Epistaxis
Greek term “ epistazo” means to bleed from noseBlood supply of the nasal septum
Woodruff`s plexus // posterior part of inf. Meatus
Kiesselbach`s plexus // ant. Part of the septum (Little`s area) 90%Epidemiology
Lifelong incidence of epistaxis in general populations is about 60%Fewer seek medical attendance
Peak incidence in children(2-5 yrs) & adult ( 50 -80 yrs).
AETIOLOGY
Aetiological factors
1.Idiopathic : 80%
2.Trauma : Digital, external nasal trauma or iatrogenic.
3.Coagulopathy : Idiopathic thrombocytopenia (ITP) Disseminated
intravascular coagulopathy (DIC) .
4.Drugs : Warfarin, aspirin, clopidogrel, (NSAIDs)
5.Chronic granulomatous disease : Wegener’s granuloma, sarcoidosis
6.Neoplastic: Angiofibroma, inverted papilloma, squamous cell cancer
7.Hereditary : Hereditary haemorrhagic telangiectasia (HHT), haemophilia,
Von Willebrand’s factor deficiency.
Aetiological associations
1.Septal abnormalities : Spurs, perforations2.Alcohol
3.Hypertension
Evaluation and Management
History and Physical Exam1. Age,
2. Amount of bl. loss ,onset duration,
intermittent or continuous , spontaneous or
induced, unilat or bilat. Bleeding from other site,
fainting , type of packs was previously used
indicate of severity .
3. Medical History and Blood disease ,blood
transfusion
4. Medications: antiplatelet , anticoagulants.
5. Social History: cocaine abuse, alcoholism, smoking
6. Family history , pregnancy
7. Toxin Exposure: ammonia, gasoline, phosphorus.
8. Other :trauma ,high altitude living ,allergy, sinusitis
rhinitis, URI
Physical Examination
• patient should sit up with body tilted forward• initial attempt to stop bleeding by applying pressure to nasal alae for several minutes
• decongestant/anesthetic agents .
• adequate lighting, nasal speculum, suctions machine ,attempt to
localize active bleeding (examine for abrasions, foreign bodies,
masses, sign of infection …etc.).
general ex. : vital signs ,pallor ,jaundice, ecchymosis, malena, haematuria, haemoptysis
• for chronic or recurrent epistaxis without an obvious bleeding source
patient should undergo an endoscopic exam
Investigations:
C.B.F. , E.S.R. , B/ FILM
Proth. time, partial thromboplastin time ,bleeding time and clotting time.
Liver enzymes( Liver function tests).
S. Fibrinogen ,ferritin .
Blood group
Clotting factors.
Renal function tests
Management
Control significant bleeding before lengthily historySteps:
1- first aids and resuscitations
2- localization of bleeding
3- control bleeding
4- assess blood loss.
5- prevention
First aids & resuscitation
ABCNeck should not be hyperextend to prevent blood flow into the stomach or possible aspiration.
Trotter`s method:
-- blood in mouth should not be swallowed.
-- mouth breathing.
-- direct pressure over the cartilaginous part of the nose for 5minutes is
usually sufficient
-- gauze moisten with epinephrine may be placed to promote
vasoconstriction
applying of pledge socked with anesthetic-vasoconstrictor solution into nasal cavity to anesthetize and shrink the mucosa.
Localization the site of bleeding ..
Cauterize the bleeding point with silver nitrate stick under L/A or electrocautery under local or general anesthesia.
If bleeding stops , blood sample should be sent for investigation and cross matching especially in sever cases.
Intravenous infusion to replace hypovolaemia
Antibiotics ,analgesia and sometime sedation may be essential.