Epistaxis

1. Epistaxis JC Fleming ENT Specialty Registrar

2. Anatomy Kiesselbach’s plexus – responsible for >90% Located at anterior nasal septum Confluence of vessels: INTERNAL CAROTID Opthalmic -> Ant. Ethmoid EXTERNAL CAROTID Facial -> Superior labial Maxillary -> Descending palatine -> Greater palatine Maxillary -> S phenopalatine From the anatomical literature and drawings collection at Heidelberg University— HeidICON http://www.flickr.com/photos/double-m2/sets/72157626344216704/

3. Anatomy Woodruff’s Plexus Common cause of posterior bleeds Lies inferior to posterior end of inferior turbinate Confluence of vessels: EXTERNAL CAROTID only Maxillary -> Sphenopalatine Ascending pharyngeal Also be aware of retrocolumellar vein – 2mm posterior to columella . Easily reachable by a child’s finger!

4. Classification Multiple methods! Main ones to remember are common sense: ADULT v CHILDHOOD (bimodal distribution) PRIMARY v SECONDARY (causal factor attributable – more on this later!) ANTERIOR v POSTERIOR – the one you’re likely to hear on the wards. Piriform aperture used as anatomical landmark

5. PRIMARY v SECONDARY Primary or Idiopathic: Accounts for 80% Risk factors: Autumn/Winter, NSAIDS, Alcohol, Hypertension Secondary: Trauma, Surgery, Anticoagulation, Hereditary haemorrhagic telangiectasia

6. Management The nose is part of the upper airway Therefore MUST adequately assess A irway, B reathing and C irculation Often high incidence of co-morbidities, placing these patients in high-risk bracket Full history after resuscitation/ stabilisation to elucidate any underlying causes Try and get estimate of loss but often difficult for patients to accurately determine

7. Management First Aid measures have often already been attempted (badly!) Pinch ala nasi – remember directly compresses anterior source of majority of bleeds IV Access and FBC/G&S (coagulation s tudies not routinely required unless suspected abnormality from history) D etailed and accurate assessment of nose Adequate light! (headlight ideally) Semi-recumbent position if stable Suction and topical vasoconstrictive solution +/- LA Protective clothing/gloves/glasses

8. Therapeutic Ladder As treatment ascends up ladder, specialist input from ENT required DIRECT vs INDIRECT therapy

9. Indirect Used if no bleeding point identified Nasal pack As with bleed, can be anterior or posterior (or both!) Traditionally BIPP ribbon gauze Newer anterior packs – Merocel (sponge), Rapid Rhino (inflatable) Posterior packs usually F oley catheter fed into post nasal space and inflated, pulling forward until it lodges in posterior choanae . Needs to be secured anteriorly with protection to columella skin (usually with umbilical clip) Very painful therefore warn patient and adequate analgesia! GA sometimes necessary Antibiotics required if pack remains longer than 48 hours (risk of toxic shock syndrome)

10. Direct Directly treat bleeding vessel – optimal for patient Endoscope allows superior visualisation Silver Nitrate cautery +/- direct haemostatic agents If unsuccessful, ongoing uncontrolled bleed or inadequate haemostasis from indirect techniques -------------  THEATRE

11. Surgical management Direct identification and cautery of bleeding point +/- further ant/post packing Sphenopalatine artery ligation Transantral Maxillary artery ligation (classic approach) External Carotid artery ligation (rarely required) Anterior/posterior ethmoidal artery ligation – usually only required in confirmed ethomidal bleeds e.g. traumatic injury Also – septoplasty

12. And . . . .Embolisation http:// commons.wikimedia.org/wiki/File:MCA_angio_lateral.jpg Courtesy of Dr Frank Gaillard Very useful for intractable haemorrhage surgically inaccessible sites/non-operative candidates BUT highly dependent on local radiological expertise

13. TAKE HOME MESSAGE Epistaxis : Can be a severe, life-threatening condition High-risk patients with multiple co-morbidities Range of treatment options: direct if possible Early involvement of ENT team