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Causes, Work Up and Management of Epistaxis

1. Epistaxis can be caused by local factors in the nose like trauma, infections, or tumors, or by general medical conditions affecting blood pressure or coagulation. 2. Management involves first aid measures like applying pressure, followed by cauterization, nasal packing, or endoscopic procedures to locate and treat the source of bleeding. 3. For severe or recurrent bleeding, procedures like arterial ligation or embolization may be considered to permanently reduce blood flow if initial measures are unsuccessful.

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Farhan Afzal
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68 views6 pages

Causes, Work Up and Management of Epistaxis

1. Epistaxis can be caused by local factors in the nose like trauma, infections, or tumors, or by general medical conditions affecting blood pressure or coagulation. 2. Management involves first aid measures like applying pressure, followed by cauterization, nasal packing, or endoscopic procedures to locate and treat the source of bleeding. 3. For severe or recurrent bleeding, procedures like arterial ligation or embolization may be considered to permanently reduce blood flow if initial measures are unsuccessful.

Uploaded by

Farhan Afzal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Name : Farhan Afzal

Roll no: 270


Discipline: MBBS
Class : 4th year
Subject: ENT
Topic:
Causes , Work up and Management of
Epistaxis
Causes of Epistaxis:
They may be divided into:
1. Local, in the nose or nasopharynx.
2. General.
3. Idiopathic.
A. LOCAL CAUSES Nose
1. Trauma. Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third
of face and base of skull, hard-blowing of nose, violent sneeze.
2. Infections (a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis. (b) Chronic: All crust-
forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal
perforation, granulomatous lesion of the nose, e.g. rhinosporidiosis.
3. Foreign bodies (a) Nonliving: Any neglected foreign body, rhinolith. (b) Living: Maggots,
leeches.
4. Neoplasms of nose and paranasal sinuses. (a) Benign: Haemangioma, papilloma. (b)
Malignant: Carcinoma or sarcoma.
5. Atmospheric changes. High altitudes, sudden decompression (Caisson disease).
6. Deviated nasal septum. Nasopharynx 1. Adenoiditis. 2. Juvenile angiofibroma. 3.
Malignant tumours.

B. GENERAL CAUSES
1. Cardiovascular system. Hypertension, arteriosclerosis, mitral stenosis, pregnancy
(hypertension and hormonal).
2. Disorders of blood and blood vessels. Aplastic anaemia, leukaemia, thrombocytopenic
and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency and
hereditary haemorrhagic telangectasia.
3. Liver disease. Hepatic cirrhosis (deficiency of factor II, VII, IX and X)
4. Kidney disease. Chronic nephritis.
5. Drugs. Excessive use of salicylates and other analgesics (as for joint pains or
headaches), anticoagulant therapy (for heart disease).
6. Mediastinal compression. Tumours of mediastinum (raised venous pressure in the nose).
7. Acute general infection. Influenza, measles, chickenpox, whooping cough, rheumatic
fever, infectious mononucleosis, typhoid, pneumonia, malaria and dengue fever.
8. Vicarious menstruation (epistaxis occurring at the time of menstruation).

C. IDIOPATHIC
Many times the cause of epistaxis is not clear.
MANAGEMENT
In any case of epistaxis, it is important to know:
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding. DIFFERENCES BETWEEN ANTERIOR AND POSTERIOR
EPISTAXIS Anterior epistaxis Incidence Site Age Cause Bleeding More common Mostly from
Little’s area or anterior part of lateral wall Mostly occurs in children or young adults Mostly
trauma Usually mild, can be easily controlled by local pressure or anterior pack Posterior
epistaxis Less common Mostly from posterosuperior part of nasal cavity; often difficult to
localize the bleeding point After 40 years of age Spontaneous; often due to hypertension or
arteriosclerosis Bleeding is severe, requires hospitalization; postnasal pack often required
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukaemia, mitral valve disease,
cirrhosis and nephritis).
8. History of drug intake (analgesics, anticoagulants, etc.)

FIRST AID
Most of the time, bleeding occurs from the Little’s area and can be easily controlled by
pinching the nose with thumb and index finger for about 5 min. This compresses the vessels
of the Little’s area. In Trotter’s method patient is made to sit, leaning a little forward over a
basin to spit any blood and breathe quietly from the mouth

CAUTERIZATION
This is useful in anterior epistaxis when bleeding point has been located. The area is first
topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or
coagulated with electrocautery.

ANTERIOR NASAL PACKING


In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt
is made to localize the bleeding site. In minor bleeds, from the accessible sites,
cauterization of the bleeding area can be done. If bleeding is profuse and/or the site of
bleeding is difficult to localize, anterior packing should be done. For this, use a ribbon gauze
soaked with liquid paraffin. About 1 m gauze (2.5 cm wide in adults and 12 mm in
children) is required for each nasal cavity. First, few centimetres of gauze are folded upon
itself and inserted along the floor and then the whole nasal cavity is packed tightly by
layering the gauze from floor to the roof and from before backwards. Packing can also be
done in vertical layers from back to the front.

POSTERIOR NASAL PACKING


It is required for patients bleeding posteriorly into the throat. A postnasal pack is first
prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rubber
catheter is passed through the nose and its end brought out from the mouth. Ends of the
silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk
thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now
packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed
to hang in the oropharynx. It helps in easy removal of the pack later. Patients requiring
postnasal pack should always be hospitalized. Instead of postnasal pack, a Foley’s catheter
size 12-14 F can also be used. After insertion balloon is inflated with 5-10 mL of saline. The
bulb is inflated with saline and pulled forward so that choana is blocked and then an
anterior nasal pack is kept in the usual manner. These days nasal balloons are also
available.

ENDOSCOPIC CAUTERIZATION
Using topical or general anaesthesia, bleeding point is localized with a rigid endoscope. It is
then cauterized with a malleable unipolar suction cautery or a bipolar cautery. The
procedure is effective with less morbidity and decreased hospital stay. The procedure has
a limitation when profuse bleeding does not permit localization of the bleeding point.

Ligation of Vessels
1. External carotid. When bleeding is from the external carotid system and the conservative
measures have failed, ligation of external carotid artery above the origin of superior thyroid
artery should be done. It is avoided these days in favour of embolization or ligation of more
peripheral branches of sphenopalatine artery. 2. Maxillary artery. Ligation of this artery is
done in uncontrollable posterior epistaxis. Approach is via Caldwell-Luc operation.
Posterior wall of maxillary sinus is removed and the maxillary artery or its branches are
blocked by applying clips. This procedure is now superceded by transnasal endoscopic
sphenopalatine artery ligation. 3. Ethmoidal arteries. In anterosuperior bleeding above the
middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries,
which supply this area, can be ligated. The vessels are exposed in the medial wall of the orbit
by an external ethmoid (Lynch) incision.

Transnasal Endoscopic Sphenopalatine Artery Ligation (TESPAL)


The procedure can be done with rigid endoscopes under topical anaesthesia with sedation or
under a general anaesthesia. A mucosal flap is lifted in posterior part of lateral nasal wall,
sphenopalatine artery (SPA)is localized as it exits the foramen and closed with a vascular
clip. Distal branches of the artery can be additionally cauterized and the flap then
reposited. Anterior ethmoidal artery can also be ligated by Lynch incision as an adjunctive
procedure. SPA ligation gives high success in control of refractory posterior bleed.

Embolization It is done by an interventional radiologist through femoral artery


catheterization. Internal maxillary artery is localized and the embolization is performed with
absorbable gelfoam and/or polyvinyl alcohol or coils. Both ipsilateral or bilateral
embolizations may be required for unilateral epistaxis because of cross circulation.
Embolization is generally a safe procedure but may have potential risks like cerebral
thromboembolism, haematoma at local site. Ethmoidal arteries cannot be embolized.

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