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Epistaxis
hadeel Owies
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Nose anatomy : 2/3 cartilaginous ,1/3 bony.
Bony bridge extremely strong .skin very closely related to the skeleton .
Nose function:
Warming ,moistering and filtering the incoming
air
Detecting olfactory stimuli
Modifying speech vibrations
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Why bleeding from the nose ?
Vascular organ secondary toincredible heating/humidification
requirements
Vasculature runs just under mucosa(not squamous)
Arterial to venous anastamoses
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Blood supply:1.External Carotid
Artery
-Sphenopalatine artery
-Greater palatine artery
-Ascending pharyngeal artery
-Posterior nasal artery
-Superior Labial artery
2.Internal Carotid Artery-Anterior Ethmoid artery
-Posterior Ethmoid artery
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Kesselbachs
Plexus/Littles Area:
-Anterior Ethmoid (Opth)
-Superior Labial A (Facial)
-Sphenopalatine A (IMAX)
-Greater Palatine (IMAX)
Woodruffs Plexus:-Pharyngeal & Post. Nasal
AA of Sphenopalatine A
(IMAX)
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Anterior vs. Posterior
Anterior: younger, usually septal vs.
anterior ethmoid, most common
(>90%), typically less severe Posterior: older population, usually
from Woodruffs plexus, more serious.
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Etiology
Local factorspontaneous
Vascular
Infectious/Inflammatory Trauma
Iatrogenic
Neoplasm
Foreign Bodies/other
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Etiology
general factors
Vascular
Infection/Inflammation
Coagulopathy
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Trauma
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear,
base of skull
Barotrauma
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Local Factors -
Infection/Inflammation
Rhinitis/Sinusitis
Allergic
Bacterial
Fungal
Viral
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Local Factors - Iatrogenic nasal
injury
Functional endoscopic sinus surgery
Rhinoplasty
Nasal reconstruction
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Local FactorsNeoplasm
benign tumor: Juvenile nasopharyngeal angiofibroma
Inverted papilloma
Polyps
Malagnant tumor:
scc
Adenocarcinoma
Melanoma
Lymphoma
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Systemic Factors -- Vascular
Hypertension/Arteriosclerosis
From woodruffs area
Elderly
Difficult to stop
May recure
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Systemic Factors
Infection/Inflammation
Tuberculosis
Syphillis
Wegeners Granulomatosis
SLE
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Systemic Factors
CoagulopathiesThrombocytopenia
Platelet dysfunction Systemic disease (Uremia)
drug-induced (Coumadin/NSAIDs/Herbal
supplements)
Clotting Factor Deficiencies Hemophilia
VonWillebrands disease
Hepatic failure
Hematologic malignancies
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Etiology and Age
Childrenforeign body, nose picking
Adultstrauma, idiopathic
Middle agetumors
Old age--hypertension
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Initial Management
ABCs
Medical history/Medications
Vital signs Physical exam
Anterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiologic studies
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managmant: If bleeding is from little area:
1. Apply digital pressure on the lower part of theseptum.
2. Pack the nose with cotton plug soaked with
lidocaine or phenylephrine for 5-10 minutes.3. If it didnt work, try to cauterize the site of
bleeding with silver nitrate stick.
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If bleeding is from an unknown site:1. Apply digital pressure on the lower part
of the septum for 5-10 minutes.
2. Let the patient lean forward.
3. Ask the patient to breath from his mouth.4. Spit out the blood and not to swallow it.
5. If healing site is visible we do
cauterization by silver nitrate or
diathermy.
6. Sometimes we need to do post nasal
packing
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Nasal packs
We can use foleys catheter, we insert itfrom the nose and once it is in the
pharynx we inflate the balloon and
pull it back untill its stuck at thenasopharynx.
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Non-surgical treatments
Avoidance of nose picking/blowing
Sneeze with mouth open
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Non-surgical treatments
Control of hypertension
Correction of
coagulopathies/thrombocytopenia
FFP or whole blood/reversal ofanticoagulant/platelets
Topical decongestants/vasocontrictors
Cautery (AgNo3 vs. TCA vs. Bipolar vs.
Bovie) Nasal packing (effective 80-90% of time)
Greater palatine foramen block
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Surgical treatment
Transmaxillary IMA ligation
Intraoral IMA ligation
Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation
External carotid artery ligation
Septodermoplasty/Laser ablation
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Indications for
surgery/embolization Continued bleeding despite nasal
packing
Pt requires transfusion
Nasal anomaly precluding packing
Patient refusal/intolerance of packing
Posterior bleed vs. failed medical
mangmant
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THANK YOU
Hadeel owies