ASSIGNMENT
Name : Ahsan Ali Roll no: 260
Discipline: MBBS. Class: 4th year
Subject : ENT
CAUSES , WORKUP AND MANAGEMENT OF
EPISTAXIS
Causes of Nosebleeds:
The purpose of the nose is to warm and humidify the air that we breathe in. The nose is
lined with many blood vessels that lie close to the surface where they can be injured
and bleed. Once a vessel starts to bleed, the bleeding tends to recur since the clot or
scab is easily dislodged. Nosebleeds, called epistaxis, can be messy and even scary,
but often look worse than they are. Many can be treated at home, but some do require
medical care.
Common causes of nosebleeds include:
Dry, heated, indoor air, which dries out the nasal membranes and causes them to
become cracked or crusted and bleed when rubbed or picked or when blowing the nose
(more common in winter months)
Dry, hot, low-humidity climates, which can dry out the mucus membranes
Colds (upper respiratory infections) and sinusitis, especially episodes that cause
repeated sneezing, coughing, and nose blowing
Vigorous nose blowing or nose picking
The insertion of a foreign object into the nose
Injury to the nose and/or face
Allergic and non-allergic rhinitis(inflammation of the nasal lining)
Use of drugs that thin the blood (aspirin, non-steroidal anti-inflammatory medications,
warfarin, and others)
High blood pressure
Chemical irritants (e.g., cocaine, industrial chemicals, others)
Deviated septum (an abnormal shape of the structure that separates the two sides of the
nose)
Tumors or inherited bleeding disorders (rare)
Facial and nasal surgery
Treatment of anterior epistaxis
Cotton pledgets soaked with a vasoconstrictor and anesthetic should be placed in the
anterior nasal cavity, and direct pressure should be applied at both sides of the nose for
at least 5 minutes. The pledgets can then be removed for reinspection of the bleeding
site.
Other treatment options include hemostatic packing with absorbable gelatin foam or
oxidized cellulose. Use of desmopressin spray may be considered for a patient with a
known bleeding disorder.
Larger vessels tend to require more aggressive treatment than direct pressure and
topical solutions. If the site of bleeding can be visualized, silver nitrate or
electrocauterization can be used to cauterize the bleeding vessel.
However, electrocauterization must be performed cautiously to avoid excessive
destruction of healthy surrounding tissues. Use of electrocauterization on both sides of
the septum may increase the risk of septal perforation.
If the above treatments fail to stop an anterior bleed, the nasal cavity will have to be
packed from posterior to anterior using ribbon gauze impregnated with petroleum jelly or
bacitracin zinc–neomycin sulfate–polymyxin B sulfate ointment.
Nonadherent gauze impregnated with petroleum jelly and 3% bismuth tribromophenate
also works well for this purpose. Each layer should be pressed down firmly before the
next layer is inserted. Once the cavity has been packed as completely as possible, a
gauze “drip pad” can be taped over the nostrils and changed periodically.
If more aggressive packing is needed, a nasal tampon can be used. 10 After a topical
anesthetic is applied to the patient’s nasal cavity, the nasal tampon can be inserted
along the floor of the cavity. The tampon will expand when it comes into contact with
blood or fluids. Saline may have to be applied to the nasal tampon to help it achieve full
expansion.
Another version of nasal packing employs an anterior balloon tampon made of
carboxymethylcellulose, a hydrocolloid material. The carboxymethylcellulose acts as a
platelet aggregator and also forms a lubricant upon contact with water.
The balloon tampon has a cuff that is inflated by air. The hydrocolloid reportedly
preserves the newly formed clot during tampon removal.When applied in the outpatient
setting, nasal packing may be left in place for 3 to 5 days to ensure adequate clot
formation
Complications associated with nasal packing procedures can range from minor to
severe. Minor complications include the packing falling out, anosmia, breathing
difficulties, nasal septal hematomas, and nasal septal perforations.
Moderate complications include abscesses from traumatic packing, sinusitis,
neurogenic syncope during packing, and pressure necrosis secondary to excessively
tight packing.
A more severe complication is that of toxic shock syndrome, which can occur with
prolonged nasal packing. Using a topical antistaphylococcal antibiotic ointment on the
packing materials might reduce this risk.
Posterior epistaxis
Epistaxis caused by posterior bleeding is much less common than that caused by
anterior bleeding. Posterior epistaxis usually is associated with atherosclerotic disease
and hypertension.
Typical sites for a posterior bleed are: Woodruff’s plexus, on the posterior aspect of the
lateral wall of inferior meatus; the posterior part of the lateral nasal wall near the
sphenopalatine foramen; the posterior end of inferior turbinate; the middle turbinate and
its medial surface; the middle and posterior parts of the septum; and the floor of the
nose beneath the inferior turbinate.
Treatment of posterior epistaxis is difficult due to the inaccessible location of the bleed.
Typically, invasive methods are required to visualize and to treat the bleed. Two
methods typically performed by an otolaryngologist are anteroposterior packing and use
of balloon systems.
Anteroposterior packing is performed by passing a catheter through one nostril, past the
nasopharynx, and out the mouth. Gauze is attached to the catheter and pulled through
until it is situated in the posterior choana, creating pressure on the bleed site. This type
of packing is uncomfortable, bleeding may persist, and vasovagal syncope is quite
possible; the patient may have to be hospitalized for monitoring.
The balloon system approach is less complicated than the anteroposterior packing
procedure. After topical anesthesia is administered, the double-balloon device is passed
into the affected nostril until it reaches the nasopharynx and sits in the posterior nasal
cavity to tamponade the bleeding source. Next, the anterior balloon is inflated to prevent
retrograde travel of the posterior balloon and subsequent airway obstruction.
