Epistasis

anatomy, history, types, first aid treatment,

1. ePISTAXIS Presented by : Dr Siddeshwar K G

2. EPISTAXIS Bleeding from inside the nose. Peak incidence seen in under 10 yr above 40 yr. 60% in there lifetime. Presents as an emergency. Epistaxis is a sign and not a disease per se.

3. HISTORY Cullen – nose bleed Lupton 1601 – “ consummatus est ” - Jesus christ - Its finished Hippocrates – pinching nostril Persian Hakim- boiling blood Morgagni James lawerence little & Kiesselbach

4. BLOOD SUPPLY OF NOSE : External and internal carotid systems, both on the septum and the lateral walls. Vessels run submucosal NASAL SEPTUM Internal carotid system : Anterior ethmoidal artery Posterior ethmoidal artery Branches of ophthalmic artery

5. EXTERNAL CAROTID SYSTEM Sphenopalatine artery (branch of maxillary artery), gives nasopalatine and posterior nasal septal branches. Septal branch of greater palatine artery (Br. of maxillary artery). Septal branch of superior labial artery (Br. of facial artery).

6. LATERAL WALL : Internal carotid system : Anterior ethmoidal Posterior ethmoidal Branches of ophthalmic artery

7. EXTERNAL CAROTID SYSTEM Posterior lateral nasal Greater palatine artery Nasal branch of anterior superior dental Branches of facial artery to nasal vestibule    From sphenopalatine artery From maxillary artery From infraorbital branch of maxillary artery

8. LATERAL WALL

9. SEPTUM

10. Little’s area It is situated in the anterior inferior part of nasal septum, just above the vestibule. 1 Anterior ethmoidal 2 S eptal branch of superior labial 3 Septal branch of S phenopalatine 4 The greater palatine This area is exposed to the drying effect of inspiratory current and to finger nail trauma, and is the usual site for epistaxis in children and young adults. Kiesselbach’s plexus

11. Woodruff’s plexus – inferior to posterior end of inferior turbinate. Retrocolumellar vein - runs vertically downwards just behind the columella , crosses the floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous bleeding in young people

12. Nasal cavity – principal location of anastomoses in H & N Vessels run submucosal vessels supplying the middle and inferior turbinate – bony conduit/tunnels and have periarterial fibrous venous cuff . Ant ethmoidal artery - mesentery attached to skull base , between ethmoid fovea and lamina papyracea . Following embolisation /ligation – compensatory anastomosis flow via facial artery - rebleed APPLIED ANATOMY

13. CAUSES OF EPISTAXIS : Local (nose or nasopharynx). General Idiopathic

14. LOCAL CAUSES Nose Trauma 2 ) Infections Acute : viral rhinitis, nasal diphtheria, acute sinusitis. Chronic :All crust-forming disease 3) Foreign bodies . Non-living : foreign body, rhinolith . Living : Maggots ,leeches . .

15. 4) Neoplasms of nose and paranasal sinuses . Benign : Haemangioma , hemangiopericytoma . Malignant: Carcinoma or sarcoma 5) Atmospheric changes - High altitudes, sudden decompression 6 ) Deviated nasal septum

16. NASOPHARYNX : A denoiditis juvenile angiofibroma Malignant tumours GENERAL : Hypertension , mitral stenosis,pregnancy ( PIH, hormonal) Disorders of blood and blood vessels. Liver disease –cirrhosis, liver failure. Kidney disease. Chronic nephritis. Drugs - salicylates , analgesics & anticoagulant therapy .

17. 6 ) Mediastinal compression. Tumours of mediastinum (raised venous pressure in the nose). 7) Acute general infection. 8) Vicarious menstruation ( epistaxis occurring at the time of menstruation). C) Idiopathic : Many times the cause of epistaxis is not clear.

18. SITES OF EPISTAXIS : Little’s area ( 90% ) . Above the level of middle turbinate. Below the level of middle turbinate. Posterior part of nasal cavity. Diffuse- septum and lateral nasal wall. Nasopharynx . .

19. CLASSIFICATION OF EPISTAXIS : Anterior epistaxis : Posterior epistaxis : Blood flows back into the throat. “Coffee coloured ” vomitus

20. Difference between anterior and posterior epistaxis Anterior epistaxis Posterior epistaxis Incidence site More common Mostly from Little’s area or anterior part of lateral wall Less common Mostly from posterosuperior part of nasal cavity Age Mostly occurs in children or young adults After 40 years of age Cause Mostly trauma Spontaneous; often due to hypertension Bleeding Usually mild, can be easily controlled by local pressure or anterior pack Bleeding is severe requires hospitalisation ; postnasal pack often required .

21. APPROACH TO EPISTAXIS Quick evaluation Resuscitate Arrest Bleeding Find & treat the cause

22. EVALUATION - HISTORY How frequent? Last episode? How much? Quantify – in equivalents. Which side? Anterior / posterior? How does it stop? Colour of blood? Does it drip drop by drop or is it brown and vomited out? Any drugs being taken? Any recent or current infection? Any recent RTA / Head injury? Any bleeding from other sites ?

23. EVALUATION - General look Air Hunger - Tachypnoea Pulse – Tachycardia BP – Hypotension/ Hypertension Active Bleeding? Anterior Posterior Any evidence of a generalized bleed?

24. FIRST AID

25. First aid : Trotter’s method Cold compresses - reflex vasoconstriction. Cauterisation : In anterior epistaxis when bleeding point has been located. The area is first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery .

26. Decongestant nasal drops ,AMICAR spray Adrenaline soaked cotton pledget Naseptin or tramcilone + petroleum jelly, silver nitrate, TCA , H 2 O 2

27. ENDOSCOPIC CAUTERIZATION Using nasal endoscope and bipolar cautery Not always available in emergency settings Requires surgical expertise Excellent results

28. Topical Anaesthesia 2.5/1.2 cm ribbon gauze , Liquid paraffin Neosporin/ BIPP Nasal Speculum Tilley’s Forceps Illumination Suction ANTERIOR NASAL PACKING

29. Anterior nasal packing : If bleeding is profuse and/or the site of bleeding is difficult to localise , anterior packing should be done. Ribbon gauze soaked with liquid paraffin. One or both cavities may need to be packed. Can be removed after 24 hours if bleeding has stopped. If kept for 2 to 3 days; systemic antibiotics given to prevent sinus infection and toxic shock syndrome.

30. Anterior nasal packing

31. MEROCIL PACKING Highly absorbent (up to 21 times its weight in fluid) Biocompatible, Polyviny alcohol Hemostatic attributes ( tamponade effect with light pressure ) Aggregates clotting factors Adhesion prevention Excellent wet state elasticity Durable and long-lasting Strong/non-shredding X-ray detectable Impregnated with various compounds Soft and compressible for easy insertion

32. Topical / General Anaesthesia Posterior Nasal Pack Liquid paraffin Neosporin/BIPP. Nasal Speculum Tilley’s Forceps Red Rubber Catheters Illumination Suction POSTERIOR NASAL PACKING

33. Posterior nasal packing : Method Patients requiring postnasal pack always be hospitalised . Folley’s catheter can also be used. Nasal balloons are also available. .

34. NASAL CATHETER

35. OTHER OPTIONS Rapid Rhino anterior balloon tampon carboxymethylcellulose , a hydrocolloid material, acts as platelet aggregator and forms a lubricant upon contact with water. T he Rapid Rhino balloon has a cuff that is inflated by air. The hydrocolloid preserves the newly-formed clot during tampon removal.

36. OTHER OPTIONS

37. Elevation of mucoperichondrial flap and SMR operation : In case of persistent or recurrent bleeds from the septum, elevation of mucoperichondrial flap and then repositioning it helps to cause fibrosis and constrict blood vessels. SMR operation remove any septal spur

38. ARTERIAL LIGATION Sphenopalatine artery(ESPAL) Anterior ethmoidal artery /Posterior ethmoidal artery External carotid artery Internal maxillary artery

39. ARTERIAL LIGATION ANTERIOR ETHMOID ARTERY LIGATION SPHENOPALATINE ARTERY LIGATION

40. EXTERNAL CAROTID ARTERY LIGATION External carotid artery is ligated distal to its first branch i.e. SUPERIOR THYROID ARTERY

41. NEWER METHODS IN MANAGEMENT Arterial embolization: selective . Lasers Coblation

42. General Measures in Epistaxis : T he patient put in semi recumbent position and record any blood loss through spitting or vomiting. Reassure the patient. Mild sedation. Keep check on pulse, BP and respiration. Maintain haemodynamics : Blood transfusion. Antibiotics to prevent sinusitis, if pack is be kept beyond 24 hours. Investigate and treat the patient for any underlying local or general cause.

43. SUMMARY Commonly seen condition Most of the patients respond to conservative therapy Follow the management protocol for best results Endoscopic methods are very accurate Arterial ligations are last options in cases of intractable epistaxis Newer methods have excellent outcome but expensive

44. REFERENCES Scott-browns otolaryngology 7 th edition Cummings otolaryngology and head &neck surgery 6 rd edition.

45. THANK YOU