MANAGEMENT OF

EPISTAXIS

BY
M.GOPINATHAN
DEPARTMENT OF ENT
CH.M.C
 Investigations

1. Complete blood count

2. Blood grouping & cross matching
3. Renal function test
4. Blood sugar
5. Liver function test
6. Peripheral blood film
7. Screening for coagulation disorders
Prothrombin time, Platelet count,
serum fibrinogen ,Fibrin breakdown
product
8. X ray para nasal sinuses
9. Nasal endoscopy
10. CT scan
11. MRI
Patient History
• Previous bleeding episodes
• Site of bleeding
• Amont of blood loss
• Nasal trauma
• Family history of bleeding
• Hypertension - current medications and
how tightly controlled
• Hepatic diseases
• Use of anticoagulants
• Other medical conditions - DM, CAD, etc
Physical Exam-Equipment
• Protective equipment - gloves, safety goggles
• Headlight if available
• Nasal Speculum
• Suction with Frazier tip
• Bayonet forceps
• Tongue depressor
• Vasoconstricting agent (e.g oxymetazoline)
• Topical anesthetic
• Variety of nasal packing materials
• Silver nitrate cautery sticks
• 10cc syringe with 18G and 27G 1.5inch
needles
• Local anesthetic for p.n injection
• Gelfoam, Collagen absorbable hemostat,
Surgicel or other hemostatic materials.
General Epistaxis Supplies
Physical Examination
• By anterior Rhinoscopy and rigid
endoscope .
• First ask the patient to blow to clean the
nose from blood clot.
• If site is obscure, the nasal mucosa
should be anaesthesized and
vasoconstrictor is applied
Look for site of bleeding
• Unilateral or bilateral
• Anterior or posterior
• Above middle turbinate (bleeding from
anterior or posterior ethmoidal arteries)
or
• below middle turbinate (from the
sphenopalatine artery.)
 First aid
• Reassurance
• patient is managed in the sitting position
with the head slightly flexed and leaning
forward
• If the patient is shocked, he is put in
supine position with the head lowered.
• Cold compresses to the forehead and
ice to suck.
• Pinch the tip of the nose between two
fingers for ten minutes, this compresses
little’s area & stops most anterior
bleeding.
• Apply vasoconstrictor drops
Please Monitor
• Examine the patient for Signs of
Shock
• Weak rapid pulse
• Irritability (restlessness)
• Hypotension
• Pallor & cold sweating
• Decreased urine output
• If so------ start anti shock treatment.
-- I.V.crystalloids or colloids
-- blood transfusion……
Cauterization
• In cases where site of bleeding is seen
• Mild to moderate cases.,
• Electrical cautery
• Chemical cautery
• Silver nitrate stick, solution,
crystal
• Trichlor acetic acid & Carbolic
acid , irritant therefore avoided
• Thermal cautery by heat
• Cryocautery by freezing ice probes
• After cautery:avoid hard nose
blowing,hot food,apply lubricant nasal
drops for one wk.,
Nasal packs

Nasal packing

Ant. Nasal packing Post. Nasal packing

Traditional methods Newer methods

Different products used for nasal packing

1. Vaseline gauze
2. Bismuth iodine paraffin pack
3. Foleys catheter
4. Gel foam packing
Traditional anterior pack

Adv.: Easy to insert & resorbable.

Disadv.: Doesn’T cause compression
Newer methods of ant.pack
1.Merocl pack-easy to insert and remove

2.Ant . nasal
balloons-
antibiotic
cover for 24
to 48 hours
Traditional Posterior Pack
Newer methods
Complications of N. packing
1. Immediate
• Pain
• Trauma to columella, septum
,turbinate .
• Vasovagal attack
• Trauma to choana.
• Hypoxia
• Hypoventilation
• Cardiac arrest
• Sleep apnoe syndrome:
vestibulitis,sinusitis
• Eustachian tube dysfunction
2. Delayed.
 Secondary hemorrhage
 Adhesions
 Septal perforation
 Toxic shock syndrome
 Pack granuloma
 Alar necrosis

3. Related to removal of pack.

 Pain
 Hemorrhage
 Trauma.
CARE OF PTS. WITH PACK
• Elderly and those with chronic diseases-
shift tio I.C.U for mgt. of complications
• CPR if required
• Antibiotic cover
• Avoid straining
• Oxygen saturation to be measured—if low
humi. Oxygen to be supplemented
• Mild sedative
• IVF
• MONITOR CARDIO-PULMONARY STATUS
SPECIAL CASES
• Haemophilia;
• Replace factor VIII, or fresh blood.
• Other clotting deficiency;
• FFP.
• Purpura;
• Platelets
• Anticoagulants;
• Stop drug, or titrate.
• Heparin is reversed with protamine sulphate,
• warfarin with vitamin K
• Unconscious head injury;
• Dangerous to pack in suspected skull #.
Greater Pal. Foramen Block
• Mechanism of action
is volume compression
of vascular structures
• Lidocaine 1% or 2%
with epinephrine
1:200,000 used
or Lidocaine
with sterile water.
• Do not insert needle
more than 25mm
Surgical methods
• INDICATIONS
• 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
TECHNIQUES
• Transmaxillary IMA ligation
• Intraoral IMA ligation
• Anterior/Posterior Ethmoidal ligation
• Transnasal Sphenopalatine ligation
• External carotid artery ligation
• Septodermoplasty/Laser ablation FOR
HHT
• SMR/septoplasty
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% (oro-antral
fistula,dental injury ophthalmoplegia)
Intraoral IMA ligation
• Posterior gingivobuccal incision beginning
at second molar
• Temporalis muscle 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
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 flap—ID neurovascular bundle
at foramen
• Ligation with titanium clip
• Reapproximate flap
• Complications –few, Failures—0-13%
ECA ligation
• Technically easy- carried out under LA/GA
• Incision along anterior border of SCM
• IDENTIFY ECA/ICA
• Ligation after clear that surrounding
structures are safe.
• compl- wound inf. Hematoma.,
Septodermoplasty/Laser
• Remove mucosa from anterior ½
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
SMR/ SEPTOPLASTY
• Indicated in recurrent bleeds
• Mechanism:
elevation of muco-perichondrial flap

fibrosis

constriction of blood vessels

co-existent septal spur treated
Arterial Embolisation
• Done after an angiography by an
radiologist
• Embolization most effective in patients
who
-Still bleeding after surgical arterial
ligation
-Bleeding site difficult to reach surgically
-Comorbidities prohibit general anesthetic
• Materials used-coils
poly-vinyl alcohol
n-butyl cyano
acrylate .,
• Conditions::
idopathic uncontrolled bleed
juvenile nasal angiofibroma
vascular malformations
hemostatic disorders
trauma,post surgical etc.,
• Possible complications
ischemia, pain
cr.nerve damage
blindness
TIA &stroke manifestations
• Contraindications: ATH predisposition
ethmoidal bleed
Epistaxis --D D
• Vascular-venous obs.,CHF,HT.,
• Inflamma-lep,TB,rhinitis,
• Neoplastic-schmincke
tumour.,ca.nose,hemangioma.,
• Non-neoplastic-adenoid,polyp
• Deficiency-vit K,apl.anemia
• Toxication-heparin,warfarin
• Hereditary-hemophilia,HTH,ITP.,
• Trauma-FB.,nasal picking
• Gynaec-mensturation,monopause.,
Thank you