Kiesselbach Plexus: Anatomy and Clinical Significance

Kiesselbach Plexus

• The Kiesselbach plexus, also known as the Kiesselbach area, is in the anteroinferior part of the nasal septum.
• Four arteries connect in this region, forming a vascular plexus.
• Named after Wilhelm Kiesselbach, the German otolaryngologist.
• The plexus is a common site for nosebleeds because it marks the convergence of blood vessels in the anterior septum.
• These vessels include branches from both the internal carotid artery (anterior ethmoidal artery) and the external carotid artery (septal branch of the superior labial artery, greater palatine artery, and sphenopalatine artery).

Importance of Kiesselbach Plexus

• About 90% of nosebleeds (epistaxis) occur in the Little's area, exposed to drying from air currents and trauma from fingernails.
• This is a typical site for nosebleeds among children and young adults.

Epidemiology of Epistaxis

• Epistaxis, defined as nasal bleeding, more frequently affects children under 10 and adults over 70.
• Local causes include digital trauma, nasal septum deviation, dry air exposure, rhinosinusitis, neoplasms, or chemical irritants like inhaled corticosteroids or persistent oxygen use via nasal cannula.
• General risk factors for increased bleeding risk include chronic renal failure, alcoholism, hypertension, vascular malformations like hereditary hemorrhagic telangiectasia, or coagulopathies, including warfarin use, von Willebrand disease, or hemophilia.

Anatomy and Physiopathology

• The superior labial branch of the facial artery connects with the anterior ethmoidal branch and the terminal end of the sphenopalatine artery.
• Together, they form the Kiesselbach plexus in the anterior nasal septum.
• About 90% of epistaxis cases originate from this structure, and they are commonly visualized during anterior rhinoscopy.
• The sphenopalatine artery, a terminal branch of the internal maxillary artery (branch of external carotid), is the vessel that most often contributes blood to posterior epistaxis.
• Endoscopy or open surgical techniques might be required for visualizing this vessel.

Clinical Manifestations

• A detailed medical history and physical examination can help identify the source of acute epistaxis.
• Important points include previous or recurrent episodes, duration and severity of the current episode, and the affected side of the nasal cavity.
• It should be determined if any anti-inflammatory drugs, warfarin, heparin, or aspirin are used.
• Inquire about alcohol or cocaine abuse, trauma, previous head and neck treatments, and personal or family history of coagulopathies.
• Be prepared to explore nasal passages and perform tamponade.
• Assemble the necessary instruments for epistaxis management, including a nasal speculum, bayonet forceps, a headlight, suction device, small cotton pads, 0.05% oxymetazoline, 4% lidocaine solution, silver nitrate applicators, and combinations of absorbable and non-absorbable materials for anterior and posterior nasal packing.
• Ensure an adequate light source, suction devices, and a nasal speculum are accessible.
• The patient is placed in a "sniffing" position, inclining the head forward to maintain the base of the nose pointing upward.
• Insert the speculum while resting an index finger on the tip of the nose.
• Orient the speculum handle parallel to the floor, opening the blades superiorly and inferiorly to visualize the bleeding site and facilitate direct hemostasis techniques.

Diagnosis

• Distinguishing between anterior and posterior bleeding is critical for treatment and patient management.
• Failure to visualize and treat each bleeding point can result in recurrent hemorrhaging and return visits.
• Anterior and posterior epistaxis can be differentiated in the emergency room, with the aid of a light source and nasal speculum.
• Typically, a posterior hemorrhage diagnosis is made in the ED only after anterior bleeding control methods have failed.
• Indicators suggesting bleeding from a posterior source include hereditary or acquired coagulopathies in older adults, significant bleeding visible in the nasopharynx, bilateral nasal bleeding, and epistaxis that is uncontrolled with anterior rhinoscopy or packing.
• Additional lab tests are not required unless there is a need to correct a concurrent pathology or achieve adequate hemostasis.
• In cases of persistent bleeding, blood should be collected for complete hematology, type and crossmatch, with coagulation tests when coagulopathy is suspected.

Treatment

• The initial management of epistaxis at the emergency department starts with a quick primary survey to identify upper airway obstruction or hemodynamic instability.
• It is important to establish IV access for patients experiencing severe bleeding, and blood for cross-matching is needed if hemodynamic instability is present.
• Transfusion is more likely needs to be considered in patients with posterior epistaxis or those on anticoagulants.
• Reversal of coagulopathies using blood products, is based on coagulation studies and the patient's individual context.
• Rapid decreases in blood pressure during acute epistaxis are discouraged.
• A slight reduction of persistent hypertension can aid clot formation by decreasing hydrostatic pressure in intractable epistaxis requiring packing or surgical intervention

Direct Nasal Pressure

• The doctor will ask the patient to blow their nose to dispel any clots and prepare the mucosa for vasoconstrictor application.
• Administer a vasoconstrictor, such as oxymetazoline or phenylephrine.
• The patient is instructed to lean forward in the sniffing position, compressing the soft parts of the nostrils using the thumb and middle finger for a continuous 10-15 minutes while breathing through the mouth.
• A free compression device can be made from two tongue depressors crossed and secured.
• Position the device in the nostrils and leave it undisturbed for 10-15 minutes.
• These initial measures typically achieve hemostasis, making further examination with anterior rhinoscopy easier.

Cauterization with Chemical Products

• If direct pressure is ineffective, cauterization with silver nitrate is indicated for mild epistaxis.
• Anesthetize the nasal mucosa using three small cotton pads soaked in equal parts of 0.05% oxymetazoline and 4% lidocaine solutions.
• Only cauterize when the bleeding vessels can be clearly visualized.
• Electrical cauterization should be performed by an otolaryngologist because there is a risk of septal perforation.
• Following visualization of the bleeding site (anterior), silver nitrate sticks can be carefully applied proximally to the bleeding point in the anterior nasal septum.
• A relatively bloodless field is required for the nitrate to work effectively, as it inhibits metallic silver precipitation and tissue coagulation in the presence of active bleeding.
• After achieving a relatively bloodless field, gently and briefly apply the silver nitrate to the bleeding point (in seconds).
• Avoid cauterizing both sides of the septum at the same time.
• Subsequent attempts should be spaced four to six weeks apart to prevent perforation.

Thrombogenic Foams and Gels

• Absorbable hemostatic agents such as Gelfoam and Surgicel can be effective when chemical cauterization fails and nasal packing is not yet indicated.
• They are placed directly on the visualized bleeding mucosa and are bioabsorbable, eliminating the need for removal.
• FloSeal, a gelatin matrix mixed with thrombin, which injected into the nasal cavity.
• Topical tranexamic acid shows promise as a procoagulant.
• A 2013 randomized comparative study found that 5 ml of injectable tranexamic acid (equivalent to 500 mg) applied to the nasal mucosa controlled anterior epistaxis in 70% of patients, compared to 31% with anterior packing alone.
• No adverse reactions were noted.

Anterior Nasal Packing

• Implement anterior nasal packing when direct pressure, vasoconstrictors, or chemical cauterization are ineffective.
• In the absence of thrombotic foams and gels, use nasal tampons, balloons, or layered gauze strips in the nasal cavity.

Balloons in Anterior Epistaxis

• Rapid Rhino epistaxis balloons are user-friendly and more comfortable than traditional gauze packing.
• Available in different lengths, they are covered with cellulose or other materials that promote platelet aggregation.
• Moisten the balloon in water and gently insert it along the floor of the nasal cavity.
• Inflate with air until the bleeding is controlled, stopping if the patient experiences discomfort.
• Do not use saline to inflate the device.
• Carefully read the instructions before use.
• If there is a string, secure it to the patient's face to keep the balloon in place.

Pre-Made Nasal Tampons or Torundas

• Pre-made materials consist of synthetic substances which expand upon coming into contact with moisture
• These are commercially available in lengths of 5 to 10 cm for anterior and posterior packing, respectively.
• Merocel, a dehydrated, compressed polyvinyl acetate sponge, should be coated with a water-soluble antibiotic ointment before gently inserting it along the floor of the nasal cavity.
• If the tampon does not expand within 30 seconds of placement, it is carefully rinsed with 5 ml of saline solution to induce expansion. Otherwise, the Merocel tampon is cut lengthwise into two halves and then lubricated.
• The two halves are introduced parallel to both the nasal septum and each other.
• The operator irrigates each half with roughly 2 mL of saline after injecting it.
• With this approach, greater compression of the septal hemorrhage is achieved.
• The string should be attached to the face with an adhesive element following either procedure in order to guarantee tampon placement and avert unobtrusive bronchoaspiration.
• Although Merocel nasal tampons are effective, they can be more painful to remove than balloons.

Packing with Gauze Strips

• If previous methods are not available, gauze packing may be utilized to stop the epistaxis.
• To properly pack the anterior nasal cavity with gauze, ensure that it conforms to the accordion in a way that each layer prevents the gauze from moving towards the nasopharynx.
• An additional 2 to 3 cm of petrolatum gauze, measuring 0.6 cm wide, is added to the first layer of gauze. The nasal speculum is used to set down the first layer over the floor of the nose.
• Bayonet forceps and speculum are removed at this stage.
• The speculum is used to apply the successive layer over the initial packing in a similar way.
• To move the placed packing into place securely, use bayonet forceps to reinsert below the initial layer of packing.
• The anterior nasal packing can successfully block a bleeding area in any region of the anterior nasal cavity and it will stay present by the practitioner until the patient removes this under their care.

Definition of Femoral and Mandibular Condyle

• These structures are a bony element found in several parts of the human skeleton, designed to articulate with other structures, and form various junctions throughout the body.
• Its main distinguishing feature is its round and distinct form, with varying sizes depending on the cavity inside where the structure will be placed.

Condyle Significance and Location

• The term condyle has Greek roots, where "kondylos" meant the knot linking a joint.
• Later, Latin speakers began to use "condylus" to describe a rounded section of bone that combines with another bony structure.
• The condyle is located in several bodily locations, one of which is the jaw region.
• It is found in the upper corner of the mandible.
• It articulates with the temporal bone in order to create the temporomandibular joint (TMJ).
• The femoral condyles are additionally positioned inside the region.
• One of them is located on the interior side, while the other is located exteriorly to the lower femoral area.

Function of Condyle

• In addition to the support provided in enarthrosis joints in the movement of the jaw and knee, the condyles also serve several purposes.
• Mandibular: Its rough part is connected to the side external ligament, in addition to the cavity connecting to the side pterygoid muscle.
• Femoral: Has multiple surfaces consisting the adductor tubercle's epicondyle, intercondylar notch, supracondylar canals, etc.

Lesions of the Mandibular and Femoral Condyle

• Mandibular condyle lesions: Disorders of the condyle-disc complex caused by functional impairment of the condyle. Can be caused by slipping and disc adhesion.
• These conditions cause changes in the joint surfaces that occur in the temporomandibular joint (TMJ), dental occlusion, oral discomfort, and muscular weakness in the head region.
• Issues are typically related to condyle disc issues, osteonecrosis and cartilaginous lesions being located inside femur.
• Femoral: A primary characteristic is the presence of pain around the femoral patella and fluid buildup.
• Osteonecrosis of the knee consists of the femoral condyle undergoing alteration in it.
• Condylar changes on bones, discomfort across oral region for mandibular/femoral, injuries are also likely to be observed.
• Medical and rehabilitative treatments depend on the cases and the areas which would be affected.
• Focus is usually on pain relief through muscle recovery and restoration of proper functions.

Anatomy of Airways

• Airway management is a vital component of our discipline.
• Morbidity and mortality associated with anesthesia can be traced back to this difficulty.
• Essential to have an understanding of airway physiology - this offers safe control.

Mouth

• From plica palatoglossa (posterior) to lips (anterior) represents the mouth.
• Composed with rigid (hard) and soft palates - 2/3 represents a large part.
• Factor to monitor whilst performing laryngoscopy rigidity is presented through the teeth.

Nose

• The cavity which is composed with the nares passing until the starting of the nasopharynx through choanas represents the nose.
• On the floor is where we find the nasal cavity - where the tabique can be found. There are three nose projections called such, or conchae.
• Nasal irrigation is primarily provided by the maxillary nasal as well as the facial maxillary artery.
• Kisselbach plexus is where you will find the anastomoses, near the nares, a main area with usefulness.

Pharynx

• Pharnyx is tube being measured in range of 12-15cm. Formed through 3 constrictor muscles and contractions allow the bolus of food to pass to the esophagus.
• It is placed at the superior body and C6 level and below represents the esophagus.

Nasopharynx

• The craniobase, along with the roof of soft tissues represents the nasopharynx.
• The posterior side is at the location of c1, and the anterior part links towards a nasal cavity for access.
• The entrance to one's auditory tube contains a crucial structure and exists along the lateral sides.
• Adenoids exist at the back area and involution occurs alongside age. Partial airway is constricted so that nasotractel tube cannot move appropriately due to increasing its dimensions (or the tissue).

Oropharynx

• Located across the soft and epiglottis (apex) and the C2/C3 posterior portion.
• Structures composing and involving the forming are collapsible.

Laryngopharynx

• The very distal side of larynx, which comprises within two regions consists of the larynx.
• It originates at C4-C6 vertebral areas where glottic openings are represented to be more significant inside this structure.

Larynx

• Portion of respiratory parts - it is structured ranging between both the laryngopharynx-trachae and its length inside adults ranges between 5 to 7cm.
• Cartiliginous structure which has ligaments and muscles that form up its structures. This includes the Hyoid bone which helps maintain a clear and distinct position.

Cartilages

• Supplies and are responsible for the structure and forming. Divided up in both paired and seperate, cartilages have distinct and critical structures that include thyroid and the epiglottis.

Ligaments

• Of importance worth bringing attention to, is the cricothyroid and it's name.
• Numerous methods and procedures such as jet V and cricothyrotomy/ retrograde I allows to open up and establish the main avenue for emergencys.

Muscles

• Inside the intrinisic, a section joins up towards a larynx and possesses main abilities, which help provide openings when needed and close towards the glottis so that strings are taut.

Hyoids

• U bone that consists of the structure to the inner membranes which are muscles and sits in the C3.

Innevation and Airways

• Responsible for airway management are 3 nerves: vagus, trigeminal and glossopharyngeal.
• Airway management - this offers the ability to simplify by viewing at regions to do with pharynx.

Nasopharynx

• Both motor and sensitive innervation is brought by trigeminal and ophthalmic. Front is where the ethmoidal nerve lies down as, as post terces are in charge and controlled via the gang spinopalatine.

Oropharynx

• Branches in the trigeminal nerve are composed with these locations, and glossopharyngeal's importance stems through how it may be managed from the anasthetic perspective.

Laryngopharynx and Trachea

• Nerve is responsible due to its functions from the recurring and superior larnyngeal nerves. Blockages for conscious patients require motor and the mobility that can prevent the chords.

Airway Evaluation

• Airway evaluation proceeds pre-inductively when applicable, and targets at evaluating all issues for airway ventilation and securing for future.
• Obesity( exceeding roughly more than 20% ) and prior airway difficulty requires such evaluation.

Airway Risk Factors

• Having to be placed at degrees from the 3 and 4 positions inside mallampati's place. Test mallampati involves sitting patient by opening with head with the maximum lengua protrusion.

Risk Factors: Ventilation

• Beard and obesity that goes over 20% and age greater than 55.

Testing

• Assessment of face for its respective attributes.

Signs of Respiratory Distress

• Respiratory distress is indicated by signs that people exhibit, indicating that they are trying to do a greater extent when they are attempting to breathe with low oxygen supply.

Common Signs

• Common includes respiratory problems - from minute of each of each breath with low supply.
• Azure skins for the faces/inside area for lips and nails.
• Groaning, a sound is likely to heard each-breath, so as body has to maintain available in opened areas. Nostrils which can get even worse to each case.
• The patient likely has issues which is from retraction. Sudation of skin and possible quick respiratory. Likely wheezing/postural and speaking difficulties

Mask for Larynx

• With these 30%, death are attributed so that managing to sustain is critical is not guaranteed - as for a unconscious/anasthesized patients, we will be able to monitor via means for face - this has surgery, including the methods for intubation is possible.

Control for Ventilation

• Mask must be coupled and align within for ventilation and for the person.
• In these cases there are methods for better facilitation and improvement by having adequate control.
• Triple maneuvers are for those. These needs another personal which can administer the ventilation. Otherwise, issues such as beard and patients likely experiences troubles.

Difficult Evaluation

• The Sat O2 has a deficieny and could not maintain what is needed. Risk includes with such intubation challenges.
• High FiO2 are required.

Breathing/Air Management

• These include bronchoespasms that must be taken care in the situation. This can be managed from using a L Mask which uses a device that is placed inside the air to support breathing through a endotrachesal tub.

ML Advantage

Can be utilized through manual, mech and for muscular respiration. The process to put it does not come with important hemodynamic exchange and changes.

ML Inconveniences/Advantage

May allow better breathing conditions when issues of brochospasms occurs and not for providing enough protection as high excess can bring issues.

• This causes regurgitation and the air may provide pressure which is harmful and needs attention.

Mask Specifics

Different properties and attributes for assisting these cases are critical. Specific masks provide support to help.