Epistaksis

Dr. dr. Abd. Qadar Punagi, Sp.T.H.T.K.L(K), FICS

Department of ENT-Rhinology,
Medical Faculty of Hasanuddin University
Epistaksis

• Nose bleeds

• Perdarahan hidung

• Mimisan
Etiologi

• Faktor lokal → Trauma, Vascular abnormalies,

infectious/inflammatory states, iatrogenic (nasal surgery), neoplasm
(JNA), desiccation, Drugs(warfarin, aspirin, cocaine) and foreign
bodies.

• Faktor sistemik → hypertension, atherosclerosis,

infectious/inflammatory diseases, blood dyscrasias, platelet
deficiencies or dysfunction, coagulopathies, kidney and liver disease.
Histori Pasien
• Previous bleeding episodes
• Nasal trauma
• Family history of bleeding
• Hypertension - current medications and how tightly controlled
• Hepatic diseases
• Use of anticoagulants
• Other medical conditions - DM, CAD, etc.
Anatomy
• ICA (branches of ophthalmic)
• Anterior ethmoid – supplies lateral wall of nose, nasal septum, nasal tip
• Posterior ethmoid – posterior lateral wall of nose, superior turbinate and sup
septum

• ECA (branches of internal maxillary)

• sphenopalatine – supplies the posterior septum, posterior middle and superior
turbinates
• Descending palatine – lower midseptum
• Superior labial (facial artery) anterior septum
Nasal Septal Blood Supply
Posisi

• ANTERIOR → littles area / Kiesselbach’s

• POSTERIOR → Woodruff’s
Vascular anatomy of the
medial and lateral nasal
walls
What is wrong with this picture?

The anterior and posterior ethmoidal come through the ethmoid sinuses, not from the skull base.
Little's (Kiesselbach's) Area

• 1/2 inch from the caudal border of the septum antero-inferiorly.

• Vessels anastomosing are; Anterior ethmoid, greater palatine, and

sphenopalatine, and septal branch of superior labial.

• Bleeding may be arterial or venous.

Little’s area

Confluence of :
• Anterior Ethmoidal a.

• Greater Palatine a.

• Sphenopalatine a.

• Sup. Labial a.
Physical Exam

• Measure blood pressure and vital signs

• Apply direct pressure to external nose to decrease bleeding

• Use vasoconstricting spray mixed with tetracaine in a 1:1 ratio for

topical anesthesia

• Identify the bleeding source

Physical Exam - Equipment

• Protective equipment - • Bayonet forceps

gloves, safety goggles • Tongue depressor
• Headlight if available • Vasoconstricting agent (such
• Nasal Speculum as oxymetazoline)

• Suction with Frazier tip • Topical anesthetic

Local Causes of Epistaxis
• Nasal trauma (nose picking, foreign
bodies, forceful nose blowing)
• Allergic, chronic or infectious rhinitis
• Chemical irritants
• Medications (topical)
• Drying of the nasal mucosa from low
humidity
• Deviation of nasal septum or septal
perforation
• Bleeding polyp of the septum or
lateral nasal wall (inverted papilloma)
• Neoplasms of the nose or sinuses
• Tumors of the nasopharynx especially
Nasopharyngeal
Angiofibroma
• Vascular
malformation
Systemic Causes of Epistaxis
• Systemic arterial hypertension
• Endocrine Causes: pregnancy, pheochromocytoma
• Hereditary hemorrhagic telangectasias
• Osler Rendu Weber Syndrome
• Anticoagulants (ASA, NSAIDS)
• Hepatic disease
• Blood diseases and coagulopathies such as
Thrombocytopenia, ITP, Leukemia, Hemophilia
• Platelet dysfunction
Drugs!
• Thrombocytopenia: chemotherapy, quinidine, sulfa preparations, H2 blockers,
oral antidiabetic agents, gold salts, rifampin, heparin, alcohol

• Affecting coagulation pathway: Warfarin, Heparin

• Affecting platelet function: Aspirin, clopidogrel, nsaids

• Herbs that may cause bleeding: Dong quai, Danshen,

Feverfew, Garlic, Ginger, Gingko, Ginseng
Local Causes

• [4] Neoplasms:
Carcinom of the Nasopharynx
• Of the
• nose,

• nasopharynx and

• sinuses.

Angiofibroma
Local Causes

• [4] Miscellaneous:

• Septal spur,

• foreign bodies
Most Common Causes of Epistaxis
• Disruption of the nasal mucosa - local trauma, dry environment, forceful
blowing, etc.
• Facial trauma
• Scars and damage from previous nosebleeds that reopen and bleed
• Intranasal medications or recreational drugs
• Hypertension and/or arteriosclerosis
• Anticoagulant medications
Types of Nosebleeds

ANTERIOR

• Most common in younger population

• Usually due to nasal mucosal dryness

• May be alarming because can see the blood

readily, but generally less severe

• Usually controlled with conservative measures

Types of Nosebleeds

POSTERIOR

• Usually occurs in older population

• May also have deviation of nasal septum

• Significant bleeding in posterior pharynx

• More challenging to control

Therapeutic Equipment to be Available

• Variety of nasal packing materials

• Silver nitrate cautery sticks

• 10cc syringe with 18G and 27G 1.5inch needles

• Local anesthetic

• Gelfoam, Collagen absorbable hemostat, Surgical or other

hemostatic materials.
General Epistaxis Supplies
Packing Tray
Management Epistaxis

• Nasal cautery: chemicals or electrical

• Nasal packs

• Types

• Surgery

• Embolization
Packing materials

• Vaseline Gauze

• Merocel - polyvinylchloride

• Surgicel – oxidized cellulose

• Gelfoam – purified pork skin gelatin

Treatment of Anterior Epistaxis
• Localized digital pressure for minimum of 5-10 minutes, perhaps up to 20
minutes
• Silver nitrate cautery - avoid cautery of bilateral nasal septum as this may lead
to necrosis and perforation of the septum
• Collagen Absorbable Hemostat or other topical
coagulant
• Anterior nasal packing for refractory epistaxis - may use
expandable sponge packing or gauze packing
Anterior Epistaxis – Tips
• Spray mucosa with co-phenylcaine spray
• Insert co-phenylcaine on cotton wool
• Wait 10 minutes
• Apply silver nitrate to source of bleeding
• May need to repeat above sequence
• Packing occasionally needed for support
• Suction very useful
• Send home with
ointment
Traditional Anterior Pack

Usually, 1/2 inch Iodiform or NuGauze is used.

Coat the gauze with a topical antibiotic ointment prior to placement.
Other Anterior Nasal Packs

• Formed expandable sponges are very

effective

• Available in many shapes, sizes and

some are impregnated with antibacterial
properties
Correct direction for placement of nasal packing
CAUTERIZATION

• Chemicals;
• Silver Nitrate stick, chromic acid bead.

• Electrical
• Apply ointment and advise against blowing and nose picking.
Posterior Epistaxis

• Unable to visualize bleeding site

• Can lose large volume quickly

• Treatment options:
• Posterior/anterior pack

• Nasal endoscopy with cauterization

• Artery ligation
Sphenopalatine foramen

The sphenopalatine foramen is located behind the posterior end of

the middle turbinate and is formed by the following structures:
• Superiorly : Sphenoid bone.

• Posteriorly : Sphenoid process of the palatine bone.

• Anteriorly : Ethmoid process of the palatine bone.

• Inferiorly : Palatine bone.

Arterial supply from the sphenopalatine artery with posterior
portion of middle turbinate have been removed.

Werner Hosemann, 2005

The distribution of nerve and arterial branches medial and
lateral to the sphenopalatine foramen

Werner Hosemann, 2005

 Schematic sagital view of right sphenopaltine foramen. (Reda Kamel, 2004)

Endoscopoic view of the sphenopalatine foramen where sphenopalatine nerve and

artery emanate. (Paolo Castelnuovo, 2005)
 Identification of sphenopalatine artery

Located directly dorsal to the posterior insertion

of the middle turbinate

Crista ethmoidalis as a landmark, which is. This allows the terminal

branches of the sphenopalatine artery to be exposed and identified.
Treatment of Posterior Epistaxis

• IV pain medication and antiemetics may be helpful

• Use topical anesthetic and vasoconstrictive spray for improved

visualization and patient comfort

• Balloon-type episaxis devices often easiest

• Foley catheter or other traditional posterior packs may be

necessary
Traditional Posterior Pack
(Bellocq’s tampon)
 Raza M. Jafri, FRCS
docraza@khi.comsats.net.pk
 Raza M. Jafri, FRCS
docraza@khi.comsats.net.pk
Posterior Balloon Packing

• Always test before placing in patient

• Fill “balloons” with water, not air

• Orient in direction shown

• Fill posterior balloon first, then anterior

• Document volumes used to fill balloons

Posterior pack
Duration of Packing Placement

• Actual duration will vary according to the patient’s particular needs.

• Typically, anterior pack at least 24-48 hours, sometimes longer.

• Posterior pack may need to remain for 48-72 hours. If a balloon

pack is used, advised tapered deflation of balloons - most
successful when volume is documented.
Complications of packing

• Toxic shock

• Ulcerations

• Nasopulmonary reflex
Other Treatments for Refractory Epistaxis
• Greater palatine foramen block
• Septoplasty
• Endoscopic cauterization
• Selective embolization by
interventional radiologist
• Internal maxillary artery ligation
• Transantral sphenopalatine artery
ligation
• Intraoral ligation of the maxillary
artery
• Anterior and posterior ethmoid
artery ligation
• External carotid artery ligation
Greater Palatine Foramen Block
• Mechanism of action is volume compression of
vascular structures

• Lidocaine 1% or 2% with epinephrine 1:200,000

used or Lidocaine with sterile water.

• Do not insert needle more than 25mm

Surgical/invasive management

• Selective arterial embolization

• Posterior endoscopic cautery

• Internal maxillary artery ligation

• Ethmoid artery ligation

Sethi Wormald
Operasi
Operasi Post operasi
Operasi
Operasi Post operasi
Other Treatments

• Ligation of vessels
• Maxillary artery
• Ethmoid arteries
• External Carotid artery

• Catheters with iced water lavage

• 2% lignocaine and adrenaline injection in greater

palatine foramen