Lecture 6 epistaxis

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Information about Lecture 6 epistaxis
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Published on March 15, 2014

Author: magician10k

Source: slideshare.net

Epistaxis vascular anatomy : 2 systems Internal carotid artery External carotid artery

Internal carotid a. Opthalmic a. Anterior ethmoidal a. Posterior ethmoidal a. Internal carotid artery Superior orbital fissure Posterior ethmoidal foramen Posterior entmoidal sinus, sphenoid sinus Cribiform plate Lateral branch Septal branch Posterosuperior of lateral nasal wall and septum Anterior entmoidal sinus, frontal sinus, dura Anterior ethmoidal foramen Lateral branch Septal branch Anterosuperior of lateral nasal wall and septum

External carotid artery External carotid a. Internal maxillary a. Facial a. Alar branch Superior labial a. Ala Septal branch Anterior nasal septum, vestibule Descending palatine a. Sphenopalatine a. Pterygopalatine fossa Sphenopalatine foramen Posterior lateral nasal branchSeptal branch Lateral wall of nasal canal, Middle, inferior turbinate & Meatus, ethmoid & maxillary sinus Sphenoid bone Lower septum, anterior septum (Little’s area) Lesser palatine Greater palatine Greater palatine canal Anterior nasal septum

Medial wall

Little’s area Anterior ethmoidal artery Septal branch of the sphenopalatine artery Greater palatine artery Branch from superior labial a (facial artery)

According to site  Anterior : Little’s area  Superior: Anterior ethmoid ( bleeding is from above ant. half of middle turbinate)  Inferior: Greater palatine  Posterior: Sphenopalatine (Bleeding is from below middle turbinate)

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)

REASONS FOR EXCESSIVE BLEEDING  Vascularity of nose.  Both external and internal carotids.  Anastomosis between arteries and veins.  Blood vessels run just under the mucosa- unprotected.  Larger vessels in the turbinate run in bony canals- cannot contract.

Local causes Idiopathic Infection & Inflammation - Rhinitis - sinusitis - nasopharyngitis Trauma - foreign body - surgery (post op.) - fracture nose - skull base fracture Tumor - Nasopharyngeal angiofibroma - CA nasopharynx - Haemangioma and telengectasia

Systemic causes -HT & Arteriosclerosis (commonest cause in elderly patients) -Pulmonary hypertension -liver Cirrhosis - coagulopathy - hemophilia - Thrombocytopenic purpura -Anti-platelets and anti-coagulant drugs -leukemia

INVESTIGATIONS OF EPISTAXIS  CBC, platelet count, clotting time, bleeding time, prothrombin time, partial thromboplastin  Liver function test  Plain x-ray  CT scan  MRI  Angiogram  Biopsy

 Lab tests to evaluate the patient's condition and underlying medical problems may be ordered depending on the clinical picture at the time of presentation.  If the bleeding is minor and not recurrent, then a lab evaluation may not be needed.

Non-surgical treatments  Control of hypertension  Correction of coagulopathies/thrombocytopenia (FFP or whole blood/reversal of anticoagulant / platelets)  Topical decongestants/vasoconstrictors

TREATMENT  First aid  Definitive treatment  Prevention of recurrences

First Aid  Make the patient sit up, pinch nose, open mouth and breath.  Ice on fore head.  Cotton pack soaked with vasoconstrictor (10 min).

DEFINITIVE TREATMENT  Assess blood loss (severity, side, site).  Hypovolumic shock management: ( tachycardia, tachypnea, hypotension, cold sweat, oliguria, restlessness) -bed rest, head down - sedative - I.V fluids (fresh blood) -warming  Locate the point after packing the nose with 4% xylocaine and 1:1000 adrenaline mixture.  Control bleeding:

CAUTERIZATION 1) Chemicals  Silver Nitrate stick, chromic acid bead. 2) Electrical  Apply ointment and advise against blowing and nose picking.  Endoscopic.

Nasal packing (effective 80-90%) A) Anterior nasal packing: - Ribbon gauze with Vaseline. - Merocel. - Epistaxis balloon tampon

B) Posterior nasal packing:  Continued hemorrhage despite anterior packing is probably result of bleeding from post. Branch of sphenopalatine artery.  Posterior bleeding is much less common than anterior bleeding.

Posterior nasal packing 1. Vaseline gauze (classical packing) 2. Foley catheter 3. Epistaxis balloon tampon

Posterior nasal packing Classical packing

Posterior nasal packing Foley catheter (10 to 14 French)

Posterior nasal packing Epistaxis balloon tampon

Arterial embolization Angiography to detect feeding vessel then injection of embolus ( gel foam). Arterial ligation -external carotid a.(cross anastomosis). -internal maxillary a (posterior bleeding). -ant and post ethmoidal a (superior bleeding).

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