PRE-OPERATIVE

( October 3, 2013 )
PGI Josh Matthew Rosales
General Data
H.C.
59 years old
Male
Married
Farmer
Brgy. Minoyan, Murcia, Negros Occidental


Chief Complaint
Epistaxis
HISTORY OF PRESENT ILLNESS

47 years PTA, noted 1
st
episode of epistaxis

9 years PTA, recurrence of epistaxis
episodes(1-2 episodes yearly)
HISTORY OF PRESENT ILLNESS
1 month PTA, noted epistaxis(massive) with
hematemesis admitted as a case of UGIB

1 day PTA, noted sudden episode of epistaxis
upon lifting a 5kg object

On the day of admission, another episode of
epistaxis, did not resolve opted consult
admission
Past Medical History
(-) DM
(-) BA
(-) thyroid problems
(-) hypertension
(-) past hospitalizations; (-) trauma
(+) excision of cyst, supraauricular, Right
(+) food allergies: crustaceans, chicken,
egg, oily foods
(-)drug allergies
Family History
(-) DM
(-) Hypertension
(-) Thyroid problems
(-) Blood dyscrasia
(-) epistaxis


Personal and Social History
Married, with 4 children
Farmer
Nonsmoker
Nonalcoholic Beverage drinker
PHYSICAL EXAMINATION
Unremarkable
Unremarkable
Unremarkable
ENT PHYSICAL EXAMINATION



Flexible Nasolaryngoscopy

CT SCAN

ASSESSMENT

Epistaxis, etiology to be
determined
DISCUSSION
Preoperative
EPISTAXIS
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
EPISTAXIS
most common otolaryngologic emergency
etiology in the majority of patients is
idiopathic, followed by primary
neoplasms and traumatic or iatrogenic
causes
management ranges from resuscitation,
through direct visualization and cautery,
nasal packing, and surgery to
embolization.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
ANATOMY
The anterior nasal
septum is the site of
a plexus of vessels
called Littles or
Kiesselbachs area

Terminal branches of the
external and internal
carotid arteries supply the
mucosa of the nasal cavity
with frequent anastomoses
between these systems
ANATOMY
External carotid artery supplies the nasal
cavity via:
facial artery supplies the superior labial artery,
(supplies the anterior nasal septum)

internal maxillary artery(courses within the
pterygopalatine fossa) terminates in the
sphenopalatine, descending palatine, pharyngeal,
infraorbital, and posterior superior alveolar arteries

ANATOMY
Sphenopalatine artery enters the nasal cavity
through the sphenopalatine foramen and then
divides into conchal (posterior-lateral) and septal
(posteriormedial) branches.

The internal carotid artery supplies the nasal
mucosa via the ethmoidal branches of the
ophthalmic artery.




Management
The amount of blood loss should be
estimated and over what period
A clinical assessment of the patients
cardiac status and circulating blood any of
findings that would indicate significant
hypovolemia)
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Management
Obtaining intravenous access, checking for
and correcting any clotting abnormalities,
and taking blood for group and save
and/or crossmatching may be required.
First aid measures: applying constant
firm pressure over the lower (non-bony)
part of the nose for 20 minutes; lean
forward with the mouth open over a bowl
so that further blood loss can be
estimated.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Management
APPROACH
1. Establish the site of bleeding.
2. Stop the bleeding.
3. Treat the cause.

Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
EtiologySelected Causes of Epistaxis
Local Causes
Idiopathicspontaneous
Trauma:
Nose picking
Foreign body
Nasal oxygen and continuous positive
airway pressure
Nasal fracture
Inflammatory/infectious:
Common cold, viral rhinosinusitis
Allergic rhinosinusitis
Bacterial rhinosinusitis
Granulomatous diseases (Wegeners
granulomatosis, sarcoid, tuberculosis)
Environmental irritants (cigarette smoking,
chemicals,
pollution, altitude)
Postoperativeiatrogenic:
Nasal surgery
Primary neoplasm:
Hemangioma of the septum, turbinates
Hemangiopericytoma
Nasal papilloma
Pyogenic granuloma Angiofibroma
Carcinoma and other nasal
malignancies
Structural:
Septal deformity, spurs
Septal perforation
Drugs:
Topical nasal steroids
Cocaine abuse
Occupational substances

General Disorders, Systemic Causes
Hypertension (not more common, but
more troublesome)
Arteriosclerosis
Platelet deficiencies, dysfunction;
coagulopathies (e.g., warfarin,
liver disease)
Leukemia, von Willebrands disease
Hereditary hemorrhagic telangiectasia
Organ failure (liver, kidney)
Headlamp Examination Using Local
Anesthesia
The key to controlling most epistaxis is to
find the site of the bleeding, and although
chemical cautery with silver nitrate can be
used, bipolar diathermy is more effective
for stopping the bleeding.
Once the clots have been sucked out, the
nasal airway should be inspected, initially
with a headlamp and then, if the bleeding
point cannot be located, with an
endoscope.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Epistaxis in Children
Young children usually bleed from a vessel
just inside the nose at the mucocutaneous
junction on the septum, and the bleeding
invariably stops spontaneously.
Those who have leukemia or are undergoing
chemotherapy often have epistaxis associated
with thrombocytopenia.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Epistaxis in Adults
The caudal end of the septum, where
several branches of the external and
internal carotid anastomose in Littles area
or Kiesselbachs plexus, is the most
common site of bleeding in adults.
Less commonly bleeding,comes from
further back on the septum, and a septal
deviation may make it difficult to visualize
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Epistaxis in Adults
The association between hypertension
and epistaxis is disputed
Nosebleeds in patients with hypertension
are more likely to lead to admission and
to be associated with comorbidity
A range of drugs has been linked with
epistaxis: warfarin, aspirin, clopidogrel,
and nonsteroidal antiinflammatory drugs

Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Epistaxis in Adults
In over-anticoagulated patients, fresh frozen
plasma, clotting factor extracts, and vitamin K
help.
In patients who do not have a history of a
bleeding disorder or undergoing anticoagulant
therapy, routine clotting studies do not add to
the management
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Topical Treatment
A randomized controlled trial of silver
nitrate cautery with topical antiseptic
nasal carrier cream versus topical alone
showed both to be effective.
Collagen-derived particles with bovine-
derived thrombin have been found to be
better than nasal packs
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Cautery
Most anterior epistaxis can be controlled
with identification of the bleeding point
and cautery using a headlamp.
The vast majority of posterior bleeding
sites can be identified by endoscopy
without the use of general anesthesia.
The majority of posterior idiopathic bleeds
are from the septum, usually from the
septal branch of the sphenopalatine artery
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Cautery
When the site of bleeding cannot clearly be
identified with a headlamp, the use of a rigid
nasal endoscope by an experienced
endoscopist is best.
The key is to identify the site of the bleeding
and gain control using silver nitrate cautery
or bipolar suction diathermy.
After cautery the patient should be advised
against blowing the nose for about 10 days
to allow the area to heal
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Cautery
Packing of the nose before endoscopy can
complicate detection of the exact site of
bleeding, because packing often causes
mucosal trauma and misleads
Rarely, nasal tumors can manifest as
epistaxis, so it is important to check for a
nasal mass, especially beyond a septal
deviation.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Nasal Packing
If a bleeding point cannot be found, ideally
the nose is packed with an absorbable
hemostatic agent that produces minimal
mucosal trauma
If an anterior pack fails and there is no access
to an experienced surgeon , more packing to
tamponade the bleeding point may be
required.
The role of prophylactic systemic antibiotics
in patients who have nasal packs is not well
established
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Nasal Packing
If the patient does not experience
rebleeding within 12 to 24 hours, the
packs should be removed.
The nose should be inspected with a rigid
endoscope to exclude any disease that
may have been responsible for the
bleeding.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Maxillary Artery Ligation
Another technique to control posterior
epistaxis is ligation of the internal maxillary
artery in the pterygopalatine fossa.
Reported success rate of approximately 90%.
Treatment failures are due to the difficulty in
finding the artery and its branches.
Complications: sinusitis, facial pain, oroantral
fistula, and facial, dental paresthesia
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Endoscopic sphenopalatine artery
ligation(ESPAL)
If bleeding cannot be controlled after
endoscopic examination and cautery and/or
nasal packing, examination with use of either a
general anesthetic or a local anesthetic with
sedation is indicated.
diathermy of any bleeding points or ESPAL is
the treatment of choice
Clipping or diathermy of the sphenopalatine
artery is now the accepted treatment for
management of persistent posterior epistaxis
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Endoscopic sphenopalatine artery
ligation(ESPAL)
Various reports have claimed success
rates for ESPAL between 92% and 100% in
controlling epistaxis.
Failure to clip all the branches of the
sphenopalatine artery may be the reason
for continued epistaxis after the
procedure.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Embolization
Arterial embolization has been shown to be
effective in the treatment of intractable
epistaxis.
Complications: cerebrovascular accident,
hemiplegia, ophthalmoplegia, facial nerve
palsy, seizures, and soft tissue necrosis.
Embolization technique is effective mainly for
the external carotid artery supply and very
dangerous for the internal carotid supply


Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Hot Water Irrigation
Hot water irrigation as a noninvasive
treatment for posterior epistaxis has
received some renewed attention
Experiments showed that irrigating the
nose at 40 to 46C does not lead to any
histologic changes of the mucosa and
those higher than 46C result in
vasodilatation and, in particular, edema of
the mucosa. local compression of blood
vessel and propagate cascade for
hemostasis

Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
Summary
The role of rigid nasal endoscopy as part of
the initial assessment of epistaxis, with direct
visualization and control of the bleeding point,
is effective in the majority of patients and
reduces the need for nasal packing.
Endoscopic sphenopalatine artery ligation is
well established as the treatment of choice
when cautery and nasal packing fail.
Flint et al. Cummings Otolaryngology Head and Neck Surgery:5
th
Edition. Philadelphia: 2010
THANK YOU.