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Page 1: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

EPISTAXIS

Page 2: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Introduction and History5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”A condition with a long history—Hippocrates to Henry Goodyear.

Page 3: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Anatomy/Physiology of EpistaxisAnatomy

Nasal cavityVascular supply

PhysiologyVascular natureMucosa

Page 4: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Why bleeding from the nose ? Vascular organ secondary to incredible

heating/humidification requirementsVasculature runs just under mucosa (not squamous)Arterial to venous anastamosesICA and ECA blood flow

Page 5: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Anatomy of the Lateral Nasal Wall

SPF

-class I (35%)

-class II (56%)

-class III (9%)

Page 6: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

External Carotid Artery

-Sphenopalatine artery

-Greater palatine artery

-Ascending pharyngeal artery

-Posterior nasal artery

-Superior Labial artery

Internal Carotid Artery

-Anterior Ethmoid artery

-Posterior Ethmoid artery

Page 7: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Pterygopalatine Vasculature

--Internal maxillary artery

Page 8: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Anatomy of the Nasal Cavity and Vasculature

Page 9: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Sphenopalatine AA

Ethmoid AA

Greater Palatine A

Page 10: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those
Page 11: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those
Page 12: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Kesselbach’s Plexus/Little’s Area:

-Anterior Ethmoid (Opth)

-Superior Labial A (Facial)

-Sphenopalatine A (IMAX)

-Greater Palatine (IMAX)

Woodruff’s Plexus:

-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX)

Page 13: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those
Page 14: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Anterior vs. PosteriorMaxillary sinus ostiumAnterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severePosterior: older population, usually from Woodruff’s plexus, more serious.

Page 15: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

EtiologyLocal factors

VascularInfectious/InflammatoryTrauma (most common)IatrogenicNeoplasmDessicationForeign Bodies/other

Page 16: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

EtiologySystemic factors

VascularInfection/InflammationCoagulopathy

Page 17: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors -- Vascular

ICA Aneurysms extradural cavernous sinus

Page 18: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors - Infection/Inflammation

Rhinitis/SinusitisAllergicBacterialFungalViral

Page 19: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors - TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses, orbits, middle ear, base of skullBarotrauma

Page 20: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Nasal Fracture with Septal Hematoma

Page 21: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgeryRhinoplastyNasal reconstruction

Page 22: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors - NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphoma

Page 23: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those
Page 24: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors – Dessication

Cold, dry air—more common in wintertimeDry heat—Phoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitis

Page 25: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Local Factors - Other

Self-inflicted (pedi) vs. traumatic foreign bodiesIntranasal parasitesSeptal perforationChemical (cocaine, nasal sprays, ammonia, etc.)

Page 26: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Systemic Factors -- Vascular

Hypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias (OWR)

Page 27: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Systemic Factors – Infection/Inflammation

TuberculosisSyphillisWegener’s GranulomatosisPeriarteritis nodosaSLE

Page 28: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Systemic Factors – Coagulopathies Thrombocytopenia

Platelet dysfunctionSystemic disease (Uremia)drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor DeficienciesHemophiliaVonWillebrand’s diseaseHepatic failure

Hematologic malignancies

Page 29: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Etiology and AgeChildren—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o)Adults—trauma, idiopathicMiddle age—tumorsOld age--hypertension

Page 30: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Initial ManagementABC’s

Medical history/Medications

Vital signs—need IV?

Physical examAnterior rhinoscopy

Endoscopic rhinoscopy

Laboratory exam

Radiologic studies

Page 31: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

suction

good lightanesthetic

silver nitrate

merocels

gelfoam

bacitracin

endoscopes

suction bovie/bipolar

Afrin

T.C.A.

surgicel

epistat

bayonet forceptsvaseline gauze

Page 32: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Non-surgical treatments Control of hypertension

Correction of coagulopathies/thrombocytopenia FFP or whole blood/reversal of anticoagulant/platelets

Pressure/Expulsion of clots

Topical decongestants/vasocontrictors

Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie)

Nasal packing (effective 80-90% of time)

Greater palatine foramen block

Page 33: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Non-surgical treatments – on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrest

Page 34: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Nasal packsAnterior nasal packs

TraditionalRecent modifications

Posterior nasal packsTraditional Recent modifications

Ant/Post nasal packing

Page 35: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Pick a Pack, any pack

Page 36: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Pick a pack to pack with

Page 37: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

TSS—Nugauze vs. Merocel

Electron microscopy

Page 38: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Posterior Packs – Admission Elderly and those with other chronic diseases may need to be admitted to the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVF

Page 39: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Indications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of <38% (barlow)Nasal anomaly precluding packingPatient refusal/intolerance of packingPosterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

Page 40: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Selective Angiography/embolizationHelps identify location of bleedingEmbolization most effective in patients who

Still bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min90+% success rate, complication rate of 0.1%Only able to embolize external carotid & branchesComplications: minor (18-45%)/major (0-2%)Contraindicated in bad atherosclerosis, Ethmoid bleed

Page 41: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Surgical treatment

Transmaxillary IMA ligation

Intraoral IMA ligation

Anterior/Posterior Ethmoidal ligation

Transnasal Sphenopalatine ligation

External carotid artery ligation

Septodermoplasty/Laser ablation

Page 42: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Transmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA --descending palatine & sphenopalantine most importantRecurrence rate (failure rate) of 10-15%Complication rate of 25-30% (oa fistula,dental, n)

Page 43: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those
Page 44: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Intraoral IMA ligationPosterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized, clipped and dividedAdvantages: children/facial fracturesDisadvantages: more proximal ligationComplications: trismus, damage to infraorbital n

Page 45: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Ant./Post. Ethmoidal ligationPatients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclearLynch incisionFronto-ethmoid

suture line12-24-6

(14-18, 8-10, 4-6)

Page 46: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Transnasal Endoscopic Sphenopalatine Artery ligation

Follow Middle Turbinate to posteriormost aspectVertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs)Elevation of flap—ID neurovascular bundle at foramenLigation with titanium clipReapproximate flapComplications –few, Failures—0-13%

Page 47: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Transnasal Spheno-palatine Artery ligation

Page 48: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

ECA ligationEffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are safe.

Page 49: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Septodermoplasty/LaserRemove mucosa from anterior ½ septum, floor of nose, lateral wallSTSG vs. cutaneous, myocutaneous, microvascular free flaps vs. AutograftsNeodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod diseaseStill bleed, but not as badDefinitive treatment (severe disease)—closure of nose

Page 50: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Statistically speaking,….Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.Others compared all medical treatment to surgery and showed cost cut using medical management.Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%Cost analysis: IMAX vs. Embolization vs. Surgical Cautery—about equalFailure rates: PP-30%, Sx-17%, Emb-4%

Page 51: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Tips and PearlsRed rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more (not on both sides of septum)Antihistamines to prevent rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels (2 or more) injected with cortisporin oticAmicar spray

Page 52: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Tips and PearlsHot water irrigationCold water irrigationSalt PorkDon’t pack nose in unconscious person with suspected skull fractures.Antibiotic cream vs. silver nitrateIntranasal pressureEstrogen cream to nasal septum

Page 53: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Tips and PearlsTransnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed)Submucosal supraperichondrial dissection of nasal septumNot all hospitals have embolization-trained interventionalistsNo hard-set outline. Do what is best for your particular patient

Page 54: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

CASE REPORT45 yo Vietnamese fisherman--stable, but uncomfortableProfuse nasal bleeding since 0200 this a.m.History: No known medical problems. Drinks 6-12 beers/day. Takes no medications. No history of easy bleeding. No family history.Physical exam: Profuse bleeding from both nostrils L>R and bleeding down the back of his throat—coughing up clots. Unable to locate precise location of bleed—appears to be posterior/superior.

Page 55: EPISTAXIS. Introduction and History 5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those

Case 1 – cont’dHgb 12.5Lactated Ringers IVF bolusNasal packs – removed two days later in the clinic,…rebleeds.Requires transfusion for Hgb of 6.5Angiography—no obvious bleed/EmbolizationAnt/Post Ethmoid Artery ligation


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