introduction and management of EPISTAXIS.pptx

Introduction and management of Epistaxis

1. EPISTAXIS : ETIOLOGY AND MANAGEMENT

2. INTRODUCTION Epistaxis is defined as acute haemorrhage from within the nasal cavity including the nasopharynx . It is a common condition ranging in severity from a single short-lived episode to a less common life-threatening haemorrhage. The majority of cases are self-limiting and do not require medical intervention.

3. Epistaxis is classified as primary epistaxis , where no cause can be found or secondary epistaxis where there is a defined cause for example nasal trauma . Although epistaxis can occur at any age, there is a bimodal distribution of children up to age 10 and adults greater than age 50.

4. Incidence The reported incidence of an episode of epistaxis occurring during a lifetime is approximately 60%, with less than 10% requiring medical attention. It has a bimodal age distribution, with peaks at younger than 10 and between 70 and 79 years of age.

5. ANATOMY Terminal branches of the external and internal carotid arteries supply the nasal cavity with frequent anastomosis between them on the nasal septum, lateral wall and midline. The anterior nasal septum is a particularly well-described site of anastomosis between the external and internal carotid arterial systems where an abundant plexus of vessels called Little’s or Kiesselbach’s area are found.

6. Anatomical sites for epistaxis .

7. Nosebleeds from the anterior nasal blood supply are more common than bleeds from the posterior blood supply. In fact, 90% of nosebleeds are from the anterior nasal blood supply . Posterior bleeds are much more difficult to evaluate and treat because the posterior nares blood supply is more difficult to access than the anterior nares blood supply.

8. In rare situations, posterior nosebleeds are due to a malignancy, internal carotid aneurysm, or major trauma. Blood vessels supplying the nasal passageway. (From Savage S. Management of epistaxis . In: Pfenninger JL, Fowler GC, editors. Pfenninger and Fowler’s procedures for primary care. 3rd edition. Philadelphia: Saunders; 2011; with permission.)

9. ETIOLOGY Most causes of epistaxis can be identified through a directed history and physical examination. The patient history should include details of the initial presentation of bleeding, previous bleeding episodes and their treatment, comorbid conditions, and current medications . Risk factors and causes of secondary epistaxis can be divided into local and systemic aetiologies.

10. Despite no obvious cause in primary epistaxis , it is well recognized that there is an increased frequency of epistaxis in the autumn and winter months. This correlates with changes in temperature and humidity, which may be the causative factors. It has also been found that there is a circadian rhythm, with peaks in incidence of epistaxis in the morning and late evening.

11. Causes of refractory epistaxis by incidence, from Christensen et al. in 2005 [10].

12. PREVENTION There are few large studies on epistaxis prevention, but experts indicate that liberal application of petroleum jelly to each nostril to prevent mucosal drying is an efficacious and cost-effective way to prevent anterior epistaxis . Several small studies have shown that antiseptic cream for recurrent epistaxis in children is effective.

13. A humidification unit, especially in dry climates and in centrally heated areas, should be used while sleeping, especially after having a nosebleed. Parents should keep children’s fingernails trimmed to minimize trauma from nose picking.

14. History and initial assessment The initial assessment of any patient presenting with bleeding should always start with checking their airway, breathing and circulation. A patient with persistent bleeding and a reduced conscious level as seen in alcohol/drug intoxication or head injury is at risk of aspirating and will require prompt action to protect the airway.

15. A quick assessment of the vital signs and any available laboratory results should be done . After ensuring the patient is stable a more in-depth history should then be taken. This should include: side of bleeding, duration, amount and frequency of bleeding, a judgment on amount of blood swallowed, any preceding trauma or precipitating causes.

16. Any previous history of epistaxis and any previous treatments for it should be asked . The past medical history and current medications are also important especially with respect to the systemic causes.

17. It was previously thought that nonsteroidal anti-inflammatory drugs , aspirin, and high blood pressure were causes of nosebleeds. There is no association between nonsteroidal anti-inflammatory drugs and epistaxis . Aspirin has been shown in some studies to increase the risk of epistaxis and in other studies there is no difference compared with nonaspirin users. A population-based study has shown that there is no association between hypertension and epistaxis .

18. EXAMINATION Before performing a physical examination, the clinician should wear appropriate personal protection equipment. Occasionally patients will have bilateral bleeding or cannot give an accurate history, so close examination with a nasal speculum may be necessary.

19. If a more extensive examination is indicated, placing a pledget moistened with a vasoconstrictive medication ( eg , oxymetazoline ) and an anesthetic (2% lidocaine ) may be required.

20. Epistaxis tray.

21. Once the patient is anesthetized, they should lie back at 30 degree. Good lighting should be available. Using a nasal specula, the anterior mucosa is examined, focusing on the Kiesselbach plexus, which is located in the Little’s area. Blood clots may obscure optimal visualization and having the patient blow their nose to remove clots will help clear the nares . A small suction catheter can also be used to remove clots .

22. In patients that continue to bleed the examination is often combined with the management so as to stop or reduce bleeding to allow for a better assessment. Head and Neck examination....

23. Application of a topical vasoconstrictor with the patient applying bilateral, pinching pressure just caudal to the bridge of the nose is often effective in stopping anterior bleeds , at least temporarily . Application of a topical anesthetic and vasoconstrictor maybe useful to ensure patient comfort and control the bleeding enough to allow for a thorough physical examination.

24. In patients unable to tolerate examination, cautious use of oral or parenteral anxiolytics and analgesics may be helpful.

25. Management Position the patient sitting, with their head over a bowl. Their nostrils should be pinched together firmly for at least 5-10 minutes, alongside cooling with an icepack on the nose or sucking an ice if available . Squeezing the top part of the nose over the bony dorsum never works. Persistent bleeding after 20 minutes requires further intervention.

26. DIFFERENTIATING BETWEEN ANTERIOR NASAL BLEEDS AND POSTERIOR NASAL BLEEDS It is useful to divide epistaxis into anterior and posterior when discussing their management. Posterior nasal bleeds tend to bleed more heavily than anterior nasal bleeds , although anterior ones can bleed heavily on occasion. A nosebleed with a large volume of blood does not necessarily mean it is from a posterior source. However, a small bleed usually indicates an anterior source.

27. The patient who has bilateral bleeding may have a posterior nasal source. If the side from which the bleeding originates cannot be determined from the history and initial examination, bilateral anterior nasal packing can be placed. If the patient is still having heavy bleeding after bilateral anterior nasal packing, then a posterior source is more likely. Bilateral bleeding may also occur if the patient has a nasal septal defect or bilateral nasal lesions.

28. A MANAGEMENT PATHWAY Management of Epistaxis A stepwise approach to epistaxis management is advocated. In order, this should be initial management, followed by direct therapy, tamponade , and vascular intervention. When control of bleeding is not achieved, timely progression through the management steps is essential.

29. Step 1. Initial management of epistaxis Immediate management includes an Advanced Life Support–type ABC assessment (Airway , Breathing, Circulation) and resuscitation. Epistaxis is not usually an immediate airway threat but patients should be sat upright, and encouraged to lean forward and clear any clots from their pharynx.

30. The side of bleeding as well as whether it is predominantly anterior or posterior should be determined . In exceptional circumstances, postnasal bleeding may be so heavy as to warrant an immediate balloon pack ( eg , Foley catheter and anterior pack) to prevent further blood loss , with arrangements for transfer to theater .

31. Depending on the bleeding site, and local skills and facilities, this may be best achieved with a nasal speculum in conjunction with a headlight or mirror, an auroscope , microscope, or endoscope, noting that each approach has its limitations. Nasal speculum

32. Blood will likely obstruct the view to the bleeding site . In anterior nasal bleeding, this can be controlled through anterior nasal compression for 10 to 60 minutes in conjunction with topical vasoconstrictors . If hemostasis is not achieved or nasal compression only leads to postnasal bleeding, it should be discontinued, and an attempt made to clear blood and visualize the site with suction, forceps, irrigation , or nose blowing.

33. Topical Vasoconstrictors .... 1:1000 adrenaline (epinephrine), 0.5% phenylephrine hydrochloride, 4% cocaine, or 0.05 % oxymetazoline solution. Investigations ....

34. Step 2. Direct therapy Silver nitrate cautery : Silver nitrate cautery is common but is difficult in the context of active bleeding, where electrocautery or electrocoagulation (diathermy) may be more effective. A local cauterizing solution is achieved by touching a dry salt silver nitrate tipped applicator against moist mucosa.

35. Objective : The objective is direct cautery of the bleeding site, but initial circumferential contact may facilitate control of bleeding and more definitive results. Availablity : 75% and 95% preparations.

36. Disadvantages : Septal perforation. Increased depth of burn. Silver nitrate (AgNO3) can cause black staining.

37. Electrocautery and electrocoagulation (diathermy ) : Although specialist equipment is required, electrocautery (hot wire) or diathermy may have advantages over silver nitrate, which can be difficult to apply to the site in cases of uncontrolled bleeding.

38. After direct therapy, in some cases of minor ongoing bleeding, the addition of a hemostatic dressing such as Surgicel (Ethicon) or Kaltostat ( ConvaTec Ltd, Skillman, NJ ), or the use of a very localized pack over the bleeding site, may help to prevent further pathway progression.

39. Step 3. Nasal packs or dressings If local therapy fails, control of bleeding can be achieved by tamponade , using a variety of nasal packs, or by promotion of hemostasis through nasal dressings. Modern nasal packs are easily and relatively comfortably inserted by practitioners. Once a pack is inserted, it is usually recommended that it is left in place for 24 hours, necessitating admission.

40. A variety of nasal packing materials is available. Examples include polyvinyl acetal polymer sponges ( eg , Merocel , Medtronic Inc, Minneapolis, MN), nasal balloons ( eg , the Rapid Rhino Balloon pack with a self-lubricating hydrocolloid fabric covering, ArthroCare Corp, Austin, TX), nasal dressings ( eg , Kaltostat calcium alginate, Conva -Tec Ltd), and traditional ribbon packs, for example, BIPP (Bismuth, Iodoform , Paraffin Paste ) or petroleum jelly–coated ribbon gauze.

41. Fig. 2. Common nasal packs and dressings. (A) Merocel (polyvinyl acetal polymer sponge pack ); (B) Rapid Rhino (self-lubricating hydrocolloid covered balloon pack); (C) a traditional ribbon pack, in this case BIPP (Bismuth Iodoform Paraffin Paste); (D) Surgicel (oxidized regenerated cellulose absorbable hemostat ); (E) Algosteril ( alginate fiber absorbable hemostat ).

42. Complications : Postnasal packs are extremely uncomfortable and are prone to cause significant hypoxia. Displacement with airway obstruction, P ressure necrosis of the palate, Alar or columellar skin, and Sinus infection or toxic shock syndrome.

43. Therefore, prolonged packing should be avoided and anti-staphylococcal antibiotics prescribed if a pack is to remain in situ for more than 24 hours. Balloon packs may deflate over time, so should be checked after the first hour or if bleeding recommences.

44. Following pack removal it is imperative to examine the nasal cavity, to exclude underlying abnormality and to identify and manage the bleeding source if possible.

45. TREATMENT FOR ANTERIOR NOSEBLEEDS While performing the history, the patient should sit and lean forward .... Then oxymetazoline (Afrin) should be sprayed twice into the bleeding side.

46. The patient should be instructed to continuously hold pressure on the nares by pinching the nostrils tightly for 10 to 15 minutes, giving the clinician enough time to take the history. Patient positioned and pinching nostrils tightly for treatment of minor epistaxis .

47. Anterior nosebleeds can often be located visually without much difficulty and direct treatment can be undertaken. The 2 most common direct treatments are chemical cautery ( eg , silver nitrate) and electrocautery . Direct treatment is ideal for the patient’s comfort because this avoids uncomfortable nasal packing. If there is any rebleeding or the clinician cannot find the source, nasal packing may be necessary.

48. However, if the bleeding source’s location is not visualized, then the pledget soaked in decongestent may have to be placed. In that case , a pledget should be placed in the 3 most likely sites of an anterior bleed: one superior , one posterior, and one inferior. The pledgets should stay in place for the next 10 minutes.

49. One technique that works well is to surround the bleeding vessel in a circular motion, cauterizing the surrounding mucosa and slowly moving toward the center of the spiral, eventually cauterizing the bleeding vessel. After making sure that the bleeding has stopped, a small amount of ointment or petroleum jelly should be applied to keep the area moist.

50. Nasal Packing .. If the above measures do not stop the bleeding, an anterior pack will need to be inserted and remain in place for 24 to 48 hours.

51. In general, preformed packing products are covered with a lubricant and inserted quickly but gently into the affected side. The packing usually expands by absorbing the blood that is present. If the packing does not expand, irrigating with 5 to 10 mL of saline may be necessary.

52. Different methods for insertion are possible. One method starts by inserting the free end of the gauze into the affected nares as far posteriorly as possible without entering the pharynx . An alternative method involves folding the gauze in half, making it 2 to 3 feet in length, and then inserting the folded pleat first.

53. Whichever method is used, the inserted gauze will need to be pressed down firmly against the inferior nares . Subsequent rows of gauze are inserted and pressed down firmly. This process will be repeated, in an accordion-like fashion, until the nose is packed completely.

54. Start the packing on the inferior turbinate. (From Savage S. Management of epistaxis . In: Pfenninger JL, Fowler GC, editors. Pfenninger and Fowler’s procedures for primary care. 3rd edition. Philadelphia: Saunders; 2011; with permission.)

55. Continue packing in accordion-like fashion until nasal passageway is completely full of gauze. (From Savage S. Management of epistaxis . In: Pfenninger JL, Fowler GC, editors Pfenninger and Fowler’s procedures for primary care. 3rd edition. Philadelphia: Saunders; 2011 ; with permission.)

56. After placing the packing, the physician will need to monitor the patient for 30 minutes to observe for any possible posterior bleeding. If there is no bleeding, the physician may discharge the patient home. The patient should be sent home with prophylactic antibiotics that will cover for nasal pathogens. First-line treatment is cephalexin 250 mg 4 times a day or amoxicillin/ clavulanate 250 mg 3 times a day.

57. The patient will need follow-up in 24 to 48 hours , at which point the anterior pack will be removed. If the patient has bleeding, fever, drainage , or increased pain, they should return sooner than 48 hours for evaluation. Before removing the packing, irrigating the packing with 5 to 10 mL of saline and waiting 5 to 10 minutes will help keep the gauze from sticking to the mucosa during removal .

58. TREATMENT FOR POSTERIOR NOSEBLEEDS Several posterior balloon packs are available and effective ( ie , Epistat and Storz T-3100 ). The balloon should be lubricated with a water-soluble lubricant. The device should be inserted into the nasal passageway of the affected side, until it can be visualized in the oropharynx .

59. The balloon is then inflated with 7 to 10 mL saline. Next, the balloon is pulled firmly, but not aggressively, back into the nasal cavity . An umbilical clamp or equivalent device is placed on the nasal end of the tube to prevent movement of the balloon. A piece of gauze can be placed between the clamp and the nares to prevent compression necrosis

60. The posterior balloon should be seated firmly in the posterior pharynx. (From Savage S. Management of epistaxis . In: Pfenninger JL, Fowler GC, editors. Pfenninger and Fowler’s procedures for primary care. 3rd edition. Philadelphia: Saunders; 2011; with permission .)

61. Demonstration of Foley catheter tamponade technique. Notice the tip of the catheter in the posterior oropharynx . At this point the catheter may be inflated and the opposite end withdrawn from the nare to tamponade posterior bleeding.

62. Some nasal bleeds may have an anterior and posterior component, especially in cases that are secondary to underlying pathologic abnormality ( ie , Osler-Weber- Rendu syndrome ). In these cases, the posterior nasal packing should be placed. Then, if an anterior bleed is also suspected, placement of an anterior pack may be necessary.

63. The patient with anterior and posterior packing will need to be admitted for close monitoring. The patient will require prophylactic antibiotics while the foreign body is in place. To prevent tissue necrosis and infection, the packing will need to be removed within 48 to 72 hours. A potential complication of both anterior and posterior packing that is kept in place for extended periods of time is toxic shock syndrome.

64. Step 4. Ligation/ embolization In the past, ligation was commonly of the maxillary artery or the external carotid artery. Although the distribution of these arteries is wider, recent studies suggest that SPA ligation is more successful, possibly because of difficulties in completing the other procedures, or a failure to address more distal collateral circulation.

65. SPHENOPALATINE ARTERY LIGATION The SPF is located most frequently (87%) at the transitional zone between the superior and middle meatus . Terminal branches of the SPA include the posterior septal artery and the posterior lateral nasal artery branches. The SPA exits the SPF as a single branch in 60% to 75%, as two branches in 20% to 30%, and three or more branches in less than 10 %.

66. Example of right SPA dissection before ligation. The arrow points to the SPA as it exits the sphenopalatine foramen. SPA branches are identified by wide exposure of soft tissue behind the crista ethmoidalis before ligation.

67. Using the endoscope a small flap of lateral wall nasal mucosa is elevated about a centimeter anterior to the posterior end of the middle turbinate . A crest of bone ( crista ethmoidalis ) is found projecting medially and the sphenopalatine foramen is encountered just behind this. The sphenopalatine artery exits here and needs to be closely inspected as it has variable branching patterns.

68. The artery and any associated branches are ligated with clips as near to the foramen as possible, and are either divided or electro-cauterized. Picture demonstrating clips on the sphenopalatine artery. ( Kindly supplied by G. McGarry , Glasgow).

69. ANTERIOR ETHMOID ARTERY LIGATION The AEA is a branch of the ophthalmic artery that supplies mucosa of the anterior nasal cavity before entering intracranially to form meningeal branches . From an endoscopic approach, the AEA is identified on average 17.5 mm from the axilla of the middle turbinate. From an external, transorbital approach, the artery averages 24 mm from the anterior lacrimal crest.

70. Anatomy of the left AEA. The AEA in this example traverses the left ethmoid roof via bony mesentery below the skull base. The image-guided frontal probe (bottom right image) confirms the location of the artery.

71. Approaches :

72. Transcaruncular approach : A transcaruncular approach provides access to the AEA while avoiding a transfacial incision. Dissection in a natural plane between Horner muscle and the medial orbital septum exposes the posterior lacrimal crest, which is the attachment of Horner muscle. Next, the periorbita along the posterior lacrimal crest is incised to expose the medial orbital wall.

73. Subperiosteal dissection then allows access to the medial wall. The AEA is then ligated . The periorbita does not require closure , whereas the caruncle and conjunctiva are closed using 6–0 resorbable sutures.

74. Trancaruncular approach in a left orbit for control anterior ethmoid artery ligation. The medial orbital wall is exposed (A) after incising periorbital along the posterior lacrima crest . The anterior ethmoid is identified and ligated (B). The arrow points to the surgical clip applied to the artery.

75. MANAGEMENT OF VENOUS BLEEDING : Venous bleeding is typically encountered at the pterygopalatine venous plexus, cavernous sinus, and basilar venous plexus during endoscopic skull base surgery. These can be controlled via tamponade . In addition, application of gelatin -based hemostatic agents provides excellent and rapid control of high-flow venous bleeding.

76. In this example, venous bleeding in the pterytopalatine venous plexus is controlled with a gelatin -based hemostatic agent.

77. Septal surgery Septoplasty and submucous resection (SMR) have a role in epistaxis management. Elevating the mucoperiosteum from the septum interrupts the blood supply here and provides effective bleeding control.

78. Straightening of the nasal septum is a useful adjunct for other procedures where a deviated septum makes access difficult to assess where the bleeding is coming from and to manage it.

79. Medical therapies Products include fibrin-based agents which are typically packaged as a two-vial system containing fibrinogen, thrombin, factor XIII and calcium. Other agents include gelatin , collagen, and cellulose.

80. Floseal is a gelatin and thrombin combination which can be used for anterior and posterior epistaxis . However a recent study looking at using Floseal in epistaxis has demonstrated only limited success. It is also a costly alternative to traditional methods of cautery and nasal packing but may have a limited role as second-line treatment particularly in frail patients for whom a general anaesthetic is risky.

81. Other agents tried have included topical IV tranexamic acid soaked into the nasal dressing or pack . There has also been more recent interest in a natural product e microporous polysaccharide hemospheres (MPH).

82. MPH is a bio-degradable substance derived from potato starch and is produced in spheres ranging from 10 to 200 mm with tiny pores acting like a biological sieve. The powerful osmotic action dehydrates and gels the blood on contact to accelerate the natural clotting process.

83. ADULT EPISTAXIS MANAGEMENT PATHWAY :

84. In conclusion, the management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. A thorough knowledge of the anatomy of the nasal cavity and surrounding region is imperative in the effective management of nasal hemorrhage . The treating oral and maxillofacial surgeon needs to have a complete understanding of the available treatment modalities and have a stepwise plan formulated prior to initiating care.

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