EPISTAXIS



Epistaxis may be:-
1. Anterior or posterior
2. Spontaneous or induced.


Etiology (Causes)


A) Local Causes-
A) Congenital-multiple telangiectasea are characterized by multiple capillary haemangiomas in the nose and tongue.
B). Traumatic– i) Trauma to the nose,para-nasal sinuses or the head result in epistaxis..
ii) Postoperative-alter any operative procedure in the nose and para-nasal sinuses,one may have primary, reactionary or secondary hemorrhage.
iii) Pricking the nose – Particularly in little’s area accounts 4 a large no. of cases having epistaxis..
iv) Barotrauma may cause it..



C). Inflammatory
a) Acute inflammation(i) Specific– Nasal diphtheria is characterized by blood stained discharge from one or both nostrils in children.
(ii) Nonspecific– Acute vestibulitis may produce epistaxis. Acute rhinitis and sinusitis may produce epistaxis. Adenoids may cause inflammatory and congestion in the nose which results in epistaxis.
b) Chronic inflammation
(i) Non specific– 1.Chronic rhinitis and chronic sinusitis produce epistaxis due to congestion..
2. Rhinitis sicca.
3. Atrophic rhinitis causes mild epistaxis.
(ii) Specific=1. Rhinosporidiosis forms mulberry like red polypoidal swellings which may bleed profusely.
2. Tuberculosis, Syphilis, Leprosy and Lupus may produce granulomas.
D). Neoplasms– i) Angiomas from nasal septum may bleed profusely.
ii). malignant- The commonest ares for malignancy are the maxillary sinus, the ethmoidal sinuses, nasopharynx.



B)Systemic causes
i)Hypertension- The bleeding may persist because of the atherosclerotic blood vessels of the hypertensive patients fail to retract.
ii) Bleeding disorders- E.g. Leukemia, Haemophilia, Purpura, Agranulocytosis and Hodgkin’s disease.
iii) Increased pressure in superior vena cava.
iv) Infections may causes epistaxis due to crying n congestion..like viral fevers like Influenza, Measles, Enteric fever, Rheumatic fever, etc.
v). Drugs like salicylates, anticoagulants and quinine may cause it.
vi). Chronic renal failure, uremia and toxemia may lead to epistaxis.

C) Idiopathic– In many cases no cause for epistaxis is detected in spite of thorough investigations.


COMMON SITES OF EPISTAXIS

Nose: Anatomy and Histology of the Human Nose | Medical Library


1- Nasal septum- Little’s area accounts for almost 90%of cases.
2. Above the middle turbinate – Anterior ethmoidal vessels may bleed due to Hypertension.



Clinical Features
1. Quantity may vary from trivial to profuse lethal quantity.
2. Anterior or posterior bleeding may occur anteriorly or it may be postnasal.
3. Continuous or intermittent bleeding may occur.
4. Haemoptysis or haematemesis.
5. Anxiety.
6. Shock may be present in cases of severe epistaxis.



INVESTIGATIONS



1. Blood pressure should be checked.
2. Haemogram inform about anemia.
3. Tests
4 Coagulation may detect bleeding disorders.
4. Radiography-Acute sinusitis, fracture may be detected.
5. CT-scan may be advised.
6. Endoscopy of nose and para-nasal sinuses may be performed for detecting bleeding point.
7. Biopsy reveals the nature of the lesions like Rhinosporidiosis, Angioma.


TREATMENT


Specific cause–if there is any specific cause it should be treated.
First-Aid
a) Cold packs- Applied on the bridge of the more to arrest the bleeding by vasoconstriction.
b) Trotters procedure- Used for hypertensive. Epistaxis patient has to spit out blood & not allowed to swallow.
c) Pinching the nose – For a minute to keep pressure on the littles area to arrest bleeding.


Local Management –


A) Cautery- If bleeding point is visible it is cauterized with 50% silver nitrate.
B) Packing-


1) Anterior nasal packing -The nose is packed with ribbon gauze impregnated with lubricant like Vaseline nose is packed from bottom to top in layers. Packs are removed after 48 hours adrenaline packs are not used as they tends to raise the blood pressure.
2) Posterior nasal packing -Used when bleeding continues in spite of anterior nasal packing.
3) Foley catheter- It may be used to control post nasal bleeding. It is less comfortable than posterior nasal packing. Foley catheter is inserted through bleeding nostril when it reaches nasopharyngeal wall balloon is inflated & pressure is applied.
C) Lubricant – If bleeding is due to crushing in the vestibule then lubricants like oil Vaseline, ghee are applied.



Systemic management
1) Blood pressure is checked to detect hypertension & to access blood loss.
2) Pulse & respiration rate are monitored.
3) Replacement of the blood loss.
4) Coagulants like calcium, vitamin C, K, Ethamsylate are routinely used but their efficacy is doubtful.
5) Antibiotics to prevent infections
6) Sedatives to allay apprehension

Surgical
1) Ligation- Intractable cases may require ligation of external carotid ,maxillary or ant ethmoidal artery.
2) Sub-mucus resection & Septoplasty – Performed to gain access to the bleeding point in patients with severe DNS.