3. Anterior epistaxis:
Bleeding from a source anterior to the plane of the piriform
aperture.
This includes bleeding from the anterior septum and rare
bleeds from the vestibular skin and mucocutaneous
junction.
Posterior epistaxis:
Bleeding from a vessel situated posterior to the piriform
aperture.
This allows further subdivision into lateral wall, septal and
nasal floor bleeding.
4. Management of
epistaxis
direct
Bleeding point
specific
Endoscopic control
bipolar diathermy,
chemical cautery
(difficult in
posterior bleeds),
electrocautery
or direct pressure
from miniature
targeted packs
silver nitrate
cautery.
indirect
Donot require
identification of
bleeding points
9. Systemic medical therapy:
Tranexamic acid &
epsilon aminocaproic aci
reduce the severity and
risk of rebleeding
at a dose of 1.5 g three
times a day.
Preexisting
thromboembolicdisease
is a contraindication
11. Posterior nasal packing
General anaesthesia is preferrable.
Nasopharyngeal tamponade is achieved using special
gauze packs inserted transorally and positioned by
means of tapes passed from the posterior choana to the
anterior nares bilaterally.
12.
13. Alternative is to insert a Foley urethral
catheter (size 12 or 14) along the floor
of the nasal cavity until the nasopharynx
is reached.
The Foley catheter is inflated with up to
15mL of water, pulled forward to engage
in the posterior choana and anterior
packing is then inserted.
The Foley catheter needs to be secured
anteriorly, taking care not to cause
pressure over the columella.
Complications :
Posterior packing causes considerable
pain and may cause hypoxia secondary to
soft palate oedema.
Sinusitis and middle ear effusions are
common.
More serious complications include
necrosis of the septum and columella.
14. Ligation:
Ligation should be performed as close as possible to the
likely bleeding point.
sphenopalatine artery;
internal maxillary artery;
external carotid artery;
anterior/posterior ethmoidal artery.
15. sphenopalatine artery:
An incision is made approximately 8mm anterior to and under
cover of the posterior end of the middle turbinate.
The incision is carried down to the bone and a mucosal flap is
elevated.
The foramen can be difficult to identify, but its location is
signalled by the crista ethmoidalis.
Once the main vessel is identified, it can be ligated using
haemostatic clips and divided or coagulated using bipolar
diathermy
16.
17. internal maxillary artery:
The artery is exposed transantrally via
anterior (sublabial) or
combined anterior and medial(endoscopic) techniques.
In the traditional sublabial approach, an antrostomy is
formed taking care to preserve the infraorbital nerve.
The mucosa of the posterior wall of the antrum is then
elevated and a window is made through into the
pterygopalatine fossa.
The branches of the internal maxillary artery are
identified pulsating within the fat of the fossa and are
carefully dissected out prior to clipping with haemostatic
clips.
18.
19. The proximal internal maxillary artery, descending
palatine and sphenopalatine branches are all clipped and
ideally divided.
An endoscopic variation on this technique uses a middle
meatus antrostomy, as an instrument port with a 4-mm
endoscope is inserted through a small canine fossa
antrostomy.
Transantral ligation controls haemorrhage in 89 percent
of cases.
Complications include sinusitis, damage to the
infraorbital nerve, oroantral fistula, dental damage and
anaesthesia and rarely ophthalmoplegia and blindness.
20. ECAL:
This procedure can be carried out
under local or general anaesthetic
using either a skin crease incision or a
longitudinal incision parallel with the
anterior border of the sternomastoid.
The carotid bifurcation is identified
and the external carotid confirmed,
double-checked for arterial branches
and then ligated in continuity.
Complications
wound infection,
haematoma and
neurovasculardamage.
21. Anterior/posterior ethmoidal
artery ligation:
The arteries are approached by a medial canthal incision
which is carried down to the bone of the anterior
lacrimal crest.
Periosteal elevators are then used to elevate and
laterally retract the bulbar fascia.
The anterior ethmoidal artery is seen as a
fibroneurovascular mesentry running from the bulbar
fascia into the anterior ethmoidal foramen.
The vessel is clipped and divided and dissection is
continued to identify the posterior artery which is
located approximately 12mm behind.
22.
23.
24. Septal surgery:
When epistaxis originates behind a prominent septal
deviation or vomeropalatine spur, septoplasty or
submucosal resection (SMR) may be required to access
the bleeding point.
the blood supply to the septum is interrupted and
haemostasis secured.
25. embolization:
It is essential to exclude arteriovenous malformations,
aneursyms and fistulae prior to embolization.
Once the bleeding vessel is identified, a fine catheter is
passed into the internal maxillary circulation and
particles (polyvinyl alcohol, tungsten or steel microcoils)
are used to embolize the vessels.
The ipsilateral facial artery is also embolized inorder to
prevent recirculation.
Complications includeskin necrosis, paraesthesia,
cerebrovascular accident.
26. Secondary epistaxis:
Epistaxis is commonly observed in patients with
coagulopathy secondary to liver disease, leukemia or
myelosuppression.
27. Hereditary haemorrhagic
telangiectasia
(HHT)or Rendu–Osler–Weber disease, is an autosomal
dominant condition affecting blood vessels in the skin,
mucous membranes and viscera.
The classical features are telangiectasia, arteriovenous
(AV) malformations and aneurysms. Recurrent epistaxis
occurs in 93 percent of cases.
Management involves packing, cautery, antifibrinolytics,
systemic or topical oestrogens, coagulative lasers, septal
dermoplasty, ligation and embolization and, as a last
resort, permanent surgical closure of the nostrils
(Young’s operation)
29. Enquire about the use of nasal sprays as intranasal
steroid sprays can cause localized nasal mucosal trauma
often in the region of the anterior end of the inferior
turbinate which can give rise to epistaxis.
A concomitant vestibulitis should raise the suspicion of a
retained nasal foreign body.
Idiopathic thrombocytopoenic purpura (ITPP) may
present as epistaxis.
Nasal mycoses may need to be considered, particularly
in immunocompromised children, such as those
receiving chemotherapy.
30. Commonly used methods for the management of
recurrent epistaxis in children are
the prophylactic application of petroleum jelly to the nasal
vestibule and septum,
the use of topical antiseptic creams, and
cautery of Little’s area or the retrocollumellar veins.
If the bleeding is persistently from one side, often we
find either a leash of vessels around Little’s area on the
affected side or a prominent retrocollumellar vein
31. Cautery nowadays is most often undertaken using a silver
nitrate impregnated stick.
Petroleum jelly is thought to be effective because it forms a
water-resistant film over the affected area of mucosa.
In addition, antiseptic creams are thought to sterilize
localized infection in the region of the vestibule and the
nasal septum.
32. Summary:
First line: direct therapy (bipolar/cautery, endoscopic if
required);
Second line: indirect therapy (anterior packing);
Third line: surgical therapy (ESPAL);
Fourth line: angiography and embolization.
