Epistaxis

Etiology, evaluation and management of epistaxis

1. EPISTAXIS Dr . AVINASH MALEKAR GMC Nagpur

2. Epistaxis , derived from the Greek term epistazein , is defined as bleeding from the nose

3. HISTORY Hippocratic technique Pilz (1869)= 1 st surgically treated epistaxis (Ligation of CCA) James Little (1879) Wilhem Kisselbach

4. Saiffert (1928)= via maxillary sinus ligated internal maxillary artery Woodruff (1949) Sokoloff =   first undertook angiographic embolisation for epistaxis in 1972

5. Vascular supply of nasal cavity Various anastomoses on the ipsilateral side between the internal and external carotid systems exist as well as crossover to the contralateral side Knowledge of these anastomosis is important in addressing most distal site of bleeding

6. Vascular supply of nasal cavity

7. Anterior and Posterior ethmoidal arteries

8. Sphenopalatine artery

9. Common bleeding sites Little’s area Woodruff’s plexus Retrocolumellar vein

10. Little’s area

11. Woodruff plexus

12. Retrocolumellar vein Run 2mm behind and parallel to columella C ommon cause of venous epistaxis in children

13. Classification of epistaxis

14. Anterior epistaxis Posterior epistaxis More common Less common Mostly occurs in children and young adults After age of 40 years Mostly from Little’s area or anterior part of lateral wall Mostly from posterosuperior part of nasal cavity Cause= Mostly trauma Cause= Spontaneous Bleeding is mild and controlled by local pressure or anterior pack Bleeding is severe Require hospitalization Postnasal pack often required

15. Epistaxis Anterior epistaxis Posterior epistaxis

16. Local causes

17. Systemic causes Hypertension: No direct causal relationship Altered clotting abilities= Drugs (NSAIDs, apsirin , clopidogrel ), Liver disease Inherited blood diatheses= Hemophilia (Factor VIII deficiency), Von Willebrand’s disease Hereditary hemorrhagic telengiectasia (HHT) - Autosomal dominant - widespread cutaneous, mucosal and visceral telengiectasia

18. Approach to a patient with epistaxis A} History of epistaxis - Onset - Frequency - Duration - Quantity - Uni /Bilateral - Previous episodes - Hematemesis / Hemoptysis B} History of - Trauma - Exanthematous fever - Foreign body - Bleeding disorders - Hypertension - Drug intake

19. C} Examination of nose and PNS D} Systemic examination E} Blood investigations= BT,CT, Coagulation profile F} Radiological investigations= X ray, CT scan G} Biopsy E} Endoscopy

20. Management of epistaxis Establish the site of bleeding Stop the bleeding Treat the cause

21. Management of epistaxis

22. Cauterization Chemical Silver nitrate Thermal Bipolar suction dithermy

23. Merocel nasal tampon

24. Posterior nasal packs Bivona nasal pack Foley’s catheter

25. Posterior nasal packs Rapid rhino

26. Complications of nasal packing Septal hematoma/ abscess Sinusitis Pressure necrosis Toxic shock syndrome

27. Endoscopic ligation of sphenopalatine artery

28. Anterior and posterior ethmoidal artery ligation Lynch incision ( curvilinear incision halfway between medial canthus and tip of the nasal dorsum

29. Maxillary artery ligation Sublabial approach - Antrostomy formed Mucosa of posterior wall of antrum elevated Window made through pterygopalatine fossa Ligation of maxillary artery done

30. External carotid artery ligation Horizontal skin incision is made between the hyoid bone and the superior border of the thyroid cartilage Subplatysmal skin flaps are then raised, and the sternocleidomastoid muscle is retracted posteriorly . Carotid sheath is opened and its contents exposed Usually ligated just distal to the superior thyroid artery

31. Epistaxis in children Causes Common Less common Idiopathic Infection Trauma: Nose picking Vestibulitis Nasal allergy Local= septal deformity, tumors Systemic= coagulopathies HHT

32. Guidelines for Management of epistaxis in children Expectant treatment in mild cases= Pinching nose, allay anxiety of child and parents Petrolium jelly used as primary treatment= forms water resistant film over affected area Nasal barrier cream ( Chlorhexidine , neomycin)offer limited benefit If cautery is considered: Silver nitrate is optimum method Electrocautery should rarely considered

33. Laser therapy, fibrin glue and septoplasty have limited role based on individual basis Neither systemic or local tranexamic acid has any place in treatment of childhood epistaxis Endoscopic ligation of arteries have limited role in children

34. References Scott-Brown's Otorhinolaryngology : Head and Neck Surgery 7Ed Cummings otolaryngology, Head and neck surgery 5 th Ed Ballenger’s otorhinolaryngology , Head and neck suregry

35. Thank you