EPISTAXIS

Glen Porter, MD Francis B. Quinn, MD UTMB-Galveston Galveston, Texas

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 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 historyHippocrates to Henry Goodyear.

Anatomy/Physiology of Epistaxis
Anatomy
Nasal cavity Vascular supply

Physiology
Vascular nature Mucosa

Why bleeding from the nose ?

Vascular organ secondary to incredible heating/humidification requirements Vasculature runs just under mucosa (not squamous) Arterial to venous anastamoses ICA and ECA blood flow

SPF -class I (35%) -class II (56%) -class III (9%)

Anatomy of the Lateral Nasal Wall

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

Pterygopalatine Vasculature --Internal maxillary artery

Anatomy of the Nasal Cavity and Vasculature

Sphenopalatine AA Ethmoid AA Greater Palatine A

Kesselbachs Plexus/Littles Area:

-Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX)

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

Anterior vs. Posterior

Maxillary sinus ostium Anterior: younger, usually septal vs. anterior ethmoid, most common (>90%), typically less severe Posterior: older population, usually from Woodruffs plexus, more serious.

Etiology
Local factors
Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Dessication Foreign Bodies/other

Etiology
Systemic factors
Vascular Infection/Inflammation Coagulopathy

Local Factors -- Vascular

ICA Aneurysms
extradural cavernous sinus

Local Factors - Infection/Inflammation

Rhinitis/Sinusitis
Allergic Bacterial Fungal Viral

Local Factors - Trauma

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

Nasal Fracture with Septal Hematoma

Local Factors - Iatrogenic nasal injury

Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction

Local Factors - Neoplasm

Juvenile nasopharyngeal angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Esthesioneuroblastoma Lymphoma

Local Factors Dessication

Cold, dry airmore common in wintertime Dry heatPhoenix and Death valley Nasal oxygen Anatomic abnormalities Atrophic rhinitis

Local Factors - Other

Self-inflicted (pedi) vs. traumatic foreign bodies Intranasal parasites Septal perforation Chemical (cocaine, nasal sprays, ammonia, etc.)

Systemic Factors -- Vascular

Hypertension/Arteriosclerosis Hereditary Hemorrhagic Telangectasias (OWR)

Systemic Factors Infection/Inflammation

Tuberculosis Syphillis Wegeners Granulomatosis Periarteritis nodosa SLE

Systemic Factors Coagulopathies

Thrombocytopenia Platelet dysfunction
Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal supplements)

Clotting Factor Deficiencies

Hemophilia VonWillebrands disease Hepatic failure

Hematologic malignancies

Etiology and Age

Childrenforeign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o) Adultstrauma, idiopathic Middle agetumors Old age--hypertension

Initial Management
ABCs Medical history/Medications Vital signsneed IV? Physical exam
Anterior rhinoscopy Endoscopic rhinoscopy

Laboratory exam Radiologic studies

bayonet forcepts suction T.C.A. bacitracin

vaseline gauze

gelfoam good light anesthetic Afrin epistat endoscopes silver nitrate suction bovie/bipolar merocels surgicel

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

Non-surgical treatments on d/c

Humidity/emolients Discontinue offending meds Nasal saline sprays Avoidance of nose picking/blowing Sneeze with mouth open Avoid straining/bedrest

Nasal packs
Anterior nasal packs
Traditional Recent modifications

Posterior nasal packs

Traditional Recent modifications

Ant/Post nasal packing

Pick a Pack, any pack

Pick a pack to pack with

TSSNugauze vs. Merocel Electron microscopy

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

Indications for surgery/embolization

Continued bleeding despite nasal packing Pt requires transfusion/admit hct of <38% (barlow) Nasal anomaly precluding packing Patient refusal/intolerance of packing Posterior bleed vs. failed medical mgmt after >72hrs (wang vs. schaitkin)

Selective Angiography/embolization
Helps identify location of bleeding Embolization most effective in patients who
Still bleeding after surgical arterial ligation Bleeding site difficult to reach surgically Comorbidities prohibit general anesthetic

Effective only when bleeding is >.5 ml/min 90+% success rate, complication rate of 0.1% Only able to embolize external carotid & branches Complications: minor (18-45%)/major (0-2%) Contraindicated in bad atherosclerosis, Ethmoid bleed

Surgical treatment
Transmaxillary IMA ligation Intraoral IMA ligation Anterior/Posterior Ethmoidal ligation Transnasal Sphenopalatine ligation External carotid artery ligation Septodermoplasty/Laser ablation

Transmaxillary IMA ligation

Waters view Caldwell-Luc Electrocautery of posterior wall before removal Microscopic dissection and ligation of IMA -descending palatine & sphenopalantine most important Recurrence rate (failure rate) of 10-15% Complication rate of 25-30% (oa fistula,dental, n)

Intraoral IMA ligation

Posterior gingivobuccal incision beginning at second molar Temporalis mm split and partially dissected IMAX visualized, clipped and divided Advantages: children/facial fractures Disadvantages: more proximal ligation Complications: trismus, damage to infraorbital n

Ant./Post. Ethmoidal ligation

Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear Lynch incision Fronto-ethmoid suture line 12-24-6 (14-18, 8-10, 4-6)

Transnasal Endoscopic Sphenopalatine Artery ligation

Follow Middle Turbinate to posteriormost aspect Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs) Elevation of flapID neurovascular bundle at foramen Ligation with titanium clip Reapproximate flap Complications few, Failures0-13%

Transnasal Sphenopalatine Artery ligation

ECA ligation
Effectiveness Anterior border of SCM ID ECA/ICA Ligation after clear that surrounding structures are safe.

Septodermoplasty/Laser
Remove mucosa from anterior septum, floor of nose, lateral wall STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease Still bleed, but not as bad Definitive treatment (severe disease)closure of nose

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 Cauteryabout equal Failure rates: PP-30%, Sx-17%, Emb-4%

Tips and Pearls

Red rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more (not on both sides of septum) Antihistamines to prevent rebleeds Cautery does not work with no platelets/clotting Glove packing H2O2 Merocels (2 or more) injected with cortisporin otic Amicar spray

Tips and Pearls

Hot water irrigation Cold water irrigation Salt Pork Dont pack nose in unconscious person with suspected skull fractures. Antibiotic cream vs. silver nitrate Intranasal pressure Estrogen cream to nasal septum

Tips and Pearls

Transnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed) Submucosal supraperichondrial dissection of nasal septum Not all hospitals have embolization-trained interventionalists No hard-set outline. Do what is best for your particular patient

CASE REPORT
45 yo Vietnamese fisherman--stable, but uncomfortable Profuse 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 bleedappears to be posterior/superior.

Case 1 contd
Hgb 12.5 Lactated Ringers IVF bolus Nasal packs removed two days later in the clinic,rebleeds. Requires transfusion for Hgb of 6.5 Angiographyno obvious bleed/Embolization Ant/Post Ethmoid Artery ligation