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EPISTAXIS
Introduction and History
5-10% of the population experience an episode
of epistaxis each year. 10% of those will see a
physician. 1% of those seeking medical care will
need a specialist.
Mythology: brown paper, nails, scissors, scarlet
threads,“lead that has never touched the ground”
A condition with a long history—Hippocrates to
Henry Goodyear.
Anatomy/Physiology of Epistaxis
Anatomy
Nasal cavity
Vascular supply
Physiology
Vascular nature
Mucosa
Why bleeding from the nose ?
Vascular organ secondary to incredible
heating/humidification requirements
Vasculature runs just under mucosa (not
squamous)
Arterial to venous anastamoses
ICA and ECA blood flow
SPF
-class I (35%)
-class II (56%)
-class III (9%)
Anatomy of the Lateral Nasal Wall
External Carotid Artery
-Sphenopalatine artery
-Greater palatine artery
-Ascending pharyngeal artery
-Posterior nasal artery
-Superior Labial artery
Internal Carotid Artery
-Anterior Ethmoid artery
-Posterior Ethmoid artery
Pterygopalatine Vasculature
--Internal maxillary artery
Anatomy of the Nasal Cavity
and Vasculature
Sphenopalatine AA
Ethmoid AA
Greater Palatine A
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)
Anterior vs. Posterior
Maxillary sinus ostium
Anterior: younger, usually septal vs. anterior
ethmoid, most common (>90%), typically less
severe
Posterior: older population, usually from
Woodruff’s plexus, more serious.
Etiology
Local factors
Vascular
Infectious/Inflammatory
Trauma (most common)
Iatrogenic
Neoplasm
Dessication
Foreign Bodies/other
Etiology
Systemic factors
Vascular
Infection/Inflammation
Coagulopathy
Local Factors -- Vascular
ICA Aneurysms
extradural
cavernous sinus
Local Factors - Infection/Inflammation
Rhinitis/Sinusitis
Allergic
Bacterial
Fungal
Viral
Local Factors - Trauma
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasogastric/nasotracheal intubation
Trauma to sinuses, orbits, middle ear, base of
skull
Barotrauma
Nasal Fracture with Septal Hematoma
Local Factors - Iatrogenic nasal injury
Functional endoscopic sinus surgery
Rhinoplasty
Nasal reconstruction
Local Factors - Neoplasm
Juvenile nasopharyngeal angiofibroma
Inverted papilloma
SCCA
Adenocarcinoma
Melanoma
Esthesioneuroblastoma
Lymphoma
Local Factors –
Dessication
Cold, dry air—more common in wintertime
Dry heat—Phoenix and Death valley
Nasal oxygen
Anatomic abnormalities
Atrophic rhinitis
Local Factors - Other
Self-inflicted (pedi) vs. traumatic foreign bodies
Intranasal parasites
Septal perforation
Chemical (cocaine, nasal sprays, ammonia, etc.)
Systemic Factors -- Vascular
Hypertension/Arteriosclerosis
Hereditary Hemorrhagic Telangectasias (OWR)
Systemic Factors –
Infection/Inflammation
Tuberculosis
Syphillis
Wegener’s Granulomatosis
Periarteritis nodosa
SLE
Systemic Factors – Coagulopathies
Thrombocytopenia
Platelet dysfunction
Systemic disease (Uremia)
drug-induced (Coumadin/NSAIDs/Herbal supplements)
Clotting Factor Deficiencies
Hemophilia
VonWillebrand’s disease
Hepatic failure
Hematologic malignancies
Etiology and Age
Children—foreign body, nose picking, nasal
diptheria (1/3 with chronic bleeds have
coagulation d/o)
Adults—trauma, idiopathic
Middle age—tumors
Old age--hypertension
Initial Management
ABC’s
Medical history/Medications
Vital signs—need IV?
Physical exam
Anterior rhinoscopy
Endoscopic rhinoscopy
Laboratory exam
Radiologic studies
bayonet forcepts
vaseline gauze
suction
T.C.A.
bacitracin
gelfoam
good light
anesthetic
Afrin
epistat
endoscopes
silver nitrate
suction bovie/bipolar
merocels
surgicel
Non-surgical treatments
Control of hypertension
Correction of coagulopathies/thrombocytopenia
FFP or whole blood/reversal of anticoagulant/platelets
Pressure/Expulsion of clots
Topical decongestants/vasocontrictors
Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)
Nasal packing (effective 80-90% of time)
Greater palatine foramen block
Non-surgical treatments – on d/c
Humidity/emolients
Discontinue offending meds
Nasal saline sprays
Avoidance of nose picking/blowing
Sneeze with mouth open
Avoid straining/bedrest
Nasal packs
Anterior nasal packs
Traditional
Recent modifications
Posterior nasal packs
Traditional
Recent modifications
Ant/Post nasal packing
Pick a Pack, any pack
Pick a pack to pack with
TSS—Nugauze vs. Merocel
Electron microscopy
Posterior Packs – Admission
Elderly and those with other chronic diseases
may need to be admitted to the ICU
Continuous cardiopulmonary monitoring
Antibiotics
Oxygen supplementation may be needed
Mild sedation/analgesia
IVF
Indications for surgery/embolization
Continued bleeding despite nasal packing
Pt requires transfusion/admit hct of <38%
(barlow)
Nasal anomaly precluding packing
Patient refusal/intolerance of packing
Posterior bleed vs. failed medical mgmt after
>72hrs (wang vs. schaitkin)
Selective Angiography/embolization
Helps identify location of bleeding
Embolization most effective in patients who
Still bleeding after surgical arterial ligation
Bleeding site difficult to reach surgically
Comorbidities prohibit general anesthetic
Effective only when bleeding is >.5 ml/min
90+% success rate, complication rate of 0.1%
Only able to embolize external carotid & branches
Complications: minor (18-45%)/major (0-2%)
Contraindicated in bad atherosclerosis, Ethmoid bleed
Surgical treatment
Transmaxillary IMA ligation
Intraoral IMA ligation
Anterior/Posterior Ethmoidal ligation
Transnasal Sphenopalatine ligation
External carotid artery ligation
Septodermoplasty/Laser ablation
Transmaxillary IMA ligation
Waters view
Caldwell-Luc
Electrocautery of posterior wall before removal
Microscopic dissection and ligation of IMA -descending palatine & sphenopalantine most
important
Recurrence rate (failure rate) of 10-15%
Complication rate of 25-30% (oa fistula,dental, n)
Intraoral IMA ligation
Posterior gingivobuccal incision beginning at
second molar
Temporalis mm split and partially dissected
IMAX visualized, clipped and divided
Advantages: children/facial fractures
Disadvantages: more proximal ligation
Complications: trismus, damage to infraorbital n
Ant./Post. Ethmoidal ligation
Patients s/p IMAX ligation still bleeding, superior
nasal cavity epistaxis, or in conjunction when
source unclear
Lynch incision
Fronto-ethmoid
suture line
12-24-6
(14-18, 8-10, 4-6)
Transnasal Endoscopic
Sphenopalatine Artery ligation
Follow Middle Turbinate to posteriormost aspect
Vertical mucoperiosteal incision 7-8mm anterior
to post middle turb (between mid. and inf. turbs)
Elevation of flap—ID neurovascular bundle at
foramen
Ligation with titanium clip
Reapproximate flap
Complications –few, Failures—0-13%
Transnasal Sphenopalatine Artery ligation
ECA ligation
Effectiveness
Anterior border of SCM
ID ECA/ICA
Ligation after clear that surrounding structures
are safe.
Septodermoplasty/Laser
Remove mucosa from anterior ½ septum, floor of
nose, lateral wall
STSG vs. cutaneous, myocutaneous, microvascular
free flaps vs. Autografts
Neodymium-yttrium-garnet (Nd-YAG) laser or Argon
laser + topical steroid best nonsurg rx for mild/mod
disease
Still bleed, but not as bad
Definitive treatment (severe disease)—closure of
nose
Statistically speaking,….
Some authors (Wang and Vogel) showed surgical
intervention to have lower failure rates (14.3 vs. 26.2),
decreased complications (40 vs. 68), and shorter
hospital stays (2.2 less) than those w/posterior packs.
Others compared all medical treatment to surgery and
showed cost cut using medical management.
Complication rates: posterior packs-25-40%,
embolization 27%, IMAX ligation 28%
Cost analysis: IMAX vs. Embolization vs. Surgical
Cautery—about equal
Failure rates: PP-30%, Sx-17%, Emb-4%
Tips and Pearls
Red rubber on suction in contralateral nasal cavity
AgNO3 x 30seconds or more (not on both sides of
septum)
Antihistamines to prevent rebleeds
Cautery does not work with no platelets/clotting
Glove packing
H2O2
Merocels (2 or more) injected with cortisporin otic
Amicar spray
Tips and Pearls
Hot water irrigation
Cold water irrigation
Salt Pork
Don’t pack nose in unconscious person with suspected
skull fractures.
Antibiotic cream vs. silver nitrate
Intranasal pressure
Estrogen cream to nasal septum
Tips and Pearls
Transnasal endoscopic bipolar cautery of
sphenopalatine artery (7% failure in pts with obvious
source of bleed)
Submucosal supraperichondrial dissection of nasal
septum
Not all hospitals have embolization-trained
interventionalists
No hard-set outline. Do what is best for your particular
patient
CASE REPORT
45 yo Vietnamese fisherman--stable, but
uncomfortable
Profuse nasal bleeding since 0200 this a.m.
History: No known medical problems. Drinks 6-12
beers/day. Takes no medications. No history of
easy bleeding. No family history.
Physical exam: Profuse bleeding from both nostrils
L>R and bleeding down the back of his throat—
coughing up clots. Unable to locate precise
location of bleed—appears to be posterior/superior.
Case 1 – cont’d
Hgb 12.5
Lactated Ringers IVF bolus
Nasal packs – removed two days later in the
clinic,…rebleeds.
Requires transfusion for Hgb of 6.5
Angiography—no obvious bleed/Embolization
Ant/Post Ethmoid Artery ligation