Lecture (3) 16/10/2018 د.عماد ناظم الكواز
The Nose
Epistaxis
Definition : Bleeding per nose. It is a known disease of unknown aetiology.Classification of epistaxis: It is either:
Anterior epistaxis:Most common.
It arises from Little,s area .
It occurs in young and middle aged patients.
The bleeding is trivial, easy to stop and tends to recur.
Posterior epistaxis:
Its less common.
It arises far back in the nose , blood may flow to the pharynx & if it swallowed the patient will vomit blood & mis-diagnosed as upper GIT bleedind .
It occurs in elderly hypertensive patients.
The bleeding is profuse and difficult to stop.
Causes:
Local causes
Idiopathic : Commonest cause 90%
Trauma:Accedintal injury (Nose picking,Fructure,FB) or nasal surgery.
Inflammatory: Rhinitis, Sinusitis .
Neoplastic: Nasal tumours( hemangioma , carcinoma), Postnasal tumour ( angiofibroma, carcinoma).
Miscellaneous: Septal deviation may disturb air flow resulting in mucosal drying and epistaxis or kinking & streching the blood vessels.
General causes
Cardiovascular : Hypertension: the nasal mucosa is often atrophic and cracks easily which eventually leads to exposure of the arteriosclerotic vessel producing severe bleeding during a hypertensive episode.Haematologicl : Haemophilia, leukaemia and ITP.
Hepatic : liver failure
Drugs: antiplatlete as aspirin and anticoagulants as warfarin.
Management of epistaxis (FACT)
FIRST AID :Patient placed in sitting position & leaning foreward.
Pinch the nostriles between 2 fingers.
The patient is instructed to breath quietly through the mouth , spit & not swallow the blood.
Cold compresses: Apply ice packs over the nasal bridge and forehead.
ASSESSMENT :
History :
Bleeding is unilateral or bilateral.
Recurrent or not.
History of trauma or systemic diseases as hypertension, hepatic diseases.
Drug history : aspirin , warfarin .
Examination:
Side of bleeding : unilateral / bilateral.Site of bleedind :
Antero-inferior (little's area).
Antero-superior ( above middle turbinate).
Postero-inferior ( below middle turbinate).
Severity & Shock: Hypotension, tachycardia, tachypnea, cold clammy sweaty skin, oligurea,restlessness & irritability.
Investigations:
Send for investigations according to the possible causes:Coagulation profile,CBP,CT scan of nasal cavity (the investigations can be postponed after stabilisation of the patient).
CONTROL OF BLEEDING :
Mild epistaxis :Cauterization :
Anterior epistaxis : Either chemical (silver nitrate , trichloracetic acid) or electrocautery.
Posterior epistaxis: Endoscopic assisted electrocautery.
Nasal packing : if cautarization failed.
Sever epistaxis:
Nasal packing : either
Anterior nasal pack :
Ribbon gauze soaked with vasaline and antibiotic ointment.
Arranged in layers in the nasal cavity from below upwards.
The pack is left for 48 hours.
Posterior nasal pack :If anterior pack failed & for posterior epistaxis.
Under GA.Further anterior pack is placed against the posterior pack.
The posterior pack stays in place for 48 hours.
Systemic antibiotics should be used to prevent secondary bacterial infection as sinusitis and otitis media.
SHAPE \* MERGEFORMAT
Surgery :
If packing is failed to stop bleeding.According to the possible source of bleeding
Maxillary artery ligation.
Ethmoidal arteries ligation
External carotid artery ligation less likely because of collateral circulation.
Enodovascular embolization Perform angiography to detrmine the feeding vessls then do embolization using (polyvinyl alcohol,steel microcoil).
TREATMENT OF UNDERLYING CAUSES:
Control of BP, treatment of bleeding tendency accordingly and surgical corection of deviated septum or tumours.TREATMENT OF SHOCK:
Bed rest with head down and lower limb elevation.Establishment of I.V. Line .
Send blood sample for cross match and compatability and prepare blood.
I.V. Fluid replacemrnt : fresh blood.
Warming the patient.