This document discusses epistaxis (nosebleeds), including its definition, anatomy, causes, classification, and management. It notes that epistaxis accounts for 30% of ENT admissions and can be caused by local nasal issues or systemic factors like high blood pressure. Treatment involves initial measures to stop bleeding followed by tests to identify the underlying cause. Options include nasal packing, cauterization, surgery, or embolization to control severe or recurrent bleeding. The document provides details on different surgical procedures for anterior vs. posterior bleeds.
15. 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.
26. Non-surgical treatments
Control of hypertension
Correction of coagulopathies/thrombocytopenia
FFP or whole blood/reversal of anticoagulant/platelets
Pressure/Expulsion of clots
Topical decongestants/vasocontrictors
Cautery (AgNo3 , Bipolar)
Nasal packing (effective 80-90% of time)
27. Nasal packs
Anterior nasal packs
Traditional
Recent modifications
Posterior nasal packs
Traditional
Recent modifications
Ant/Post nasal packing
29. 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
30. 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)
31. 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
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
33. 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% (oa fistula,dental, n)
34. Intraoral IMA ligation
Posterior gingivobuccal incision beginning at
second molar
Temporalis mm split and partially dissected
IMAX visualized, clipped and divided
Advantages: children/facial fractures
Disadvantages: more proximal ligation
Complications: trismus, damage to infraorbital n
35. 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
12-24-6
(14-18, 8-10, 4-6)
36. 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%