Epistaxis_Presentation_covering-anterior&posterior-bleeds.pptx

This presentation in power point is on epistaxis

1. EPISTAXIS SUPERVISOR : Dr. V ICKY TUBADI NKUNA

2. PLAN Epidemiology Etiology Vascicula anatomy Classification Patient approach Magt options, contraindications Procedural steps and considerations, complications

3. Introduction Bleeding from the nose or paranasal sinuses Common complaint but rarely life-threatening Causes anxiety among patients and relatives Over 90% managed by emergency physicians or at community level

4. Epidemiology Affects up to 60% of population in lifetime 6% of cases require medical attention Incidence peaks in <10 years and >40 years Higher in males than females

5. Vascular Anatomy Overview Rich supply from internal and external carotid systems Located in septal and lateral nasal walls Internal carotid branches: anterior and posterior ethmoidal arteries External carotid branches: sphenopalatine, greater palatine, facial arteries

6. Little’s Area ( Kiesselbach’s Plexus) Commonest site for anterior epistaxis Located antero -inferiorly on septum above vestibule Anastomosis of 4 vessels forming a vascular plexus Bleeding mostly arterial due to fragile mucosa

7. Woodruff’s Area Common site for posterior epistaxis Located under posterior end of inferior turbinate Formed by anastomosis of sphenopalatine and posterior pharyngeal arteries Retrocolumellar vein may cause venous bleeding

8. Sites of Epistaxis Little’s area – 90% of cases Above middle turbinate – ethmoidal vessels Below middle turbinate – sphenopalatine branches Posterior cavity – blood flows into pharynx Diffuse bleeding – systemic disorders or coagulopathies

9. Classification of Epistaxis Anterior: 80–90%, from anterior septum Posterior: 10%, usually venous, flows to throat Primary: spontaneous, idiopathic Secondary: due to trauma, surgery, or anticoagulants

10. Primary vs Secondary Primary: Between 70% and 80% of all cases of epistaxis are idiopathic , spontaneous bleeds without any proven precipitant or causal factor Secondary: A small proportion of cases are due to a clear and definite cause such as trauma, surgery or anti-coagulant overdose .

11. Age Distribution Bimodal pattern – childhood and sixth decade Childhood: <16 years, often anterior Adults: >16 years, may be posterior or systemic Epistaxis under 2 years suggests underlying disorder or trauma

12. Etiology Overview Local, systemic, environmental, and iatrogenic causes Common local causes include trauma and infection Systemic conditions like hypertension and blood disorders Certain drugs can precipitate bleeding

13. Local Causes Trauma (nose picking, foreign body, surgery ) Infection and inflammation (rhinitis, sinusitis ) Granulomatous diseases (TB, syphilis, Wegener’s, sarcoidosis Neoplasms – benign and malignant Foreign bodies – living or non-living

14. Systemic Causes Hypertension and arteriosclerosis Liver disease causing clotting factor deficiency Renal failure causing platelet dysfunction Blood disorders – leukemia, anemia, hemophilia

15. Drug-Induced Causes Aspirin and NSAIDs – antiplatelet activity Warfarin and heparin – anticoagulants Cocaine or nasal steroids – mucosal damage Vicarious menstruation – rare cause

16. Atmospheric & Vascular Causes High altitude or decompression syndromes Internal carotid aneurysm rupture into sphenoid sinus Increased venous pressure from mediastinal compression Acute generalized infections – viral hemorrhagic fevers

17. General Management Goals Arrest hemorrhage and stabilize the patient Assess blood loss and correct hypovolemia Identify and treat underlying cause Prevent recurrence and complications

18. Initial Assessment ABC s – airway, breathing, circulation Record vital signs and look for shock Provide IV fluids or transfusion if needed Suspect cervical spine injury in trauma cases

19. History Taking Mode, duration, and laterality of bleeding Previous episodes and medical history , family history Medication use – especially anticoagulants Associated vomiting or systemic symptoms

20. Physical Examination Inspect nasal cavity after clearing clots Identify bleeding site via anterior rhinoscopy Endoscopic exam if needed Oropharyngoscopy for posterior bleed

21. Investigations CBC with differential: recurrent or systemic suspicion. Hematocrit, type & cross match if heavy bleed. PT/INR, aPTT if anticoagulants or liver disease. Imaging (CT, MRI) if trauma, tumor, sinusitis suspected. Nasopharyngoscopy : evaluate posterior or tumor causes.

22. First Aid (Trotter’s Maneuver) Patient sits upright and leans forward Pinch nostrils for 5–10 minutes while breathing through mouth Spit out swallowed blood to prevent vomiting Apply antiseptic or antibiotic cream post-bleed

23. Cont . If the bleeding stops with first aid measures, a topical antiseptic cream. (e.g. with chlorhexidine hydrochloride 0.1% and neomycin sulfate 0.5%) can be applied and continued twice daily for up to 2 weeks to minimize crusting. If there is a history of peanut, neomycin or soya allergy, mupirocin ointment can be prescribed twice daily for 1 week as an alternative

24. If Bleeding Persists Apply cotton pledgets with vasoconstrictor and anesthetic Inspect oropharynx for posterior bleeding Use phenylephrine or oxymetazoline sprays Continue gentle pressure for 5 minutes Call ENT.

25. cont nose blowing followed by gently placing cotton pledgets soaked in vasoconstrictor and local anaesthetic such as Co- phenylcaine (lignocaine hydrochloride 5% with phenylephrine hydrochloride 0.5%) or Oxymetazoline in the anterior nasal cavity . This is followed by further digital pressure for 5 minutes.

26. Chemical Cautery Use 75% silver nitrate for anterior visible bleeding point Apply for up to 5 seconds until eschar forms Clean excess and apply antiseptic ointment Continue topical care for 1–2 weeks

27. Nasal Packing Used for profuse or unidentified bleeding sites Can be anterior, posterior, or both Apply constant pressure for 24–48 hours Use Vaseline gauze or absorbable materials

28. Anterior nasal pack The placement of an anterior nasal pack under direct vision may be required if the bleeding continues. May use balloon or gauze Make packing tight If its to stay >24hrs ATB are administered to prevent sinus infection and toxic shock syndrome It is recommended that anterior nasal packs are lubricated with petroleum jelly or antibiotic ointment on insertion. Absorbable packs such as gelatin sponge, alginate or oxidized cellulose are favoured in children over non-absorbable pack

29. Posterior Packing Required for posterior bleeds unresponsive to anterior packing Often under general anesthesia Use Foley catheter or inflatable devices Administer antibiotics and hospitalize patient

30. Steps for posterior pack Pass rubber catheter from nose to oropharynx Attach threads of pack to end of catheter then withdraw into nasopharynx by pulling on nose piece Guide pack behind soft palate using fingers Put a tight anterior pack Tie threads of rubber catheter together at collumella

31. Contraindications & Complications Avoid packing in base skull fracture or uncontrolled hypertension Infections: sinusitis, otitis media, pharyngitis Airway obstruction from loose pack Septal ischemia or mucosal trauma

32. Endoscopic & Medical Therapy Endoscopic cauterization for posterior bleeding Tranexamic acid – 1.5 g three times daily Topical thrombin and haemostatic agents Precise localization reduces tissue damage

33. Surgical Options Indicated if bleeding persists despite packing Includes maxillary, sphenopalatine, or ethmoidal artery ligation External carotid ligation for refractory cases Endoscopic approaches preferred for precision

34. Maxillary Artery Ligation Reduces intravascular pressure to posterior nasal cavity Performed via Caldwell-Luc approach Success rate around 87 % Indicated after failed medical therapy or heavy transfusion need

35. Endonasal Sphenopalatine Ligation Targets main nasal blood supply directly Performed under local or general anesthesia Ligation or diathermy of sphenopalatine artery High success with minimal complications

36. References Cummings & Dhingra ENT Textbooks Joseph J, Martinez- Devesa P, Bellorini J, Burton MJ (Cochrane, 2018) https://pmc.ncbi.nlm.nih.gov/articles/PMC6360570/ Crohn’s et al., 2015 – Antibiotic use in nasal packing Any questions