Scribd Logo
Upload

Welcome to Scribd!

  • 50 views

    Management of Epistaxis: Susritha Pg2 Year ASRAM Eluru

    Uploaded by

    Ernesto Fer Fdez
    This document summarizes the management of epistaxis. It classifies epistaxis as anterior or posterior based on the bleeding location. It describes various endoscopic, packing, cautery, and medical therapies as first-line treatments. More invasive options include ligation techniques, septal surgery, and embolization. It notes special considerations for pediatric epistaxis, coagulopathies, and hereditary hemorrhagic telangiectasia. The overall approach is described as first using direct therapies, then indirect packing, followed by surgical ligation or embolization if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Management of Epistaxis: Susritha Pg2 Year ASRAM Eluru

    Uploaded by

    Ernesto Fer Fdez
    50 views34 pages
    This document summarizes the management of epistaxis. It classifies epistaxis as anterior or posterior based on the bleeding location. It describes various endoscopic, packing, cautery, and medical therapies as first-line treatments. More invasive options include ligation techniques, septal surgery, and embolization. It notes special considerations for pediatric epistaxis, coagulopathies, and hereditary hemorrhagic telangiectasia. The overall approach is described as first using direct therapies, then indirect packing, followed by surgical ligation or embolization if needed.

    Original Title

    managementofepistaxis-140416083939-phpapp02.pdf

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document summarizes the management of epistaxis. It classifies epistaxis as anterior or posterior based on the bleeding location. It describes various endoscopic, packing, cautery, and medical therapies as first-line treatments. More invasive options include ligation techniques, septal surgery, and embolization. It notes special considerations for pediatric epistaxis, coagulopathies, and hereditary hemorrhagic telangiectasia. The overall approach is described as first using direct therapies, then indirect packing, followed by surgical ligation or embolization if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    50 views34 pages

    Management of Epistaxis: Susritha Pg2 Year ASRAM Eluru

    Uploaded by

    Ernesto Fer Fdez
    This document summarizes the management of epistaxis. It classifies epistaxis as anterior or posterior based on the bleeding location. It describes various endoscopic, packing, cautery, and medical therapies as first-line treatments. More invasive options include ligation techniques, septal surgery, and embolization. It notes special considerations for pediatric epistaxis, coagulopathies, and hereditary hemorrhagic telangiectasia. The overall approach is described as first using direct therapies, then indirect packing, followed by surgical ligation or embolization if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 34

    Management of epistaxis

    Susritha
    Pg 2nd year
    ASRAM;eluru.
    Classification:
     Anterior epistaxis:
     Bleeding from a source anterior to the plane of the piriform
    aperture.
     This includes bleeding from the anterior septum and rare
    bleeds from the vestibular skin and mucocutaneous
    junction.

     Posterior epistaxis:
     Bleeding from a vessel situated posterior to the piriform
    aperture.
     This allows further subdivision into lateral wall, septal and
    nasal floor bleeding.
    Endoscopic control

    bipolar diathermy,

    chemical cautery
    Bleeding point (difficult in
    direct
    specific posterior bleeds),
    electrocautery
    Management of
    epistaxis
    Donot require or direct pressure
    indirect identification of from miniature
    bleeding points targeted packs

    silver nitrate
    cautery.
    Nasal packing:

    sinusitis, septal
    Ribbon gauze perforation, alar
    impregnated necrosis,
    (BIPP) 24 and 72 hours.
    with petroleum hypoxia and
    jelly or myocardial
    infarction
    Hot water irrigation:

    vasodilatation
    and reduction
    Hot water
    irrigation 50C in nasal lumen
    dimensions
    Systemic medical therapy:

    Tranexamic acid & Preexisting


    reduce the severity and at a dose of 1.5 g three
    thromboembolicdisease
    epsilon aminocaproic aci risk of rebleeding times a day.
    is a contraindication
    Surgical
    management

    Posterior Ligation Septal


    embolisation
    packing techniques surgery
    Posterior nasal packing

     General anaesthesia is preferrable.


     Nasopharyngeal tamponade is achieved using special
    gauze packs inserted transorally and positioned by
    means of tapes passed from the posterior choana to the
    anterior nares bilaterally.
     Alternative is to insert a Foley urethral
    catheter (size 12 or 14) along the floor
    of the nasal cavity until the nasopharynx
    is reached.
     The Foley catheter is inflated with up to
    15mL of water, pulled forward to engage
    in the posterior choana and anterior
    packing is then inserted.
     The Foley catheter needs to be secured
    anteriorly, taking care not to cause
    pressure over the columella.
     Complications :
     Posterior packing causes considerable
    pain and may cause hypoxia secondary to
    soft palate oedema.
     Sinusitis and middle ear effusions are
    common.
     More serious complications include
    necrosis of the septum and columella.
    Ligation:

     Ligation should be performed as close as possible to the


    likely bleeding point.
     sphenopalatine artery;
     internal maxillary artery;
     external carotid artery;
     anterior/posterior ethmoidal artery.
    sphenopalatine artery:

     An incision is made approximately 8mm anterior to and under


    cover of the posterior end of the middle turbinate.
     The incision is carried down to the bone and a mucosal flap is
    elevated.
     The foramen can be difficult to identify, but its location is
    signalled by the crista ethmoidalis.
     Once the main vessel is identified, it can be ligated using
    haemostatic clips and divided or coagulated using bipolar
    diathermy
    internal maxillary artery:

     The artery is exposed transantrally via


     anterior (sublabial) or
     combined anterior and medial(endoscopic) techniques.
     In the traditional sublabial approach, an antrostomy is
    formed taking care to preserve the infraorbital nerve.
     The mucosa of the posterior wall of the antrum is then
    elevated and a window is made through into the
    pterygopalatine fossa.
     The branches of the internal maxillary artery are
    identified pulsating within the fat of the fossa and are
    carefully dissected out prior to clipping with haemostatic
    clips.
     The proximal internal maxillary artery, descending
    palatine and sphenopalatine branches are all clipped and
    ideally divided.
     An endoscopic variation on this technique uses a middle
    meatus antrostomy, as an instrument port with a 4-mm
    endoscope is inserted through a small canine fossa
    antrostomy.
     Transantral ligation controls haemorrhage in 89 percent
    of cases.
     Complications include sinusitis, damage to the
    infraorbital nerve, oroantral fistula, dental damage and
    anaesthesia and rarely ophthalmoplegia and blindness.
    ECAL:
     This procedure can be carried out
    under local or general anaesthetic
    using either a skin crease incision or a
    longitudinal incision parallel with the
    anterior border of the sternomastoid.
     The carotid bifurcation is identified
    and the external carotid confirmed,
    double-checked for arterial branches
    and then ligated in continuity.
     Complications
     wound infection,
     haematoma and
     neurovasculardamage.
    Anterior/posterior ethmoidal
    artery ligation:
     The arteries are approached by a medial canthal incision
    which is carried down to the bone of the anterior
    lacrimal crest.
     Periosteal elevators are then used to elevate and
    laterally retract the bulbar fascia.
     The anterior ethmoidal artery is seen as a
    fibroneurovascular mesentry running from the bulbar
    fascia into the anterior ethmoidal foramen.
     The vessel is clipped and divided and dissection is
    continued to identify the posterior artery which is
    located approximately 12mm behind.
    Septal surgery:

     When epistaxis originates behind a prominent septal


    deviation or vomeropalatine spur, septoplasty or
    submucosal resection (SMR) may be required to access
    the bleeding point.
     the blood supply to the septum is interrupted and
    haemostasis secured.
    embolization:

     It is essential to exclude arteriovenous malformations,


    aneursyms and fistulae prior to embolization.
     Once the bleeding vessel is identified, a fine catheter is
    passed into the internal maxillary circulation and
    particles (polyvinyl alcohol, tungsten or steel microcoils)
    are used to embolize the vessels.
     The ipsilateral facial artery is also embolized inorder to
    prevent recirculation.
     Complications includeskin necrosis, paraesthesia,
    cerebrovascular accident.
    Secondary epistaxis:

     Epistaxis is commonly observed in patients with


    coagulopathy secondary to liver disease, leukemia or
    myelosuppression.
    Hereditary haemorrhagic
    telangiectasia

     (HHT)or Rendu–Osler–Weber disease, is an autosomal


    dominant condition affecting blood vessels in the skin,
    mucous membranes and viscera.
     The classical features are telangiectasia, arteriovenous
    (AV) malformations and aneurysms. Recurrent epistaxis
    occurs in 93 percent of cases.
     Management involves packing, cautery, antifibrinolytics,
    systemic or topical oestrogens, coagulative lasers, septal
    dermoplasty, ligation and embolization and, as a last
    resort, permanent surgical closure of the nostrils
    (Young’s operation)
    Paediatric epistaxis:
     Enquire about the use of nasal sprays as intranasal
    steroid sprays can cause localized nasal mucosal trauma
    often in the region of the anterior end of the inferior
    turbinate which can give rise to epistaxis.
     A concomitant vestibulitis should raise the suspicion of a
    retained nasal foreign body.
     Idiopathic thrombocytopoenic purpura (ITPP) may
    present as epistaxis.
     Nasal mycoses may need to be considered, particularly
    in immunocompromised children, such as those
    receiving chemotherapy.
     Commonly used methods for the management of
    recurrent epistaxis in children are
     the prophylactic application of petroleum jelly to the nasal
    vestibule and septum,
     the use of topical antiseptic creams, and
     cautery of Little’s area or the retrocollumellar veins.
     If the bleeding is persistently from one side, often we
    find either a leash of vessels around Little’s area on the
    affected side or a prominent retrocollumellar vein
     Cautery nowadays is most often undertaken using a silver
    nitrate impregnated stick.
     Petroleum jelly is thought to be effective because it forms a
    water-resistant film over the affected area of mucosa.
     In addition, antiseptic creams are thought to sterilize
    localized infection in the region of the vestibule and the
    nasal septum.
    Summary:

     First line: direct therapy (bipolar/cautery, endoscopic if


    required);
     Second line: indirect therapy (anterior packing);
     Third line: surgical therapy (ESPAL);
     Fourth line: angiography and embolization.
    Thank you…
    Journal club---04.04.2014

     By dr.bala teja (laryngeal amyloidosis)

    You might also like