Epistaxis

Epistaxis:

Epistaxis is defined as bleeding from the nose due to any cause.

can be,local or systemic.

Through :anterior nares and posterior nares

Origin of blood from:

• Nose
• Nasopharynx
• PNS
• Antrior cranial fossa

VASCULAR ANATOMY:

Nose is supplied by both external & internal carotid systems.

External carotid system comprises of:

• Sphenopalatine br of Maxillary A
• Gr.Palatine br of Maxillary A
• Superior labial br of Facial A
• Internal carotid system (Ophthalmic A) comprises of:
• Ant ethmoidal Artery
• Post ethmoidal Artery

LITTLE's AREA

Situated in the ant inf part of nasal septum

Kiesselbach’s plexus comprised by:

•Ant ethmoidal

• Septal br of Sup labial

• Gr.Palatine

•Septal br of SPA

LITTLE's Area

Exposed to drying inspiratory air currents and digital trauma

Commonest site of epistaxis in children and young adults

Leads to arterial bleeding.

RETROCOLUMELLAR VEIN:

A vein running down just behind the columella crossing the floor and joining the venous plexus the lateral wall of nose .May bleed in young people

WOODRUFF's PLEXUS:

Venous plexus on the lateral wall of the inf. meatus posteriorly.Also called naso-nasopharyngeal plexus .Site of epistaxis in elderly

SPHENOPALATINE ARTERY:-

Artery of epistaxis .Terminal br of int maxillary Artery.Enters nose by traversing the sphenopalatine foramen.

SITE OF EPISTAXIS:

Little’s area ,Woodruff’s area ,Above middle turbinate (ant & post eth.A).Below middle turbinate (br of SPA),Diffuse bleeding,Nasopharynx,Roof of nasal cavity ,Post. Part of nasal septum (Brown’s area) .

PATHOPHYSIOLOGY:

Various factors are involved.Vessel wall damage by trauma ,Sudden rise of pressure(violent exp effort) in a weak vessel wall rupture,Inherent weakness of capillary wall,Infection,inflammation,fragility of capillary wall,bleeding,Vitamin deficiencies (K,C) cause weakness of capillary wall ,clotting factor deficiency

Impaired coagulation eg:epistaxis as in coag disorders, aspirin

AETILOGY:

Age: Children: nosepicking, FB, adenoids, diphtheria , adolescent: JNA, trauma, rhinosinusitis ,adults: infection, injuries,lderly: HT, neoplasm, sex: no sex prediliction.

It can be due to Local,systemic and idiopathic factors.

LOCAL:

• Most common
• Can be
• Congenital - multiple telangiectasiasis(Osler Rendu Weber syndrome)
• Traumatic
• Foreign body
• Inflammation ,neoplasm,miscellaneous..

LOCAL TRAUMATIC:-Digital trauma

• Nasal #
• # ant cranial fossa
• Surgical trauma
• Chemical trauma…eg..arsenic
• Traumatic septal perforation
• Forceful blowing of nose and sneezing
• local foriegn body:-
• Maggots
• Rhinolith
• Neglected FB

LOCAL INFLAMMATION:Acute non specific rhinosinusitis

• Acute specific—nasal diphtheria
• Chronic non specific
• Atrophic rhinitis
• Rhinitis sicca
• Rhinitis caseosa
• Chronic rhinitis

Chronic specific :

• Rhinosporidosis
• TB, Lupus
• Syphilis
• Leprosy
• Rhinoscleroma

LOCAL NEOPLASMS:-

Benign growth, bleeding polyps of septum, angiofibroma, inverted papilloma

Malignant growths of the nose, PNS and nasopharynx

LOCAL-miscellaneous:-

• Vicarious menstruation
• Barotrauma
• Deviated nasal septum

SYSTEMIC:-

• Congenital- hemophilia and other disorders of coagulation
• Infective

• Disorders of blood and blood vessels
• Systemic diseases
• Drugs
• Mediastinal compression
• miscellaneous

SYSTEMIC-Infective:-

• Acute exanthematous fevers—measles, varicella, influenza
• Malaria
• Typhoid
• Kala-azar
• Pertussis
• Rheumatic fever
• Dengue fever
• Infectious mononucleosis

Blood and blood vessels:-

• Purpuras
• Leukemias
• Haemophilias
• Aplastic & pernicious anaemias
• Vit K def
• DIC

SYSTEMC DISEASES:-

• Hypertension
• Atherosclerosis
• Mitral stenosis
• Cirrhosis
• Chronic nephritis

DrUGS:-

• Anticoagulants
• Aspirin
• Phenytoin

SYSTEMIC:-

• Mediastinal compression by tumours of the lower neck and mediastinal growths

Miscellaneous:

• Prolonged exertion
• Pregnancy
• Puberty

Management:-

• Surgical emergency
• Treatment consists of
• Assess gen condition of patient and resuscitate if necessary
• Local measures to stop haemorrhage
• Treatment of the specific cause of bleeding

General measures:-

• Record vital signs
• Hb, PCV
• history-amount of bleeding, ppt cause, medical illness, drugs, family history
• Fluid replacement
• Blood transfusion
• Oxygen masks
• Bleeding profile, X-rays, CT scans if required

Management:-

• Control of hypertension
• Correction of coagulopathies/ thrombocyto penia
• FFP or whole blood/reversal of anticoagulant/platelets
• Topical decongestants/vasocontrictors
• Cautery (AgNo3 vs. TCA vs. Bipolar)
• Nasal packing (effective 80-90% of time)
• Greater palatine foramen block.
• Humidity/emolients
• Discontinue offending meds
• Nasal saline sprays
• Avoidance of nose picking/blowing
• Sneeze with mouth open
• Avoid straining/bedrest .

LOCAL MEASURES:-

• Temporary pressure over alae—pinch nose with pt upright
• Ice cubes over nose—vasoconstriction
• Trotters method: NOT DONE NOW
• Pt sit on a chair leaning forward with open mouth—bleed till hypotensive. Risk of coronary thrombosis .

CAUTERIZATION:-

• Nasal endoscopy after local spray to locate bleeding point.
• Cauterization of the bleeding point
• Chemical cautery :
• 50% trichloroacetic acid
• 10% silver nitrate
• Electric cautery
• Cryo cautery

NASAL PACKS:-

• Anterior nasal packs
• Traditional
• Recent modifications
• Posterior nasal packs
• Traditional
• Recent modifications
• Ant/Post nasal packing .

Complications of nasal packing:-

• Early:pain,vasovagal attack,injury to soft palate,columella,nares,mucosa,choana.

Intermediate :

• Hypoxia & hypoventilation
• Sleep
• Apnoea
• Arrythmias and cardiac arrest
• ET dysfunction

Late :

• Secondary haemorrhage
• Septal necrosis and perforation
• Toxic shock syndrome
• Synechiae
• Atrophic rhinitis

Surgical treatment:-

• Last resort in epistaxis control
• ECA ligation as 90% mucosa is supplied by it
• Arteries that can be ligated are:
• Internal maxillary A: transantral/ transoral approach
• ECA: cervical incision
• Sphenopalatine A: transantral/ endoscopic
• Ant and Post ethmoid A: Lynch incision

EMBOLIZATION:-

For severe post epistaxis—IMA embolized

Using gelfoam, oil, balloon, poly vinyl alcohol particle

Side effect: CVA

Nasal balloon:-

• For posterior epistaxis
• Foley’s catheter is used
  
• Catheter with 2 balloons--- one in nasopharynx and other in the nasal