37: EPISTAXIS. 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.

TSS—Nugauze vs. Merocel

Electron microscopy

Page 38: EPISTAXIS. 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.

Posterior Packs – Admission Elderly and those with other chronic diseases may need to be admitted to the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVF

Page 39: EPISTAXIS. 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.

Indications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of <38% (barlow)Nasal anomaly precluding packingPatient refusal/intolerance of packingPosterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

Page 40: EPISTAXIS. 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.

Selective Angiography/embolizationHelps identify location of bleedingEmbolization most effective in patients who

Still bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min90+% success rate, complication rate of 0.1%Only able to embolize external carotid & branchesComplications: minor (18-45%)/major (0-2%)Contraindicated in bad atherosclerosis, Ethmoid bleed

Page 41: EPISTAXIS. 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.

Surgical treatment

Transmaxillary IMA ligation

Intraoral IMA ligation

Anterior/Posterior Ethmoidal ligation

Transnasal Sphenopalatine ligation

External carotid artery ligation

Septodermoplasty/Laser ablation

Page 42: EPISTAXIS. 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.

Transmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA --descending palatine & sphenopalantine most importantRecurrence rate (failure rate) of 10-15%Complication rate of 25-30% (oa fistula,dental, n)

Page 43: EPISTAXIS. 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.
Page 44: EPISTAXIS. 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.

Intraoral IMA ligationPosterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized, clipped and dividedAdvantages: children/facial fracturesDisadvantages: more proximal ligationComplications: trismus, damage to infraorbital n

Page 45: EPISTAXIS. 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.

Ant./Post. Ethmoidal ligationPatients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclearLynch incisionFronto-ethmoid

suture line12-24-6

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

Page 46: EPISTAXIS. 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.

Transnasal Endoscopic Sphenopalatine Artery ligation

Follow Middle Turbinate to posteriormost aspectVertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs)Elevation of flap—ID neurovascular bundle at foramenLigation with titanium clipReapproximate flapComplications –few, Failures—0-13%

Page 47: EPISTAXIS. 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.

Transnasal Spheno-palatine Artery ligation

Page 48: EPISTAXIS. 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.

ECA ligationEffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are safe.

Page 49: EPISTAXIS. 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.

Septodermoplasty/LaserRemove mucosa from anterior ½ septum, floor of nose, lateral wallSTSG vs. cutaneous, myocutaneous, microvascular free flaps vs. AutograftsNeodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod diseaseStill bleed, but not as badDefinitive treatment (severe disease)—closure of nose

Page 50: EPISTAXIS. 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.

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

Page 51: EPISTAXIS. 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.

Tips and PearlsRed rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more (not on both sides of septum)Antihistamines to prevent rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels (2 or more) injected with cortisporin oticAmicar spray

Page 52: EPISTAXIS. 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.

Tips and PearlsHot water irrigationCold water irrigationSalt PorkDon’t pack nose in unconscious person with suspected skull fractures.Antibiotic cream vs. silver nitrateIntranasal pressureEstrogen cream to nasal septum

Page 53: EPISTAXIS. 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.

Tips and PearlsTransnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed)Submucosal supraperichondrial dissection of nasal septumNot all hospitals have embolization-trained interventionalistsNo hard-set outline. Do what is best for your particular patient

Page 54: EPISTAXIS. 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.

CASE REPORT45 yo Vietnamese fisherman--stable, but uncomfortableProfuse 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.

Page 55: EPISTAXIS. 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.

Case 1 – cont’dHgb 12.5Lactated Ringers IVF bolusNasal packs – removed two days later in the clinic,…rebleeds.Requires transfusion for Hgb of 6.5Angiography—no obvious bleed/EmbolizationAnt/Post Ethmoid Artery ligation


Pediatric Otogenic Lateral Sinus Thrombosis: Role of ...complication from anticoagulation use was an episode of epistaxis lasting less than 10 minutes that resolved with pressure at

Pediatric Otogenic Lateral Sinus Thrombosis: Role of ...complication from anticoagulation use was an episode of epistaxis lasting less than 10 minutes that resolved with pressure at

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Management of Epistaxis - PHARMAC

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Epistaxis Handbook - The Master Surgeonthemastersurgeon.com/books_publications/books/Epistaxis Handbook.pdf · Epistaxis is classified as anterior or posterior depending upon the

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Supplementary Online Content€¦ · The Epistaxis Severity Score (ESS) is derived from 6 questions about epistaxis frequency, epistaxis duration, epistaxis intensity, presence of

Supplementary Online Content€¦ · The Epistaxis Severity Score (ESS) is derived from 6 questions about epistaxis frequency, epistaxis duration, epistaxis intensity, presence of

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Epistaxis new

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ITEM 85 - EPISTAXIS V3

ITEM 85 - EPISTAXIS V3

Management of Severe Epistaxis during Pregnancy: A Case ......Few cases of severe epistaxis during pregnancy were describedinliterature[–,](Table).Weexcludedcases of epistaxis associated

Management of Severe Epistaxis during Pregnancy: A Case ......Few cases of severe epistaxis during pregnancy were describedinliterature[–,](Table).Weexcludedcases of epistaxis associated