1、Introduction and History5-10%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.Mythology:brown paper,nails,scissors,scarlet threads,“lead that has never touched the ground”A condition with a long his
2、toryHippocrates to Henry Goodyear.Anatomy/Physiology of EpistaxisAnatomyNasal cavityVascular supplyPhysiologyVascular natureMucosaWhy bleeding from the nose?Vascular organ secondary to incredible heating/humidification requirementsVasculature runs just under mucosa(not squamous)Arterial to venous an
3、astamosesICA and ECA blood flowAnatomy of the Lateral Nasal WallSPF-class I(35%)-class II(56%)-class III(9%)Sphenopalatine foramen(SPF)ClassClass 1:the opening of the SPF is purely into the superior meatusClass 2:the SPF spans the ethmoidal crest(i.e opens to both superior and middle meati Class 3:t
4、here are two separate opening into the superior and middle meatiExternal Carotid Artery-Sphenopalatine artery-Greater palatine artery-Ascending pharyngeal artery-Posterior nasal artery-Superior Labial arteryInternal Carotid Artery-Anterior Ethmoid artery-Posterior Ethmoid arteryPterygopalatine Vascu
5、lature -Internal maxillary arteryFunctional endoscopic sinus surgeryNasal Fracture with Septal HematomaCold,dry airmore common in wintertimeMaxillary sinus ostiumNasal fractureAnterior:younger,usually septal vs.Woodruffs Plexus:Reapproximate flapNasal packing(effective 80-90%of time)Electron microsc
6、opyTemporalis mm split and partially dissectedTraditionalAdenocarcinomaAvoid straining/bedrestIndications for surgery/embolizationAnatomy of the Nasal Cavity and VasculatureSphenopalatine AAEthmoid AAGreater Palatine AKesselbachs Plexus/Littles Area:-Anterior Ethmoid(Opth)-Superior Labial A(Facial)-
7、Sphenopalatine A(IMAX)-Greater Palatine(IMAX)Woodruffs Plexus:-Pharyngeal&Post.Nasal AA of Sphenopalatine A(IMAX)Anterior vs.PosteriorMaxillary sinus ostiumAnterior:younger,usually septal vs.anterior ethmoid,most common(90%),typically less severePosterior:older population,usually from Woodruffs plex
8、us,more serious.EtiologyLocal factorsVascularInfectious/InflammatoryTrauma(most common)IatrogenicNeoplasmDessicationForeign Bodies/otherEtiologySystemic factorsVascularInfection/InflammationCoagulopathy Local Factors-VascularICA Aneurysms extradural cavernous sinus Local Factors-Infection/Inflammati
9、onRhinitis/SinusitisAllergicBacterialFungalViralLocal Factors-TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses,orbits,middle ear,base of skullBarotraumaAnterior border of SCMStill bleed,but not as badLigation after clear that surrounding struc
10、tures are safe.ICA AneurysmsTrauma(most common)cutaneous,myocutaneous,microvascular free flaps vs.Nasal fractureIntroduction and HistoryHematologic malignanciesLocal Factors DessicationDont pack nose in unconscious person with suspected skull fractures.Do what is best for your particular patientMicr
11、oscopic dissection and ligation of IMA-descending palatine&sphenopalantine most importantSome authors(Wang and Vogel)showed surgical intervention to have lower failure rates(14.Vascular natureStill bleed,but not as badNasal packing(effective 80-90%of time)Indications for surgery/embolizationIMAX vis
12、ualized,clipped and dividedTransnasal endoscopic bipolar cautery of sphenopalatine artery(7%failure in pts with obvious source of bleed)-Greater Palatine(IMAX)Anterior border of SCMNasal Fracture with Septal HematomaSystemic disease(Uremia)TraditionalRecurrence rate(failure rate)of 10-15%Nose pickin
13、gLynch incisionClass 1:the opening of the SPF is purely into the superior meatusAnatomy of the Lateral Nasal WallNasal Fracture with Septal HematomaLocal Factors-Iatrogenic nasal injuryFunctional endoscopic sinus surgeryRhinoplastyNasal reconstructionLocal Factors-NeoplasmJuvenile nasopharyngeal ang
14、iofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphomaLocal Factors DessicationCold,dry airmore common in wintertimeDry heatPhoenix and Death valleyNasal oxygenAnatomic abnormalitiesAtrophic rhinitisLocal Factors-OtherSelf-inflicted (pedi)vs.traumatic foreign bodiesIntran
15、asal parasitesSeptal perforationChemical(cocaine,nasal sprays,ammonia,etc.)Systemic Factors-VascularHypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias(OWR)Systemic Factors Infection/InflammationTuberculosisSyphillisWegeners GranulomatosisPeriarteritis nodosaSLESystemic Factors Coagul
16、opathies ThrombocytopeniaPlatelet dysfunctionSystemic disease(Uremia)drug-induced(Coumadin/NSAIDs/Herbal supplements)Clotting Factor DeficienciesHemophiliaVonWillebrands diseaseHepatic failureHematologic malignanciesEtiology and AgeChildrenforeign body,nose picking,nasal diptheria(1/3 with chronic b
17、leeds have coagulation d/o)Adultstrauma,idiopathicMiddle agetumorsOld age-hypertensionInitial ManagementABCsMedical history/MedicationsVital signsneed IV?Physical examAnterior rhinoscopyEndoscopic rhinoscopyLaboratory examRadiologic studiessuctiongood lightanestheticsilver nitrate merocelsgelfoambac
18、itracinendoscopessuction bovie/bipolarAfrin surgicelepistatbayonet forceptsvaseline gauzeNon-surgical treatments Control of hypertension Correction of coagulopathies/thrombocytopenia FFP or whole blood/reversal of anticoagulant/plateletsPressure/Expulsion of clotsTopical decongestants/vasocontrictor
19、sCautery(AgNo3 vs.TCA vs.Bipolar vs.Bovie)Nasal packing(effective 80-90%of time)Greater palatine foramen block Non-surgical treatments on d/cHumidity/emolientsDiscontinue offending medsNasal saline spraysAvoidance of nose picking/blowingSneeze with mouth openAvoid straining/bedrestNasal packsAnterio
20、r nasal packsTraditionalRecent modificationsPosterior nasal packsTraditional Recent modificationsAnt/Post nasal packingPick a Pack,any packPick a pack to pack withTSSNugauze vs.MerocelElectron microscopyPosterior Packs Admission Elderly and those with other chronic diseases may need to be admitted t
21、o the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVFIndications for surgery/embolizationContinued bleeding despite nasal packingPt requires transfusion/admit hct of 72hrs(wang vs.schaitkin)Selective Angiography/embolizationHelps iden
22、tify location of bleedingEmbolization most effective in patients whoStill bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit general anestheticEffective only when bleeding is.5 ml/min90+%success rate,complication rate of 0.1%Only able to emboli
23、ze external carotid&branchesComplications:minor(18-45%)/major(0-2%)Contraindicated in bad atherosclerosis,Ethmoid bleedSurgical treatmentTransmaxillary IMA ligationIntraoral IMA ligationAnterior/Posterior Ethmoidal ligationTransnasal Sphenopalatine ligationExternal carotid artery ligationSeptodermop
24、lasty/Laser ablationTransmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA-descending palatine&sphenopalantine most importantRecurrence rate(failure rate)of 10-15%Complication rate of 25-30%(oa fistula,dental,n)Int
25、raoral IMA ligationPosterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized,clipped and dividedAdvantages:children/facial fracturesDisadvantages:more proximal ligationComplications:trismus,damage to infraorbital nAnt./Post.Ethmoidal ligatio
26、nPatients s/p IMAX ligation still bleeding,superior nasal cavity epistaxis,or in conjunction when source unclearLynch incisionFronto-ethmoid suture line12-24-6 (14-18,8-10,4-6)Transnasal Endoscopic Sphenopalatine Artery ligationFollow Middle Turbinate to posteriormost aspectVertical mucoperiosteal i
27、ncision 7-8mm anterior to post middle turb(between mid.and inf.turbs)Elevation of flapID neurovascular bundle at foramenLigation with titanium clipReapproximate flapComplications few,Failures0-13%Transnasal Spheno-palatine Artery ligationFunctional endoscopic sinus surgeryLaboratory examVascular sup
28、plyTopical decongestants/vasocontrictorsWegeners GranulomatosisAntihistamines to prevent rebleedsAnatomy/Physiology of Epistaxis68),and shorter hospital stays(2.-Greater Palatine(IMAX)traumatic foreign bodiesOthers compared all medical treatment to surgery and showed cost cut using medical managemen
29、t.Hypertension/ArteriosclerosisLocal Factors Dessication68),and shorter hospital stays(2.Non-surgical treatments on d/cECA ligationEffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are safe.Septodermoplasty/LaserRemove mucosa from anterior septum,floor of
30、nose,lateral wallSTSG vs.cutaneous,myocutaneous,microvascular free flaps vs.AutograftsNeodymium-yttrium-garnet(Nd-YAG)laser or Argon laser+topical steroid best nonsurg rx for mild/mod diseaseStill bleed,but not as badDefinitive treatment(severe disease)closure of noseStatistically speaking,.Some aut
31、hors(Wang and Vogel)showed surgical intervention to have lower failure rates(14.3 vs.26.2),decreased complications(40 vs.68),and shorter hospital stays(2.2 less)than those w/posterior packs.Others compared all medical treatment to surgery and showed cost cut using medical management.Complication rat
32、es:posterior packs-25-40%,embolization 27%,IMAX ligation 28%Cost analysis:IMAX vs.Embolization vs.Surgical Cauteryabout equalFailure rates:PP-30%,Sx-17%,Emb-4%Tips and PearlsRed rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more(not on both sides of septum)Antihistamines to pr
33、event rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels(2 or more)injected with cortisporin oticAmicar sprayTips and PearlsHot water irrigationCold water irrigationSalt PorkDont pack nose in unconscious person with suspected skull fractures.Antibiotic cream vs.silver
34、nitrateIntranasal pressureEstrogen cream to nasal septumTips and PearlsTransnasal endoscopic bipolar cautery of sphenopalatine artery(7%failure in pts with obvious source of bleed)Submucosal supraperichondrial dissection of nasal septumNot all hospitals have embolization-trained interventionalistsNo
35、 hard-set outline.Do what is best for your particular patient典型录像下鼻道后端：鼻后外侧动脉出血中鼻甲下端：鼻后外侧动脉中鼻甲支下鼻甲上缘：鼻后外侧动脉分支鼻中隔上端：筛前动脉鼻中隔前端：筛前动脉末端等鼻内镜下止血门诊止血成功率大约95需要鼻内镜手术并止血的：鼻中隔偏曲合并鼻出血，眶壁骨折合并鼻出血，鼻腔肿物或鼻窦肿瘤合并鼻出血需要栓塞的：颈内动脉假性动脉瘤，颈内动脉海绵窦动静脉瘘Anatomy/Physiology of EpistaxisAnatomyNasal cavityVascular supplyPhysiologyVa
36、scular natureMucosaAnatomy of the Lateral Nasal WallSPF-class I(35%)-class II(56%)-class III(9%)Vascular natureAnterior border of SCMMaxillary sinus ostiumcutaneous,myocutaneous,microvascular free flaps vs.Pt requires transfusion/admit hct of 38%(barlow)Wegeners GranulomatosisInfectious/Inflammatory
37、Local Factors-NeoplasmAnterior:younger,usually septal vs.External carotid artery ligationNot all hospitals have embolization-trained interventionalistsMild sedation/analgesiaMicroscopic dissection and ligation of IMA-descending palatine&sphenopalantine most importantVonWillebrands disease下鼻甲上缘：鼻后外侧动
38、脉分支Local Factors-TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses,orbits,middle ear,base of skullBarotraumaNon-surgical treatments Control of hypertension Correction of coagulopathies/thrombocytopenia FFP or whole blood/reversal of anticoagula
39、nt/plateletsPressure/Expulsion of clotsTopical decongestants/vasocontrictorsCautery(AgNo3 vs.TCA vs.Bipolar vs.Bovie)Nasal packing(effective 80-90%of time)Greater palatine foramen blockNasal packsAnterior nasal packsTraditionalRecent modificationsPosterior nasal packsTraditional Recent modifications
40、Ant/Post nasal packingStatistically speaking,.Some authors(Wang and Vogel)showed surgical intervention to have lower failure rates(14.3 vs.26.2),decreased complications(40 vs.68),and shorter hospital stays(2.2 less)than those w/posterior packs.Others compared all medical treatment to surgery and sho
41、wed cost cut using medical management.Complication rates:posterior packs-25-40%,embolization 27%,IMAX ligation 28%Cost analysis:IMAX vs.Embolization vs.Surgical Cauteryabout equalFailure rates:PP-30%,Sx-17%,Emb-4%Tips and PearlsRed rubber on suction in contralateral nasal cavity AgNO3 x 30seconds or more(not on both sides of septum)Antihistamines to prevent rebleedsCautery does not work with no platelets/clottingGlove packingH2O2Merocels(2 or more)injected with cortisporin oticAmicar spray典型录像下鼻道后端：鼻后外侧动脉出血中鼻甲下端：鼻后外侧动脉中鼻甲支下鼻甲上缘：鼻后外侧动脉分支鼻中隔上端：筛前动脉鼻中隔前端：筛前动脉末端等
