EPISTAXIS

Dr SS Nayyar, MS ENT
www.nayyarENT.com

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EPISTAXIS
 BLEEDING FROM INSIDE THE NOSE.

 VERY COMMON– 60-70% OF POPULATION.

 SEVERITY VARIES – FEW DROPS TO
TORRENTIAL.

 BE MENTALLY PREPARED TO DEAL WITH
SEVERE EPISTAXIS.

EPISTAXIS
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BLOOD SUPPLY – IMP. POINTS
 Both ECA AND ICA systems.
 Predominantly- ECA.

 Middle turbinate virtually acts as a rough dividing
line between ECA/ ICA systems.

 Arterio- arterial anastamoses+, which might lead to
failure of ligation of ECA.

 Retrocollumellar venous bleeding can be significant.
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BLOOD SUPPLY - SEPTUM
Sphenopalatine
Artery &
Branches
Septal Branches
of Superior
Labial Art
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BLOOD SUPPLY - LAT WALL OF NOSE
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Woodruff’s
Plexus
Little’s Area
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AETIOLOGY
 LOCAL
 Trauma---- picking, #s of nose/ maxillo-facial
region, hard blowing/ sneezing.
 Infections – Acute: URTIs, Sinusitis,Vestibulitis.
-- Chronic:Atrophic rhinitis, Rh sicca, TB,
Syphilis, Rhinosporiodiosis.
 Foreign Bodies- animate/ inanimate.
 DNS, Polypi.
 Tumours – Juvenile nasopharyngeal angiofibroma
(JNA), others – papilloma,haemangioma,Ca
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AETIOLOGY
 GENERAL
 Hypertension
 Bleeding disorders – coagulopathies,
thrombopathies.
 Chronic Liver Disease/ Renal disease.
 Drug induced.
 Severe infections.
 ENVIRONMENTAL – High altitude, dry weather.
 IDIOPATHIC
 CONGENITAL- Osler’s disease
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CLASSIFICATION/ TYPES OF
EPISTAXIS
 ANTERIOR
 More common
 Site – generally Little’s area
or antero-lat wall.
 Age – generally children/
young
 Cause– commonly trauma.

 Bleeding – mild, local
pressure/ ant pack suffice
 POSTERIOR
 Less common
 Postero- superior, difficult to
localise
 > 40 yrs

 Spontaneous – hypertension/
arteriosclerosis
 Severe, both ant/ post packs may
be reqd.

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HISTORY TAKING IN EPISTAXIS
 How frequent? Last episode?
 How much? Quantify – in equivalents.
 Which side? Anterior / posterior?
 How does it stop?
 Colour of blood? Does it drip drop by drop or is it brown and
vomited out?
 Any drugs being taken?
 Any recent or current infection?
 Any recent RTA / Head injury?
 Any bleeding from other sites ?
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INVESTIGATIONS
 Hb %, TLC, DLC
 BT, CT
 PT/PTT
 Platelet count
 Blood grouping – cross matching
 ECG – where required
 X Rays
CT
MRI
Angio
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BLOOD STAINED RHINORRHEA IN HEAD
INJURY
 Lean patient forward for many minutes
 Presence of sugar
 Halo sign
 Beta-2 Transferrin analysis*

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MANAGEMENT
 Effective history taking
 Simultaneous preparation for treatment continues
 No panic – but urgency ++
 Check Pulse, BP – ABC initially; i.v. fluids
 Mild, anterior bleeding – pinch nostrils tight, ice to
suck/packs
 No Adrenaline packs
 Site seen – cauterise (chemical /electro cautery)
under LA
 If severe – anterior nasal packing
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MANAGEMENT
ANT NASAL
PACKING
.1.25 cm gauze strip
in BIPP/liquid
paraffin/Neosporin
.Merocel
.Observe patient
.If nasoph trickle +
--- OT under
controlled
conditions – Ant /
Post packing
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ANT NASAL PACK
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MANAGEMENT (contd)- Nasal packing
 Respect nasal mucosa’s integrity
 Technique – Anterior & Posterior Nasal packing
 Foley’s catheter 12/14Fr
 Epistaxis catheters
 Antibiotic cover, Sedation
 Removal – 24-48 hours
 Severe bleeding on removal
 Re-pack
 Ligation of feeding vessels
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COMMERCIAL MEROCEL PACKS
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POSTERIOR NASAL PACK
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ENDOSCOPIC
VISUALISATION
EPISTAXIS
BALLOON
CATHETER
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MANAGEMENT contd..- Ligation&
Embolisation
 Ligation
 Ethmoidal vessels – medial orbital incision
 Maxillary artery – Caldwell Luc’s approach
 ECA ligation – if required
 Embolisation
 Gel sponge/beads/desiccated dura
 In severe recurrent bleeds
 Embolisation of ICA branches – dangerous
 Embolise and then ligate
 Rare treatments for haemorrhagic telangiectasia
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THANK YOU

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