EPISTAXIS

BLOOD SUPPLY OF THE NOSE

Epistaxis

1. Introduction2. Definition3. Epidemiology4. Aetiology5. Pathogenesis6. Clinical features

or presentations

MGT

DISCUSS

Etiopathogenesis

Symptoms

Signs

7. Investigations8. Diagnosis9. Treatment

MGT OF EPISTAXIS1. Introduction2. Definition3. Hx 4. Symptoms

Signs5. Investigations6. Diagnosis7. Treatment

Pathogenesis

Etiology

Clinical features

LOCAL CAUSES

1. Idiopathic80 – 90%

2. Traumaa. Abraisions, # Nose, PNS, Base of Skull (CSF

Rhino)b. Picking of Nose in childhood & old-agec. FBs, Rhinolithsd. Burnse. Aitrogenic – Nasal surgery

Little’s Area

Retrocolumnar veins

RXN Epistaxis

2 Epitaxis

3. Inflammatory

a. Allergy

b. Non-Allergic

Infective

Specific

2. None infective

Bacterial

1. Infective Viral

Fungal

Wagner’s Granulomas Midline (Lethal) Gran.

Vasomotor Rhinits

Specific

Non-specific

TBC, Syphylis, Lepnsy, Sarcoidosis, Lypus Vulgaris, Mucorales Species

(Rhinoentomorphtomycosis), Atrophic

Rhinitis

Rhinoscleroma (K. Rhinoscleromatis –

cental, Eastern Europe, Central &South America)

characterized by:

1. Large foam cells (mikulitz cells) containing bacilli in vacoule

2. Russel bodies i.e. plasma cells with eosinophic staining cytoplasm and prominent nuclei.

Rhinoscleroma 3 types

NON – SPECIFIC: (1) Organism for common cold viral

i. Influenzaii. Picorna virus

• Coxsackie virus• Reo virus• Echo virus• Rhino virus/(commonest cause)3. RSV4. Parainfuenza5. Adenino virus

Atrophic

Tumefactive

Cicatrizing stage

2. Organisms for Bacteria

Pneunomia, a/c, ch. Rhinitis/sinusitis

4. Neoplastic

Benign Intermed Malignant• Haemangioma Inverted NPC• Angiofibroma Papilloma Lymphomas

Rhabdomy-

sarcoma

Stewarts/Lethal midline

granuloma

Melanoma

Benigns tumoursMalignant

Nose

Sinuses

Nasopharynx

5. Environmental:• High attitude• Alc – Drying

6. Vicarious Menstruation

A. Systemic Causes: Dx of Blood & Blood Vessels

i. HBP, venous pressure inii. Leukaemiaiii. Sickle cell anaemiaiv. Vit C & K deficienciesv. Osler Rendu weber dx (familial Hge

Telangectasia (Autosamal Recessive)

Lowers Atmospheric pressure

Dry effect

Cardiac Disorders

SVC, bleeding via Retrocolumella vein

Pulm, Disorder

B. Platelets defects:

i. Thrombocytopenic purpura (Aut. recessive)

ii. Thrombocytopeina

C. Coagulation Defects:i. Haemophiliacs = lack of viiiii. Xmas dx = lack of ixiii. Vit C, iv Vit K = deficiency =>

lack of ii vii ix xv. Von willebrands dx

2. Liver dx =>

PancytopeniaAgranulocytopenia

NoFunction

insufficiency

3. Kidney dx via uraemic synd.4. Anticoagulant Therapies e.g. Heparin/warfarin

Areas of Bleeding1. a. Little’s area – kiesselbach’s plexus

75 – 90%, single bld vessel/leish of vessels from the floor upwards or mucocutenous junc. Also bleeding polypus i.e. inflammatory granuloma of septum arising from little’s area.

b. - other parts of septum include a septal spur

2. Inferior turbinate & Nasal floor.

3. Above middle Turb from AEV in HBP.

4. Middle meatus – rare site but bleed from polypoid swelling must always suspicious of Neoplasm.

5. Sinuses

Blood vessels involved:

1. Ant. Ethmoidal PLEXUSES INVOLVED

2. Post Ethmoidal K!ESSELBACH’S

3. Greater palantine WOODRUFF’S

4. Sphenopalantine ECA

5. Superior labial

6. Ascending pharyngeal

Ethmoidal

Max Antrum

ICA

Clinical Features

1. Common Aldoscents & old

2. Mild – severe epistaxis

3. Ant. or post

Treatment

1.a Trotter’s positioning

- Head forward & flexed

- Breath through the mouth

1.b Pinch the Nostrils press. Compresses from outside for septal bleeds

False

Melena

HemetamesisHemophysis

2. Ice or cold pack- Bridge of Nose- Roof of mouth

3. Packing of the Nose & NasophynxAnterior packs

a. Gauze Adrenaline packb. Gauze Imp. BIPPc. Finger glove

- guaze BIPP/Genticin & Liquid Paraffin

Post packs

d. Inflatable Bag or soft Nasal splint

Post Nasal Packa. Rectangular gauze packb. Foley’s catheter

4. Cauterizationa. Chemical b. Electrical – Electrocautery

But you may anaesthetize the area with xylocaine,cocaine or GA for children.

AgNo3 – 15 – 25%Chronic AcidTrichloroacetic Acid 50%

5. EUA: Failure of the above, to enable

a. Better ID of bleeding pt.

b. Better Ant. & Post Nasal packs.

6. Arterial Ligation or Clipping:

a. Ext. carotid Artery distal to Lingual ART

b. Max Artery at the pteriygomaxillay fossa via

Transantral Approach

c. Ethmoidal Arteries via Ext. frontoethmoidectomy

7. Embolization: Embolization of max. art. Is via femoral Artey – a catheter is threaded under ultrasonic guidance to the max. Art. & Gel foam used to embolize the bleed pt.

8. Cryosurgery9. Drugs:

1. Sedatives & Bed Rest

2. Systemic A/Bs prevent infection when packing is retained > 24hrs

3. Vit C & K in large doses + cal.

4. Injection of Haemostatics e.g. Aminocaproic acid in bleeding due to ed fribrinolysis.

5. Special Situations:a. Infusion of cryo-ppts in clotting abnormalitiesb. Plasma-frozenc. Blood - whole

6. Hereditary Haemorrhagic Telangiectasia

a. Oestrogen Therapy

- induces metaplasia of the Nasal

mucosal memb. in bleeding

b. Septodermaplasty – replacing the mucous membrane of the Nose with split skin Graft.

(c) Radiation – if bleeding areas of FHT persist,

(d) Laser therapy:- argon laser can be used to Rx FHT in Nose & URT.

10. Treat Primary Lesion.

INVESTIGATIONS: 1. Hb, WBCT

Platelets, RBC, counts

TD

ESR, Film

2. Clotting Profile: clotting time, bleeding time, Prothrombin Index, PTTK,

3. Estimation of Antihaemophiliac Globulin (AHG)

4. Gp & CM Blood

5. Retroviral Tests

6. Genotype

7. LFT

8. S/U/E/CR

9. Urinalysis

10. X-Rays:a. Paranasal sinusesb. Post Nasal spacec. SMVd. CXR – PA

11. CT Scans

12. MRI

13. EUA & Biopsy of Tumours for Histology.

Dr. I.J. OKORAFORConsultant ENT SurgeonUNTH, ENUGU