EPISTAXIS

BY : NORAINI BT MOHD MUSTAFAR

What is epistaxis
Bleeding from inside the nose

Blood supply of nose

Blood supply of nose

Nasal septum

Lateral wall

Internal carotid system External carotid system

Internal carotid system External carotid system

Blood supply of nasal septum

Internal carotid system: Anterior ethmoidal artery Posterior ophthalmic artery External carotid system: Sphenopalatine artery Septal branch of greater palatine artery Superior branch of superior labial artery

Blood supply of lateral wall

Internal carotid system: Anterior ethmoidal Posterior ethmoidal External carotid system Posterior lateral nasal branches Greater palatine artery Nasal branch of anterior superior dental Branches of facial artery to nasal vestibule

Area of epistaxis
Little area
Ant.ethmoidal Septal branch of sup.labial Septal branch of sphenopalatine Greater palatine

Woodruffs area

Situated under the posterior end of inferior turbinate where sphenopalatine artery anastomoses with post.pharyngeal a.

Areas of epistaxis

Causes of epistaxis
Cause of epistaxis

local

general

idiopathic

trauma

Malignant tumor

infection

Adenoiditis

Local cause

Foreign bodies

Deviated nasal Atmospheric changes

Neoplasm

CVS

Acute general infection

Blood disorder

General cause
Mediastinal compression Liver disease

Drug

Kidney disease

Sites of epistaxis
Little area
90% bleed from this site

Above the level middle turbinate

Bleed from ant. & post ethmoidal vessel

Below the level of middle turbinate

Bleed from branches of sphenopalatine a.

Posterior part of nasal cavity

Blood flow directly to the pharynx

Diffuse
Bleed from septum and lateral nasal wall

SITES OF EPISTAXIS

Classification of epistaxis
Anterior Incidence Site More common Little area or anterior part of lateral wall Posterior Less common Posterosuperior part of nasal cavity ( diffcult to localise the bleeding point > 40 years old Spontaneous ( hpt, ateriosclerosis )

Age Cause Bleeding

Childs/young adult Trauma

Mild can be controlled by Bleeding is severe, need local pressure or anterior hospitalization, post pack nasal pack often required

management
Mode of onset Duration and frequency Amount of blood loss Side of nose where bleeding is occuring Bleeding tendency in family History of known medical illness History of drug intake

MANAGEMENT
First aid Pinch the nose with thumb and index finger for 5 minutes

MANAGEMENT
Trotters method Sitting position Lean a little forward over a basin to spit any blood Breathe through the mouth

MANAGEMENT

Cold compress reflex vasoconstriction

MANAGEMENT
Cauterisation Anterior epistaxis; bleeding point located Anaesthetised Bleeding point cauterised with bead silver nitrate / electrocautery

MANAGEMENT
Anterior nasal packing
Profuse bleeding and/or bleeding site difficult to localise Ribbon gauze soaked with liquid paraffin; 1m gauze(2.5cm wide in adults, 12mm in children) each nasal cavity

First few cm folded upon itself and inserted along the floor

Layer the gauze from floor to roof

MANAGEMENT
Anterior nasal packing One or both cavities Can be removed after 24 hours of bleeding has stopped Systemic antibiotics to prevent sinus infection and toxic shock syndrome

MANAGEMENT

MANAGEMENT
Anterior nasal pack

MANAGEMENT

Anterior nasal pack

MANAGEMENT
Posterior nasal packing
When is it required?

Bleeding posteriorly into the throat

MANAGEMENT
Posterior nasal packing
a catheter is passed through the affected nostril and through the nasopharynx, and drawn out of the mouth gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth

It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril.

gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger

MANAGEMENT
Posterior nasal packing

MANAGEMENT
Epistaxis balloon
Foleys catheter 12-14F inserted Balloon is inflated with 5-10mL saline

Bulb inflated with saline is pulled forward so that choana is blocked

Anterior nasal pack kept in the usual manner

MANAGEMENT
Epistaxis balloon

MANAGEMENT
Endoscopic Cautery
Posterior bleeding

Endoscope

Coagualated with suction cautery

Local anesthesia

MANAGEMENT
Elevation of Mucoperichondrial Flap and SMR Operation
Elevation of mucoperich -ondrial flap

Persistent or recurrent bleed from septum Elevation of mucoperichond r-ial flap and repositioning Cause fibrosis and constrict blood vessel

SMR
Remove any septal spur

Ligation of vessel
External carotid Bleeding from external carotid + failed conservative therapy Complication :: embolisation or ligation of more peripheral branch Maxillary artery Indicate for uncontrollable posterior epistaxis caldwell-luc operation Ethmoidal arteries Anterosuperior bleeding above middle turbinate Not controlled by packing