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Epistaxis

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Epistaxis

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  1. Epistaxis Dr. Vishal Sharma

  2. Definition & Causes Bleeding from within the nasal cavity. Causes: 1. Idiopathic (55 %) 2. Local 3. General

  3. Local causes (nose & P.N.S.) Congenital: hereditary telengiectasia Trauma: nose picking, injury to nose / face / skull base, nasal surgery, foreign body Infection: vestibulitis, sinusitis, atrophic rhinitis, rhinosporodiosis, rhinoscleroma Neoplasms: angiofibroma, hemangioma, inverted papilloma, malignancy Deviated nasal septum (spur)

  4. General causes • Hypertension • Bleeding disorders: haemophilia, thrombocytopenia, leukemia • Drugs: aspirin, anticoagulants • Physiological: cold + dry climate, high altitude, vicarious menstruation, violent exertion, barotrauma • Liver failure • Exanthematous fevers

  5. Common causes of epistaxis • Child: nose picking, foreign body, exanthematous fever • Adolescent: nasopharyngeal angiofibroma, trauma, sinusitis • Adults: sinusitis, trauma • Elderly: hypertension, malignancy

  6. Common sites of epistaxis • Little’s area (80-90 %): Kiesselbach’s arterial plexus at antero-inferior part of septal cartilage. Common in children. • Woodruff’s venous (?) plexus: near posterior end of middle turbinate. Common in elderly, hypertensives. • Retro-columellar vein: common in adults.

  7. Common sites of epistaxis

  8. Common sites of epistaxis

  9. Evaluation of pt. with epistaxis • mode of onset, duration, frequency, amount, side, site, previous bleeding • nasal trauma, purulent nasal discharge • hypertension, hepatic diseases, family history of bleeding, bleeding from other sites, use of anticoagulants, aspirin • measurement of pulse & blood pressure

  10. Investigations • Hemoglobin, Packed Cell Volume • Blood grouping & cross-matching • Bleeding Time, Clotting Time • Activated Partial Thromboplastin Time • Prothrombin Time • Platelet count • Diagnostic Nasal Endoscopy (D.N.E.) • C.T. scan paranasal sinus

  11. General treatment • Record pulse & blood pressure • Reassurance + bed rest in sitting posture with back rest • Adequate sedation (Diazepam) • Inj. Ethamsylate 500 mg IV Q8H • Amlodipine / Nifedipine for hypertension • IV fluids / blood transfusion for shock

  12. Anterior epistaxis • Pinch nostrils + ice pack  Bleeding continues • Insert cotton pledgets soaked in 1: 1000 adrenaline in nasal cavity  Bleeding continues • Chemical cautery with AgNO3 or electrical cautery (if bleeder is localized) or anterior nasal packing

  13. Trotter’s method Elderly pt in sitting position, leaning forward, mouth open allowing bleeding to continue till hypotension develops. May lead to coronary thrombosis + death.

  14. Adrenaline soaked pledget

  15. Chemical cautery

  16. Anterior nasal packing Anterior nasal packing for 48-72 hrs  antibiotic cover with: • Liquid paraffin + antibiotic cream gauze • Vaseline gauze • Bismuth Iodoform Paraffin Paste gauze • Merocel tampoon • Simpson balloon

  17. Anterior nasal gauze packing

  18. Anterior nasal gauze packing

  19. Anterior nasal gauze packing • Ribbon gauze soaked with liquid paraffin + antibiotic cream used. • Both nasal cavities packed tightly by layering from floor to roof. Pack removed after 48 hrs. • Systemic antibiotics given to prevent sinus infection & toxic shock syndrome.

  20. Merocel nasal tampoon

  21. Simpson’s nasal balloon

  22. Posterior epistaxis • Posterior + anterior nasal packing for 48-72 hrs  antibiotic cover with: • Post nasal gauze pack • Foley’s catheter • Brighton balloon (double lumen) • Epistat balloon (double lumen) • Bivona balloon (triple lumen)

  23. Antero-Posterior Nasal Packing with gauze pack

  24. Posterior nasal gauze pack

  25. Catheter introduction

  26. Tying of pack to catheter tip

  27. Guiding pack into nasopharynx

  28. Tying of anterior strips

  29. Anterior nasal packing

  30. Outer nasal packing

  31. Posterior nasal packing • Post nasal pack prepared by tying 3 ribbon gauze strips to piece of gauze roll • 2 Foley’s catheters passed through each nostril & their ends brought out via mouth • 2 ends of gauze strips attached to nasal pack tied to catheter tips & withdrawn from nose

  32. Posterior nasal packing • Pack that follows ribbon gauze strips, is guided into nasopharynx with index finger. • Anterior nasal packing done. 2 ribbon gauze strips tied over a gauze piece on columella. • 3rd gauze strip brought out from mouth & taped to cheek. Pack removed after 48-72 hr.

  33. Antero-Posterior Nasal Packing with Foley’s catheter

  34. Foley’s catheter

  35. Catheter introduction

  36. Catheter tip in nasopharynx

  37. Anterior nasal packing

  38. Brighton’s nasal balloon

  39. Epistat nasal balloon

  40. Bivona triple lumen catheter

  41. Epistaxis set

  42. Surgical intervention for refractory epistaxis

  43. 1. Arterial ligationby external approach • external carotid artery: ligated in neck, distal to superior thyroid artery • internal maxillary artery: ligated in pterygo- palatine fossa (Caldwell-Luc opn) • anterior or posterior ethmoidal artery: ligated in orbit (Lynch-Howarth incision)

  44. External Carotid ligation

  45. 2. Angiography and embolization 3. Submucosal Resection of septum 4. Septo-dermoplasty: for hereditary telengiectasia 5. Endoscopic cautery & clipping:  Sphenopalatine artery  Anterior or posterior ethmoidal artery

  46. Angiography + embolization

  47. Endoscopic clipping