EPISTAXIS

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EPISTAXIS

• Glen Porter, MD
• Francis B. Quinn, MD
• UTMB-Galveston
• Galveston, Texas

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Introduction and History

• 5-10 of the population experience an episode of
  epistaxis each year. 10 of those will see a
  physician. 1 of those seeking medical care will
  need a specialist.
• Mythology brown paper, nails, scissors, scarlet
  threads,lead that has never touched the ground
• A condition with a long historyHippocrates to
  Henry Goodyear.

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Anatomy/Physiology of Epistaxis

• Anatomy
• Nasal cavity
• Vascular supply
• Physiology
• Vascular nature
• Mucosa

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Why bleeding from the nose ?

• Vascular organ secondary to incredible
  heating/humidification requirements
• Vasculature runs just under mucosa (not squamous)
• Arterial to venous anastamoses
• ICA and ECA blood flow

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SPF -class I (35) -class II (56) -class III
(9)
Anatomy of the Lateral Nasal Wall
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External Carotid Artery -Sphenopalatine
artery -Greater palatine artery -Ascending
pharyngeal artery -Posterior nasal
artery -Superior Labial artery Internal Carotid
Artery -Anterior Ethmoid artery -Posterior
Ethmoid artery
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Pterygopalatine Vasculature --Internal
maxillary artery
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Anatomy of the Nasal Cavity and Vasculature
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Sphenopalatine AA Ethmoid AA Greater Palatine A
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Kesselbachs Plexus/Littles Area -Anterior
Ethmoid (Opth) -Superior Labial A
(Facial) -Sphenopalatine A (IMAX) -Greater
Palatine (IMAX) Woodruffs Plexus -Pharyngeal
Post. Nasal AA of Sphenopalatine A (IMAX)
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Anterior vs. Posterior

• Maxillary sinus ostium
• Anterior younger, usually septal vs. anterior
  ethmoid, most common (gt90), typically less
  severe
• Posterior older population, usually from
  Woodruffs plexus, more serious.

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Etiology

• Local factors
• Vascular
• Infectious/Inflammatory
• Trauma (most common)
• Iatrogenic
• Neoplasm
• Dessication
• Foreign Bodies/other

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Etiology

• Systemic factors
• Vascular
• Infection/Inflammation
• Coagulopathy

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Local Factors -- Vascular

• ICA Aneurysms
• extradural
• cavernous sinus

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Local Factors - Infection/Inflammation

• Rhinitis/Sinusitis
• Allergic
• Bacterial
• Fungal
• Viral

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Local Factors - Trauma

• Nose picking
• Nose blowing/sneezing
• Nasal fracture
• Nasogastric/nasotracheal intubation
• Trauma to sinuses, orbits, middle ear, base of
  skull
• Barotrauma

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Nasal Fracture with Septal Hematoma
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Local Factors - Iatrogenic nasal injury

• Functional endoscopic sinus surgery
• Rhinoplasty
• Nasal reconstruction

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Local Factors - Neoplasm

• Juvenile nasopharyngeal angiofibroma
• Inverted papilloma
• SCCA
• Adenocarcinoma
• Melanoma
• Esthesioneuroblastoma
• Lymphoma

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Local Factors Dessication

• Cold, dry airmore common in wintertime
• Dry heatPhoenix and Death valley
• Nasal oxygen
• Anatomic abnormalities
• Atrophic rhinitis

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Local Factors - Other

• Self-inflicted (pedi) vs. traumatic foreign
  bodies
• Intranasal parasites
• Septal perforation
• Chemical (cocaine, nasal sprays, ammonia, etc.)

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Systemic Factors -- Vascular

• Hypertension/Arteriosclerosis
• Hereditary Hemorrhagic Telangectasias (OWR)

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Systemic Factors Infection/Inflammation

• Tuberculosis
• Syphillis
• Wegeners Granulomatosis
• Periarteritis nodosa
• SLE

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Systemic Factors Coagulopathies

• Thrombocytopenia
• Platelet dysfunction
• Systemic disease (Uremia)
• drug-induced (Coumadin/NSAIDs/Herbal supplements)
• Clotting Factor Deficiencies
• Hemophilia
• VonWillebrands disease
• Hepatic failure
• Hematologic malignancies

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Etiology and Age

• Childrenforeign body, nose picking, nasal
  diptheria (1/3 with chronic bleeds have
  coagulation d/o)
• Adultstrauma, idiopathic
• Middle agetumors
• Old age--hypertension

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Initial Management

• ABCs
• Medical history/Medications
• Vital signsneed IV?
• Physical exam
• Anterior rhinoscopy
• Endoscopic rhinoscopy
• Laboratory exam
• Radiologic studies

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bayonet forcepts
vaseline gauze
suction
T.C.A.
bacitracin
gelfoam
good light
anesthetic
Afrin
epistat
endoscopes
silver nitrate merocels
suction bovie/bipolar
surgicel
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Non-surgical treatments

• Control of hypertension
• Correction of coagulopathies/thrombocytopenia
• FFP or whole blood/reversal of anticoagulant/plate
  lets
• Pressure/Expulsion of clots
• Topical decongestants/vasocontrictors
• Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)
• Nasal packing (effective 80-90 of time)
• Greater palatine foramen block

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Non-surgical treatments on d/c

• Humidity/emolients
• Discontinue offending meds
• Nasal saline sprays
• Avoidance of nose picking/blowing
• Sneeze with mouth open
• Avoid straining/bedrest

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Nasal packs

• Anterior nasal packs
• Traditional
• Recent modifications
• Posterior nasal packs
• Traditional
• Recent modifications
• Ant/Post nasal packing

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Pick a Pack, any pack
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Pick a pack to pack with
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TSSNugauze vs. Merocel Electron microscopy
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Posterior Packs Admission

• Elderly and those with other chronic diseases may
  need to be admitted to the ICU
• Continuous cardiopulmonary monitoring
• Antibiotics
• Oxygen supplementation may be needed
• Mild sedation/analgesia
• IVF

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Indications for surgery/embolization

• Continued bleeding despite nasal packing
• Pt requires transfusion/admit hct of lt38
  (barlow)
• Nasal anomaly precluding packing
• Patient refusal/intolerance of packing
• Posterior bleed vs. failed medical mgmt after
  gt72hrs (wang vs. schaitkin)

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Selective Angiography/embolization

• Helps identify location of bleeding
• Embolization most effective in patients who
• Still bleeding after surgical arterial ligation
• Bleeding site difficult to reach surgically
• Comorbidities prohibit general anesthetic
• Effective only when bleeding is gt.5 ml/min
• 90 success rate, complication rate of 0.1
• Only able to embolize external carotid branches
• Complications minor (18-45)/major (0-2)
• Contraindicated in bad atherosclerosis, Ethmoid
  bleed

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Surgical treatment

• Transmaxillary IMA ligation
• Intraoral IMA ligation
• Anterior/Posterior Ethmoidal ligation
• Transnasal Sphenopalatine ligation
• External carotid artery ligation
• Septodermoplasty/Laser ablation

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Transmaxillary IMA ligation

• Waters view
• Caldwell-Luc
• Electrocautery of posterior wall before removal
• Microscopic dissection and ligation of IMA
  --descending palatine sphenopalantine most
  important
• Recurrence rate (failure rate) of 10-15
• Complication rate of 25-30 (oa fistula,dental,
  n)

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Intraoral IMA ligation

• Posterior gingivobuccal incision beginning at
  second molar
• Temporalis mm split and partially dissected
• IMAX visualized, clipped and divided
• Advantages children/facial fractures
• Disadvantages more proximal ligation
• Complications trismus, damage to infraorbital n

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Ant./Post. Ethmoidal ligation

• Patients s/p IMAX ligation still bleeding,
  superior nasal cavity epistaxis, or in
  conjunction when source unclear
• Lynch incision
• Fronto-ethmoid
• suture line
• 12-24-6
• (14-18, 8-10, 4-6)

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Transnasal Endoscopic Sphenopalatine Artery
ligation

• Follow Middle Turbinate to posteriormost aspect
• Vertical mucoperiosteal incision 7-8mm anterior
  to post middle turb (between mid. and inf. turbs)
• Elevation of flapID neurovascular bundle at
  foramen
• Ligation with titanium clip
• Reapproximate flap
• Complications few, Failures0-13

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Transnasal Spheno-palatine Artery ligation
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ECA ligation

• Effectiveness
• Anterior border of SCM
• ID ECA/ICA
• Ligation after clear that surrounding structures
  are safe.

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Septodermoplasty/Laser

• Remove mucosa from anterior ½ septum, floor of
  nose, lateral wall
• STSG vs. cutaneous, myocutaneous, microvascular
  free flaps vs. Autografts
• Neodymium-yttrium-garnet (Nd-YAG) laser or Argon
  laser topical steroid best nonsurg rx for
  mild/mod disease
• Still bleed, but not as bad
• Definitive treatment (severe disease)closure of
  nose

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Statistically speaking,.

• Some authors (Wang and Vogel) showed surgical
  intervention to have lower failure rates (14.3
  vs. 26.2), decreased complications (40 vs. 68),
  and shorter hospital stays (2.2 less) than those
  w/posterior packs.
• Others compared all medical treatment to surgery
  and showed cost cut using medical management.
• Complication rates posterior packs-25-40,
  embolization 27, IMAX ligation 28
• Cost analysis IMAX vs. Embolization vs. Surgical
  Cauteryabout equal
• Failure rates PP-30, Sx-17, Emb-4

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Tips and Pearls

• Red rubber on suction in contralateral nasal
  cavity
• AgNO3 x 30seconds or more (not on both sides of
  septum)
• Antihistamines to prevent rebleeds
• Cautery does not work with no platelets/clotting
• Glove packing
• H2O2
• Merocels (2 or more) injected with cortisporin
  otic
• Amicar spray

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Tips and Pearls

• Hot water irrigation
• Cold water irrigation
• Salt Pork
• Dont pack nose in unconscious person with
  suspected skull fractures.
• Antibiotic cream vs. silver nitrate
• Intranasal pressure
• Estrogen cream to nasal septum

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Tips and Pearls

• Transnasal endoscopic bipolar cautery of
  sphenopalatine artery (7 failure in pts with
  obvious source of bleed)
• Submucosal supraperichondrial dissection of nasal
  septum
• Not all hospitals have embolization-trained
  interventionalists
• No hard-set outline. Do what is best for your
  particular patient

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CASE REPORT

• 45 yo Vietnamese fisherman--stable, but
  uncomfortable
• Profuse nasal bleeding since 0200 this a.m.
• History No known medical problems. Drinks 6-12
  beers/day. Takes no medications. No history of
  easy bleeding. No family history.
• Physical exam Profuse bleeding from both
  nostrils LgtR and bleeding down the back of his
  throatcoughing up clots. Unable to locate
  precise location of bleedappears to be
  posterior/superior.

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Case 1 contd

• Hgb 12.5
• Lactated Ringers IVF bolus
• Nasal packs removed two days later in the
  clinic,rebleeds.
• Requires transfusion for Hgb of 6.5
• Angiographyno obvious bleed/Embolization
• Ant/Post Ethmoid Artery ligation