Epistaxis

Epistaxis

1. Epistaxis
Dr. Krishna Koirala, MS ENT-HNS
Associate Professor
Dept. of ENT
MCOMS, Pokhara
Nepal
2020-06-29

2. •Definition
–Bleedingfrominsidethenasalcavity
•Causes
–Idiopathic(55%)
–Local
–General

3. Local causes (Nose & PNS)
•Congenital:
–Hereditaryhemorrhagictelengiectasia
•Trauma:
–Nosepicking,injurytonose/face/skullbase,nasal
surgery,foreignbody
•Infection:
–Vestibulitis,sinusitis,atrophicrhinitis,rhinosporodiosis,
rhinoscleroma
•Neoplasms:
–Angiofibroma,hemangioma, invertedpapilloma,
malignancy
•Deviatednasalseptumwithspur

4. General causes
•Hypertension
•Bleedingdisorders
–Hemophilia,thrombocytopenia,leukemia
•Drugs
–Aspirin,anticoagulants
•Physiological
–Cold+dryclimate,highaltitude,vicarious
menstruation,violentexertion,barotrauma
•Liverandkidneyfailure
•Exanthematousfevers

5. Common causes of epistaxis
•Children: Nose picking, foreign body, viral exanthemas
•Adolescent: Nasopharyngeal angiofibroma, trauma,
sinusitis
•Adults: sinusitis, trauma
•Elderly: hypertension, malignancy

6. Sites of epistaxis
•Little’s area/Kiesselbach’s plexus (80-90 %)
–Common in children and young people
•Woodruff’s venous (?) plexus
–Common in elderly, hypertensives
•Retro -columellar vein
–Common in young adults
•Others
–Septal turbinate, hemorrhagic nodules

8. Anterior
Epistaxis
Posterior
Epistaxis
Incidence More common Less common
Localization Easy Difficult
Common site Little’s areaWoodruff’s plexus
Age < 18 yr > 40 yr
Common Cause Trauma Hypertension
Treatment Anterior packPosterior pack

9. Evaluation of patients with epistaxis
•Modeofonset,duration,frequency,amount,side,
site,previousbleeding
•Nasaltrauma,purulentnasaldischarge
•Hypertension,hepaticdiseases,familyhistoryof
bleeding,bleedingfromothersites,useof
anticoagulants,aspirin
•Measurementofpulseandbloodpressure

10. Investigations
•Hemoglobin, Packed Cell Volume, platelet count
•Blood grouping
•Bleeding Time, Clotting Time
•Activated Partial Thromboplastin Time
•Prothrombin Time
•Diagnostic Nasal Endoscopy (D.N.E.)
•C.T. scan paranasal sinus

11. General treatment
•Record pulse and blood pressure
•Reassurance
•Bed rest in sitting position with back rest / support
and leaning forward
•Adequate sedation (Diazepam)
•Inj. Ethamsylate 500 mg IV TDS
•Amlodipine / Nifedipine for hypertension
•IV fluids / blood transfusion for shock

12. Anterior epistaxis
•Pinch nostrils + ice pack
Bleeding continues
•Insert cotton pledgets soaked in 1: 1000 adrenaline
in nasal cavity
Bleeding continues
•Chemical cautery with AgNO3or electrical cautery (if
bleeder is localized) or anterior nasal packing

13. Anterior epistaxis
•Pinch nostrils + apply ice pack
•Insert cotton pledgets soaked in 1: 1000 adrenaline
in nasal cavity
•Chemical cautery with AgNO3
•Electrical cautery (if bleeder is localized)
•Anterior nasal packing

15. Adrenaline soaked pledget

16. Chemical cautery

17. Anterior nasal packing
•Performed with
–Liquid paraffin & antibiotic cream in ribbon gauze
–Vaseline gauze
–Bismuth Iodoform Paraffin Paste gauze
–Merocel tampoon
–Simpson balloon
•Left inside the nostrils for 48 -72 hrs under antibiotic
cover

18. Anterior nasal packing with ribbon gauze
•Ribbongauzesoakedinliquidparaffinandantibiotic
cream/BIPPPack/Vaseline
•Bothnasalcavitiespackedtightlybylayeringfrom
floortoroof
•Packremovedafter48-72hrs
•Systemicantibioticsadministeredtopreventsinus
infectionandtoxicshocksyndrome

20. Merocel nasal tampoon

21. Simpson’s nasal balloon

22. Posterior epistaxis
•Posterior + anterior nasal packing
–Post nasal gauze pack
–Foley’s catheter
–Brighton balloon (double lumen)
–Epistat balloon (double lumen)
–Bivona balloon (triple lumen)
•Pack left in situ for 48-72 hrs underantibiotic cover

23. Antero-Posterior Nasal Packing
with gauze pack

24. Posterior nasal packing
•Postnasalpackpreparedbytying3ribbongauze
stripstoapieceofgauzeroll
•2Foley’scatheterspassedthrougheachnostriland
theirendsbroughtoutviamouth
•2endsofgauzestripsattachedtonasalpackaretied
tocathetertips&withdrawnfromnose

25. •Packthatfollowsribbongauzestrips,isguided
intonasopharynxwithindexfinger
•Ribbongauzestripstiedoveragauzepieceon
columellaandanteriornasalpackingdone
•3
rd
gauzestripbroughtoutfrommouthand
tapedtocheek
•Packremovedafter48-72hrs

26. Posterior nasal gauze pack

27. Catheter introduction

28. Tying of pack to catheter tip

29. Guiding pack into the nasopharynx

30. Tying of anterior strips

31. Anterior nasal packing

32. Outer nasal packing

33. Antero -Posterior Nasal
Packing with Foley’s
catheter

34. Foley’s catheter

35. Catheter introduction

36. Catheter tip in nasopharynx

37. Anterior nasal packing

38. Fixation of Catheter

39. Brighton’s nasal balloon

40. Epistat nasal balloon

41. Bivona triple lumen catheter

42. Surgical intervention for refractory/
intractable epistaxis
1.Arterialligationbyexternalapproach
–Externalcarotidarteryligatedinneck,distalto
superiorthyroidartery
–Internalmaxillaryarteryligatedinpterygo-palatine
fossa(Caldwell-Lucoperation)
–Anteriororposteriorethmoidalarteryligatedin
orbit(Lynch-Howarthincision)

44. External Carotid ligation

46. 2. Angiography and embolization
3. S.M.R. or Septoplasty
–Impacted DNS
4. Septo-dermoplasty
–Hereditary hemorrhagic telengiectasia
5. Endoscopic cautery and clipping:
–Anterior or posterior ethmoidal artery
–Sphenopalatine artery

47. Angiography + Embolization

48. Endoscopic clipping