Epistaxis - A Presentation PDF

EPISTAXIS Outlines Introduction Epidemiology Applied vascular anatomy of the nose Classification Etiology Diagnosis and Evaluation Management References Introduction Epistaxis is defined as bleeding from either nostril, nasal cavity or nasopharynx Its due to rupture of small bl...

EPISTAXIS Outlines Introduction Epidemiology Applied vascular anatomy of the nose Classification Etiology Diagnosis and Evaluation Management References Introduction Epistaxis is defined as bleeding from either nostril, nasal cavity or nasopharynx Its due to rupture of small blood vessels within the nose or bleeding from the nose due to any cause Epistaxis is one of the commonest ENT emergencies Most of the time, bleeding is self-limited, but can often be serious and life-threatening and may require prompt intervention Introduction… Epistaxis primarily originates from the lateral nasal wall or the septum Lateral nasal wall bleeding usually occurs in the region of the sphenopalatine artery Bleeding can be anterior or posterior 90-95% of all episodes of epistaxis are anterior The posterior nasal cavity is the source for roughly 5 to 10% of occurrences of epistaxis Epidemiology Bimodal age distribution Most cases occur in the 2-10 or 50-70 years-old age groups Incidence increase in winter True prevalence is not know because most episodes are self limited and are not reported APPLIED ANATOMY The nasal cavity is divided into 2 main areas: the anterior nasal cavity and posterior nasal cavity, The most common site of bleeding is from the plexus of vessels at the anteroinferior aspect of the nasal septum in the anterior nasal cavity. This area, most commonly referred to as the Kiesselbach’s plexus, is also known as Little’s Area. Applied vascular anatomy The plexuses Vascular anatomy of the nose Pathophysiology Variable: B’se of different predisposing factors Epistaxis is due to the rupture of a blood vessel within the richly perfused nasal mucosa. Rupture may be spontaneous or initiated by trauma or other various systemic and local causes. An increase in blood pressure (e.g. due to hypertension) tends to increase the duration of spontaneous epistaxis Pathophysiology… Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding. Anterior Vs Posterior Epistaxis Anterior epistaxis Posterior epistaxis Most common in younger Usually occurs in older population population Usually due to nasal mucosal HTN is common dryness contributing factors May be alarming because Significant bleeding in one can see blood readily, posterior pharynx thus but generally less severe less alarming because blood is swallowed Usually can be easily controlled More challenging to control ETIOLOGY IDIOPATHIC LOCAL SYSTEMIC Local causes Trauma Nose picking Nose blowing/sneezing Nasal bone fracture(s)with disruption of nasal mucosa Foreign bodies Nasal intubation Nasal surgical procedure Local causes… Inflammatory causes: Infectious causes: Rhinitis/Rhinosinusitis: Bacteria, Viruses and/or Fungi. Tuberculosis (Lupus vulgaris), Syphilis (syphilitic ulcer of the nose) Non-infectious causes: Pyogenic granuloma, allergic rhinitis. Local causes… Neoplasms Benign: Juvenile nasopharyngeal angiofibroma, Haemangioma, Inverted papilloma Malignant: Nasopharyngeal carcinoma, Sinonasal cancers Local causes… Dessication Cold, dry air—more common in winter time where the nasal mucosal becomes dry and easily cracked when sneezing/blowing the nose. This thus leads to nose bleeding. Nasal oxygen administration Atrophic rhinitis Local causes… Vascular causes Vascular malformations: Arteriovenous malformations of the nose Internal carotid artery aneurysms rupture/post-traumatic pseudoaneurysm of the internal carotid artery Local causes… Others: Anatomical anomalies: Septal deviation Septal perforation Septal varices Septal spurs Local causes… Chemical irritants: (sniffing cocaine, heroin tobacco, etc.) Medications: Antihistamines, nasal corticosteroids which causes mucosal irritation and dryness of the nasal mucous membrane Systemic causes Vascular Hereditary hemorrhagic telangiectasia (Osler Rendu Weber Syndrome) Cardiovascular causes: Mitral stenosis, Coarctation of the aorta….Due to increased systemic venous pressure Systemic causes… Coagulopathies Decreased platelet count (Thrombocytopenia): Idiopathic thrombocytopenic purpura Platelet dysfunction ✔ Systemic disease (Uremia): defects intrinsic to the platelet as well as abnormal platelet-endothelial interaction. Uremic toxins and anemia also play a role. ✔ Drug-induced: Anticoagulants (warfarin), NSAIDS (Aspirin, Ibuprofen), Antiplatelet drugs (Aspirin, clopidogrel) Systemic causes… Clotting Factor Deficiencies ✔ Hemophilia A (factor VIII def)…80%, ✔ Hemophilia B (Factor IX def, Christmas disease)…13% ✔ Von Willebrand’s disease (vWF) Systemic causes… Hematologic malignancies eg ALL, AML/CML, Aplastic anemia CKD Uremia Liver failure Diagnostic evaluation History Physical examination Investigations LABORATORY WORK UP FBP: platelet count and other differentials r/o pancytopenia from the count Bleeding indices: PT, PTT, INR, Thrombin time and Bleeding time Liver function tests: ASAT, ALAT Renal function tests: Serum creatinine, Urea Peripheral blood smear: Haematological malignancies (Leukemia) Investigations… Bone marrow aspiration/ trephine biopsy: Leukemia/ Aplastic anaemia Clotting factors assay: Factor VIII or vWF assay Biopsies: Sinonasal tumors (inverted papilloma, pyogenic granulomas) , Lupus vulgaris, JNA ❑ IMAGING WORK UP X ray of the paranasal sinuses CT scan of the paranasal sinuses Treatment Depends on type of epistaxis it can be Conservative Surgical  ANTERIOR EPISTAXIS: Treatment First aid With a patient in a sitting up position to squeeze anterior (compressible cartilaginous part) nose for 5-10 minutes and leaning forward). CAUTERY CHEMICAL CAUTERIZATION: Electro cauterization: Nasal packing Anterior Posterior Packing materials Vaselline gauze Gelfoam Nasal balloons Nasal catheters Merocel nasal tampon Correct direction for placement of nasal packing  POSTERIOR EPISTAXIS: Treatment Posterior nasal packing Epistaxis that cannot be controlled by anterior packing can be treated with a posterior pack. Inflatable balloon devices, such as 12F or 14F Foley catheters, or balloon catheters  Foley catheter is used to pack posteriorly INDICATIONS FOR SURGERY Continued bleeding despite nasal packing, cauterization. Nasal anomalies Patient intolerance of packing SURGICAL TREATMENT Arterial ligation Embolization References ❖ Ballenger’s Otorhinolaryngology, Head and Neck Surgery, 16th edition. ❖ Cummings Otolaryngology: Head and Neck Surgery, 6th edition ❖ Otolaryngology Head and Neck Surgery by R. Pasha. ❖ Bailey Head and Neck Surgery Otolaryngology, 4th edition. ❖ American Journal of Rhinology, 2015. ❖ Online published papers: bmj, bmc, Brazilian journal of otorhinolaryngology ❖ Other relevant internet sources: Medscape, uptodate