Vascular Infection/Inflammation Coagulopathy
Local Factors -- Vascular
ICA Aneurysms
extradural cavernous sinus
Local Factors - Infection/Inflammation
Rhinitis/Sinusitis
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.
Hale Waihona Puke 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
Kesselbach’s Plexus/Little’s Area:
-Anterior Ethmoid (Opth) -Superior Labial A (Facial) -Sphenopalatine A (IMAX) -Greater Palatine (IMAX)
Woodruff’s 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 Woodruff’s plexus, more serious.
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
Juvenile nasopharyngeal angiofibroma Inverted papilloma SCCA Adenocarcinoma Melanoma Esthesioneuroblastoma Lymphoma
Local Factors – Dessication
Cold, dry air—more common in wintertime Dry heat—Phoenix and Death valley Nasal oxygen Anatomic abnormalities Atrophic rhinitis
Etiology
Local factors
Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Dessication Foreign Bodies/other
Etiology
Systemic factors
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
Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”
A condition with a long history—Hippocrates to Henry Goodyear.
Nasal Fracture with Septal Hematoma
Local Factors - Iatrogenic nasal injury
Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction
Local Factors - Neoplasm