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
Vascular Infection/Inflammation Coagulopathy
Local Factors -- Vascular
ICA Aneurysms
extradural cavernous sinus
Local Factors - Infection/Inflammation
Rhinitis/Sinusitis
Mythology: brown paper, nails, scissors, scarlet threads,“lead that has never touched the ground”
A condition with a long history—Hippocrates to Henry Goodyear.
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.
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
Nasal Fracture with Septal Hematoma
Local Factors - Iatrogenic nasal injury
Functional endoscopic sinus surgery Rhinoplasty Nasal reconstruction
Local Factors - Neoplasm
Etiology
Local factors
Vascular Infectious/Inflammatory Trauma (most common) Iatrogenic Neoplasm Dessication Foreign Bodies/other
Etiology
Systemic factors
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)
Initial Management
ABC’s Medical history/Medications Vital signs—need IV? Physical exam
Anterior rhinoscopy Endoscopic rhinoscopy
Laboratory exam Radiologic studies
bayonet forcepts suctiauze
bacitracin
gelfoam
anesthetic
epistat
endoscopes
suction bovie/bipolar
silver nitrate merocels
good light Afrin
Anatomy/Physiology of Epistaxis
Anatomy
Nasal cavity Vascular supply
Physiology
Vascular nature Mucosa
External Carotid Artery -Sphenopalatine artery -Greater palatine artery -Ascending pharyngeal artery -Posterior nasal artery -Superior Labial artery
鼻出血(英文) PPT课件
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.
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
Hemophilia VonWillebrand’s disease Hepatic failure
Hematologic malignancies
Etiology and Age
Children—foreign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o) Adults—trauma, idiopathic Middle age—tumors Old age--hypertension
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
Systemic Factors – Coagulopathies
Thrombocytopenia Platelet dysfunction
Systemic disease (Uremia) drug-induced (Coumadin/NSAIDs/Herbal supplements)
Clotting Factor Deficiencies
Nasal packs
Anterior nasal packs
Traditional Recent modifications
Posterior nasal packs
Traditional Recent modifications
Ant/Post nasal packing
Pick a Pack, any pack
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
Pick a pack to pack with
TSS—Nugauze 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
Systemic Factors -- Vascular
Hypertension/Arteriosclerosis Hereditary Hemorrhagic Telangectasias (OWR)
Systemic Factors – Infection/Inflammation