Epistaxis

1
Epistaxis

• By
• Stacey Singer-Leshinsky R-PAC

2
Function of the Nose

• Vasculature just under the mucosa.
• Vasculature supply originates from the ethmoid
  branches of the internal carotid arteries and the
  facial and internal maxillary divisions of the
  external carotid arteries.
• Nose bleeds are very common

3
Epistaxis

• Acute hemorrhage from the nostril, nasal cavity,
  or nasopharynx.
• Etiology includes infection, trauma, allergic
  rhinitis, renal failure, nasal defects,
  hypertension, tumors, use of blood thinners,
  aspirin.
• History

4
Epistaxis

• Classified by the location
• Can be either anterior or posterior.

5
Anterior Epistaxis

• Kiesselbachs plexus most common.
• Clinical Manifestations
• History
• Unilateral bleeding
• No sensation of post nasal drip
• Blood is bright red

6
Anterior Epistaxis

• Diagnostics
• Hemoglobin/Hematocrit
• CBC
• Bleeding time

7
Anterior Epistaxis

• Management
• ABC
• Direct pressure. Pinch nostrils sit forward.
• Cautery- chemical, electric, thermal. Silver
  nitrate sticks
• Use of vasoconstrictors sprays. / anesthetic
  agents.
• Anterior packing Merocel compressed sponge.
• Remove any clots visualized
• Anterior epistaxis balloons.

8
Anterior Epistaxis

• Complications of nasal packing
• Septal hematomas/abscess
• Sinusitis
• Pressure necrosis

9
Posterior Epistaxis

• Usual source is the branches of the
  sphenopalatine artery. Bleeding occurs behind the
  posterior portion of the middle turbinate or
  posterior superior roof of the nasal cavity.

10
Posterior Epistaxis

• Clinical Manifestations
• Nausea, hematemesis, anemia, hemoptysis or
  melena.
• No visualized anterior source of bleeding
• Post nasal drip of blood
• Blood is dark red
• Brisk arterial bleed

11
Posterior Epistaxis

• Diagnostics
• Hemoglobin/ Hematocrit
• History of bleeding disorder

12
Posterior Epistaxis

• Management
• Attempt to locate the source
• Vasoconstrictive/ anesthetic agents
• Posterior nasal packing
• Immediate otolaryngologist referral
• Prophylactic antibiotics
• Hospitalization and monitoring

13
Posterior Epistaxis Packing
14
Posterior Epistaxis

• Indications for surgery/ embolization
• Continued bleeding with packing
• Required transfusion
• Nasal anomaly precluding packing
• Patient intolerance to packing

15
EpistaxisDifferential Diagnosis

• Local irritation
• Occupational exposure
• Allergies
• Malignancy due to systemic disease such as
  granulomatous disease(Wegeners sarcoidosis)
• Hereditary hemorrhagic telangiectasia(Osler-Weber-
  Rendu syndrome)
• Bleeding disorders
• hypertension

16
EpistaxisComplications

• Sinusitis
• Possibility of airway obstruction
• Toxic shock syndrome
• Septal hematoma or abscess
• Septal perforation

17
Osler-Weber-Rendu syndrome

• Disorder of blood vessels
• Etiology Genetic
• Clinical manifestations telangiectases on the
  lips, tongue and nasal mucosa
• Complications include hemorrhage