epistaxis ,anatomy ,aetiology, manegment

1. EPISTAXIS
Dr Ahlam Alzuway
Otorhinolaryngologi
st

2. Anatomical Types:
 From a clinical perspective, bleeding will be either from the lateral nasal wall or from the septum.
 Lateral nasal wall bleeding: (mostly posterior)
- Most major bleeds that occur without trauma will be posterior.
- Sphenopalatine artery, which enters through the sphenopalatine foramen at the posterior end of the middle turbinate.
- Almost immediately after exiting the foramen, the sphenopalatine artery gives off the posterior nasal artery. This artery
supplies branches to the superior turbinate before passing above the posterior bony choana on the anterior face of the
sphenoid sinus to the posterior aspect of the septum. This vessel may be cut if the natural ostium of the sphenoid sinus is
enlarged inferiorly and can result in an impressive arterial bleeder during surgery.
- The other potentially vascular area on the lateral nasal wall is the region under the posterior end of the inferior
turbinate where the sphenopalatine artery and posterior pharyngeal artery may anastomose and is termed Woodruff's
area.

5.  Septal bleeding: (mostly anterior)
- Responsible for the majority of nose bleeds (95%).
- Septum is supplied by the posterior nasal artery, the greater palatine artery
(through the incisor foramen), the anterior and posterior ethmoidal arteries,
and branches of the labial artery entering the nose anteriorly. These vessels
tend to anastomose in the region about 1.5 cm behind the anterior
mucocutaneous junction, which is termed either Little's area or
Kiesselbach's plexus.

7. Local Systemic
Trauma: digital, fractures Hypertension
Nasal sprays (local trauma effect) Vascular disorders
Inflammatory reactions Blood dyscrasias
Anatomic deformities (e.g., septal spur/deflection) Hematologic malignancies
Foreign bodies Allergies
Intranasal tumors Malnutrition
Chemical irritants Alcohol
Nasal prong O2, CPAP Drugs
Surgery Infections
CPAP, continuous positive airway pressure.
Etiology:

9. Blood dyscriasis:
Heriditary disorders:
The most common inherited bleeding diatheses are:
 von Willebrand disease, the most common inherited bleeding diatheses, with reduction in von
Willebrand factor (vWF). The procoagulant factor and vWF together form factor VIII.
 Hemophilia A, with a reduction of procoagulant factor of factor VIII.
 Heophilia B, less commom, caused by reduction in clotting factor IX.
 These disorders are sex-linked, occurring only in males.
 Laboratory evaluation includes a bleeding time, platelet count, partial thromboplastin time,
assay of factor VIII coagulant activity, von Willebrand’s factor antigen.
Replacement therapy with cryo-precipitate and possibly platelets, sufficient to
normalize bleeding time and factor VIII coagulant activity, is recommended for
7 days after surgical procedures

10.  Acquired disorders: including;
 Drug-mediated thrombocytopenia.
 Vitamin K deficiency: Vitamin K is essential for the synthesis of prothrombin and factors VII, IX, and X.
Vitamin K deficiency as a result of diet, disease, or medications.
 Blood malignancies.
 Liver disease: causes reduced levels of all coagulation factors except factor VIII.
 Renal disease.
Vascular disorders:
Hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber disease):
 Autosomal dominant inherited condition.
 Telangiectasias have thin fragile vessel walls lined by a single endothelial layer with absent smooth muscle,
resulting in vessel fragility and impaired vasoconstriction.
 Affects vessels from capillaries to large arteries.
 In the nose, these lesions form raised lesions on the nasal septum, lateral nasal wall, and floor of the nose.
Their increased fragility may result in spontaneous epistaxis. Removal of crusts or blood clots or excessive
nose blowing will usually result in an epistaxis.
 Arterio-venous malformations can be found in the brain, lungs, liver, and gut.
As these patients get older, regular nasal cautery will often result in the development of a
septal perforation

11. Arteriosclerotic vascular disease:
 Arteriosclerotic vascular disease is a possible explanation for the higher incidence of
nosebleeds seen in those of increased age.
 Although hypertension often is noted in the older patient with epistaxis, and although an
increased blood pressure reading is noted in the acutely bleeding patient, an actual increase
in frequency or severity of epistaxis in the hypertensive group has not been shown.
Management:
Observation
Antiseptic creams - Barrier ointments
Cauterization
Nasal packing: anterior pack, posterior nasal pack, nasopharyngeal balloon
Pterygopalatine fossa block
Laser photocoagulation
Pharmacologic control
Surgical
Arterial ligation
Angiographic embolization
Surgical reconstruction

12. Minor Hemorrhage:
 Antiseptic creams are thought to work by reducing vestibulitis and mucosal inflammation
as well as by moistening the mucosa and preventing drying and crusting.
 Barrier ointments are thought to work by preventing crusting of the septal mucosa.
 Silver nitrate cautery may be used if, on examination of Little's area, a large dilated blood
vessel is seen that is thought to be the likely cause of the recurrent epistaxis.
 Education about stopping crust removal and correct positioning of nasal sprays may reduce
the incidence of minor epistaxis.
 Packs can be placed in the anterior nasal cavity. The pack is then removed after 20
minutes.

14. Major Hemorrhage:
Post-traumatic bleeding:
 Anterior skull base fractures may cause damage to the anterior and posterior
ethmoidal arteries, whereas fractures of the maxilla may result in hemorrhage from
the internal maxillary artery or one of its branches. If the sphenoid is involved
with fractures traversing the internal carotid artery, catastrophic bleeding may
result.
 Ensure adequate intravenous access and Assessment and resuscitation of all vital
signs in the emergency room.

15.  In cooperative patient:
- Patient is given a bowl and paper towels and told to blow all the blood clots out of
his or her nose.
- Nasal cavity thoroughly sprayed with a combination of lidocaine, epinephrine (or
adrenalin), and saline.
- Rigid nasal endoscope and suction are used to clear the nasal cavity of any
residual blood clots and attempts to identify site of bleeding, management
accordingly.
In case of posterior packing; patients are admitted and should be monitored with
pulse oximetry because occlusion of the nasal cavity may induce hypoxia from
activation of the naso-pulmonary reflex and the consequent vascular shunting that
occurs. In at-risk patients such ischemia may be sufficient to trigger cardiac
arrhythmias

16. Posterior packing

17. Anterior and posterior packing

18.  In comatosed patient:
- Postnasal space balloon catheter is inserted into the nasopharynx and inflated with 15 mL
saline. In cadaveric studies, this volume has been shown to adequately occlude the
postnasal cavity and allow a platform onto which the ribbon gauze can be tightly packed.
- Should bleeding continue, the patient should be taken to the operating room and
endoscopic examination of the nose performed under general anesthetic.
- Bleeding from the region of the sphenopalatine artery can be managed by a sphenopalatine
artery ligation. If this fails to control bleeding, then the external carotid artery should be
ligated in the neck.
- Bleeding from the roof of the nose can be managed endoscopically, or by a Lynch incision
and ligation of the anterior ethmoidal artery and the posterior ethmoidal artery if necessary.
- Massive hemorrhage from the sphenoid region usually indicates an internal carotid injury.

19. Control of ethmoidal arteries:
• Endoscopic:
• Via a Lynch incision:
• Recently, Douglas (Combined) approach: a limited (1-cm) incision is
continued onto bone after which a 4-mm endoscope is placed in the incision and
dissection is continued in a subperiosteal plane, anterior lacrimal crest identified,
upper part of the lacrimal sac is lifted from the lacrimal fossa and reflected laterally.
Dissection continues posteriorly along the lamina papyracea following the fronto-
ethmoidal suture, artery is either clipped or cauterized.
+ Management of orbital hematoma

21. Endoscopic Sphenopalatine Artery Ligation:
 The procedure of choice for uncontrolled posterior epistaxis.
 If the patient is actively bleeding, a pterygo-palatine block can be done by injectiong of 2 mL of
2% lidocaine and 1:100,000 adrenalin through the greater palatine canal (( landmarks for the
greater palatine canal are the point midway between the second molar tooth and the midline of the
palate. To locate the foramen of the greater palatine canal, it is often easier to place the endoscope
in the mouth and then to palpate the posterior edge of the palate sliding the finger forward until the
indentation of the foramen is felt. The endoscope is used to define this point and the finger is
withdrawn. Bent needle to about 15 mm (the length of greater palatine canal) is introduced
alongside the endoscope and into the depression identified. Injection of local anesthetic and
adrenalin causes vasospasm of the maxillary artery and will in most cases reduce or stop the
bleeding from the sphenopalatine artery or one of its branches. This allows the surgeon to be able to
operate in the nose without ongoing significant hemorrhage.

22.  The first step is to palpate the posterior fontanelle of the maxillary sinus behind the uncinate
process. This region of the posterior fontanelle is soft.
 Moving posteriorly, the hard bone of the palatine bone is felt.
 At the junction of the posterior fontanelle and palatine bone, a vertical U-shaped incision is
made from under the horizontal portion of the middle turbinate.
 Suction elevator is used to elevate the mucosa off the underlying bone until the anterior face
of the sphenoid is reached.
 SPA is identified as it emerges from the sphenopalatine foramen. There is a bony prominence
just anterior to the sphenopalatine foramen (ethmoidal protuberance of the palatine bone)
which can be used as a landmark. This can be removed with a curette to further expose the
sphenopalatine foramen.

23.  The artery must be dissected free from the other structures and tissue that emerges with it
from the palatine foramen until it is clearly seen as a single vessel.
 Once this vessel has been clipped, further dissection posteriorly should be performed
because the posterior nasal artery that supplies the posterior aspect of the septum often
divides prior to the SPA emerging through the foramen and can be seen as a separate vessel
posterior to the SPA; it should be clipped as well.
 Mucosal flap is then replaced and if necessary dissolvable packing is placed over the flap.
 SPA ligation is successful in controlling epistaxis in 90% to 100% of patients.

24. Arteriography &
Embolization (Interventional radiology) of the Maxillary Artery:
 This procedure is reserved as the 2nd choice for the small group of patients who continue to
bleed after SPA.
 Can be useful for patients who are medically unfit to undergo SPA ligation.
 It requires an interventional radiologist with significant experience and skill because the
potential complications from embolization are more serious than for arterial ligation.
 Control rates for epistaxis vary from 65% to 85%.
 Complications varying from stroke to facial pain and facial numbness.

25. Transantral Ligation of the Maxillary Artery:
 Until recently, this was the procedure of choice, but it is rarely used today because SPA is easier, has
less complications, and is more effective at controlling epistaxis.
 This procedure is performed by exposing the anterior face of the maxillary sinus and opening this face
in the same manner as would be done for the traditional Caldwell-Luc procedure. Once the window is
sufficient, the microscope is swung into place and the posterior wall of the maxillary sinus is fractured
and flaked off exposing the fat of the pterygopalatine fossa. The fat is teased out and the blood vessels
are identified.
 The course of the maxillary artery through the pterygopalatine fossa is very tortuous, and it can be
difficult to identify whether the vessels exposed in this manner are the main trunk of the artery or one of
the branches. Thus it is relatively easy to miss either the main trunk of the artery or the sphenopalatine
branch, and this results in a failure rate of 10 to 20%.
Complications include facial paresthesia, facial pain, dental pain and numbness, hematoma, and very
rarely ophthalmoplegia and blindness

26. Management of Hereditary Hemorrhagic Telangiectasia:
 Laser Management:
- Lasers that are currently used are KTP, Nd:-YAG, and more recently pulse dye laser, because they are
selectively absorbed by the underlying microvasculature and coagulate the vessel with a minimal
damage to the surface epithelium.
- One of the critical issues with laser treatment is the need to meticulously address all the telangiectasias
within the nose. This may take a number of hours; consequently, it is usually performed under general
anesthesia.
- If there is an associated septal perforation, silastic septal splints are placed over the perforation and
held in place with a transseptal suture for 1 to 2 weeks before they are removed. This allows the
mucosa around the septal perforation to heal without crusting from turbulent airflow.
- This needs to be repeated every 4 to 6 months as the patients grows new telangiectasias.

27.  Septo-dermoplasty:
- Mucosa is removed, and kin grafts are placed on the nasal septum.
- Although it is effective in the initial stages, over time the skin graft contracts and telangiectasias are found
at the junction of the graft and the mucosa.
 Topically applied, OR Systemic Tranexamic acid (Cyclokapron):
- Antifibrinolytic that competitively inhibits the activation of plasminogen to plsmin , a molecule
responsible for the degradation of fibrin .
- Recently described for patients with severe HHT.
- Resulted in a significant reduction in bleeds per month.
- Larger studies are necessary before this can be routinely adopted as part of the treatment for HHT
patients.

28.  Management of ICA bleeding:
- If the patient is under general anesthetic, the blood pressure should be lowered by the anesthetist
to allow greater visibility for the surgeon and to facilitate the placing of packing against the
anterior face of the sphenoid sinus.
- If possible, a sphenoidotomy can be performed and packing placed into the sphenoid to gain
control of the hemorrhage.
- Muscle plug is harvested from the sternomastoid muscle in the neck. This muscle is placed against
the carotid artery in the sphenoid and a pack placed on top.
- If this fails to control the hemorrhage, a temporary vascular clamp can be placed across the
common carotid artery in the neck while a sphenoidotomy is performed and the muscle and pack
placed in the sphenoid on the carotid artery. This clamp should be removed as soon as possible
to limit cerebral ischemia and the possibility of a stroke.

29. - Patient is then sent for interventional arteriography. If the lesion is in the
vertical portion of the carotid in the sphenoid, then a stent may be placed,
but if it is in the region of the carotid siphon, then balloon occlusion of the
carotid may be necessary and embolization of the internal carotid may be
the only solution for saving the patient's life. The major risk of carotid
occlusion is cerebral ischemia, hemiplegia, and, in some cases, death.
- If the patient has undergone significant blood transfusions, then diffuse
intravascular coagulation may result in poor clotting and contribute to
ongoing hemorrhage.

30. THANKS