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Epistaxis

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Epistaxis

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  1. Epistaxis Dr. Abdussalam M jahan ENT depart, Misurata university, faculty of medicine

  2. Arterial supply of the septum

  3. Kiesselbach’s Plexus/Little’s Area: -Anterior Ethmoid (ICA) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX) Woodruff’s Plexus: - Sphenopalatine A (Pharyngeal & Post. Nasal branches) (IMAX) -Posterior ethmoid (ICA)

  4. Classification: • Anterior epistaxis (90%) • Bleeding from Little’s area. • Controlled by an anterior pack • Younger patients • Posterior epistaxis (10%) • Occurs in the area of Woodruff’s plexus • Older patients • Epistaxis not controlled by anterior nasal packing.

  5. Local Factors - Inflammation Etiology: • URI • allergic rhinitis • Sinusitis Increased vascularity and greater friability of vessels in inflamed mucosa

  6. -Trauma • Nose picking • Nose blowing/sneezing • Nasal fracture • Nasogastric/nasotracheal intubation • Trauma to sinuses, orbits, middle ear, base of skull • Barotrauma

  7. -Iatrogenic nasal injury • Functional endoscopic sinus surgery • Septoplasty or Rhinoplasty • Nasal reconstruction

  8. -Neoplasm • Juvenile angiofibroma • Inverted papilloma • SCCA • Adenocarcinoma • Melanoma • Lymphoma

  9. -Others: • Cold, dry air—more common in wintertime • Dry heat. • Anatomic abnormalities (ie: nasal septal deformity - turbulent flow (dry mucosa leading to crusting) • Atrophic rhinitis

  10. foreign bodies • Intranasal parasites • Septal perforation • Chemical (cocaine, nasal sprays, ammonia)

  11. Systemic factors • Vascular. • Infection/Inflammation. • Coagulopathy.

  12. :- Vascular • Hypertension • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) • subepidermal vessels lacking elastic tissue in capillary wall and deficiency of smooth muscle

  13. – Infection/Inflammation • Tuberculosis • Syphillis • Wegener’s Granulomatosis • Periarteritis nodosa • SLE

  14. – Coagulopathies • Primary coagulopathies (hemophilia, von Willebrand’s disease, thrombocytopenia and polycythemia vera). • Secondary coagulopathies (uremia, alcoholism, chronic liver disease, leukemia, myeloma, aplastic anemia, idiopathic thrombocytopenis purpura or hypovitaminosis). • Iatrogenic coagulopathies (heparin)

  15. Etiology and Age • Children - foreign body, nose picking • Adults - trauma, idiopathic • Middle age - tumors • Old age - hypertension

  16. Management: • Initial Management: • ABC’s. • Vital signs—need IV. • Medical history/Medications. • Labs. • Physical exam – • Rhinoscopy

  17. Exam and treatment options

  18. Non-surgical treatments • Topical decongestants/vc. • Cautery (AgNo3) • Nasal packing. • Control of hypertension • Correction of: coagulopathies/thrombocytopenia

  19. Nasal packing: • Anterior nasal packs • Traditional • Recent modifications • Posterior nasal packs • Traditional • Recent modifications

  20. Packing

  21. Posterior Packs – Admission • Elderly and those with other chronic diseases may need to be admitted to the ICU • Continuous cardiopulmonary monitoring • Antibiotics • Oxygen supplementation may be needed • Mild sedation/analgesia • IVF

  22. Discharge instructions • Humidity/emolients • Nasal saline sprays • Avoidance of nose picking/blowing • Sneeze with mouth open • Avoid straining • Avoid hot/spicy food

  23. Indications for surgery: • Continued bleeding despite nasal packing • Nasal anomaly interfering withpacking • Patient refuse/intolerance of packing • Posterior bleeding with failed non surgical treatment after >72hrs

  24. :Surgical treatment • Transmaxillary IMA ligation • Transnasal Sphenopalatine ligation • External carotid artery ligation • Anterior/Posterior Ethmoidal A. ligation Last one

  25. The end www.zahrawi.ly