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 arteryNasal anomaly precluding packingMicroscopic dissection and ligation of IMA-descending palatine&sphenopalantine most importanttraumatic foreign bodiesNasal packing(effective 80-90%of time)Follow Middle Turbinate to posteriormost aspectNasal anomaly precluding packing-
6、Anterior Ethmoid arteryOnly able to embolize external carotid&branchesSeptodermoplasty/Laser ablationCaldwell-LucNasal anomaly precluding packingTraditionalECA ligationRecent modificationsPatients s/p IMAX ligation still bleeding,superior nasal cavity epistaxis,or in conjunction when source unclear-
7、Superior Labial arteryTraditionalTrauma to sinuses,orbits,middle ear,base of skullAtrophic rhinitis-Ascending pharyngeal arteryAnatomy of the Nasal Cavity and VasculatureSphenopalatine AAEthmoid AAGreater Palatine AKesselbachs Plexus/Littles Area:-Anterior Ethmoid(Opth)-Superior Labial A(Facial)-Sph
8、enopalatine 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 plexus,
9、more serious.EtiologyLocal factorsVascularInfectious/InflammatoryTrauma(most common)IatrogenicNeoplasmDessicationForeign Bodies/otherEtiologySystemic factorsVascularInfection/InflammationCoagulopathy Local Factors-VascularICA Aneurysms extradural cavernous sinus Local Factors-Infection/InflammationR
10、hinitis/SinusitisAllergicBacterialFungalViralLocal Factors-TraumaNose pickingNose blowing/sneezingNasal fractureNasogastric/nasotracheal intubationTrauma to sinuses,orbits,middle ear,base of skullBarotraumaNasal Fracture with Septal HematomaLocal Factors-Iatrogenic nasal injuryFunctional endoscopic
11、sinus surgeryRhinoplastyNasal reconstructionAntibiotic cream vs.Pick a pack to pack withSelective Angiography/embolization下鼻甲上缘：鼻后外侧动脉分支Nasal anomaly precluding packingStill bleeding after surgical arterial ligationHematologic malignancies-Ascending pharyngeal arteryMiddle agetumorsvaseline gauzeTra
12、nsnasal endoscopic bipolar cautery of sphenopalatine artery(7%failure in pts with obvious source of bleed)Patient refusal/intolerance of packingGlove packingLigation with titanium clipVascular natureAdenocarcinomaTrauma to sinuses,orbits,middle ear,base of skullTemporalis mm split and partially diss
13、ected中鼻甲下端：鼻后外侧动脉中鼻甲支Surgical Cauteryabout equal-class II(56%)Local Factors-NeoplasmJuvenile nasopharyngeal angiofibromaInverted papillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphomaLocal Factors DessicationCold,dry airmore common in wintertimeDry heatPhoenix and Death valleyNasal oxygenA
14、natomic abnormalitiesAtrophic rhinitisLocal Factors-OtherSelf-inflicted (pedi)vs.traumatic foreign bodiesIntranasal parasitesSeptal perforationChemical(cocaine,nasal sprays,ammonia,etc.)Systemic Factors-VascularHypertension/ArteriosclerosisHereditary Hemorrhagic Telangectasias(OWR)Systemic Factors I
15、nfection/InflammationTuberculosisSyphillisWegeners GranulomatosisPeriarteritis nodosaSLESystemic Factors Coagulopathies ThrombocytopeniaPlatelet dysfunctionSystemic disease(Uremia)drug-induced(Coumadin/NSAIDs/Herbal supplements)Clotting Factor DeficienciesHemophiliaVonWillebrands diseaseHepatic fail
16、ureHematologic malignanciesSubmucosal supraperichondrial dissection of nasal septumTrauma to sinuses,orbits,middle ear,base of skullGreater palatine foramen blockVital signsneed IV?Bleeding site difficult to reach surgicallySurgical Cauteryabout equalWegeners GranulomatosisNasal packing(effective 80
17、-90%of time)90+%success rate,complication rate of 0.Patients s/p IMAX ligation still bleeding,superior nasal cavity epistaxis,or in conjunction when source unclearSeptodermoplasty/Laser ablationComplications:trismus,damage to infraorbital nComplications:trismus,damage to infraorbital nLocal Factors-
18、TraumaDefinitive treatment(severe disease)closure of noseAnatomy of the Nasal Cavity and VasculatureArterial to venous anastamosesHelps identify location of bleedingAnterior nasal packsBleeding site difficult to reach surgicallyEtiology and AgeChildrenforeign body,nose picking,nasal diptheria(1/3 wi
19、th chronic bleeds have coagulation d/o)Adultstrauma,idiopathicMiddle agetumorsOld age-hypertensionInitial ManagementABCsMedical history/MedicationsVital signsneed IV?Physical examAnterior rhinoscopyEndoscopic rhinoscopyLaboratory examRadiologic studiessuctiongood lightanestheticsilver nitrate meroce
20、lsgelfoambacitracinendoscopessuction 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/va
21、socontrictorsCautery(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
22、packsAnterior nasal packsTraditionalRecent modificationsPosterior nasal packsTraditional Recent modificationsAnt/Post nasal packingCautery(AgNo3 vs.ICA AneurysmsSome authors(Wang and Vogel)showed surgical intervention to have lower failure rates(14.Control of hypertension90+%success rate,complicatio
23、n rate of 0.Humidity/emolientsAnt/Post nasal packingCautery(AgNo3 vs.-Superior Labial A(Facial)Glove packingSphenopalatine foramen(SPF)ClassGreater palatine foramen blockSelf-inflicted (pedi)vs.Greater palatine foramen blockSome authors(Wang and Vogel)showed surgical intervention to have lower failu
24、re rates(14.Childrenforeign body,nose picking,nasal diptheria(1/3 with chronic bleeds have coagulation d/o)Definitive treatment(severe disease)closure of noseHelps identify location of bleedingPeriarteritis nodosaPeriarteritis nodosaPick a Pack,any packPick a pack to pack withTSSNugauze vs.MerocelEl
25、ectron microscopyPosterior Packs Admission Elderly and those with other chronic diseases may need to be admitted to the ICUContinuous cardiopulmonary monitoringAntibioticsOxygen supplementation may be neededMild sedation/analgesiaIVFIndications for surgery/embolizationContinued bleeding despite nasa
26、l packingPt requires transfusion/admit hct of 72hrs(wang vs.schaitkin)Selective Angiography/embolizationHelps identify location of bleedingEmbolization most effective in patients whoStill bleeding after surgical arterial ligationBleeding site difficult to reach surgicallyComorbidities prohibit gener
27、al anestheticEffective only when bleeding is.5 ml/min90+%success rate,complication rate of 0.1%Only able to embolize external carotid&branchesComplications:minor(18-45%)/major(0-2%)Contraindicated in bad atherosclerosis,Ethmoid bleedSurgical treatmentTransmaxillary IMA ligationIntraoral IMA ligation
28、Anterior/Posterior Ethmoidal ligationTransnasal Sphenopalatine ligationExternal carotid artery ligationSeptodermoplasty/Laser ablationTransmaxillary IMA ligationWaters view Caldwell-LucElectrocautery of posterior wall before removalMicroscopic dissection and ligation of IMA-descending palatine&sphen
29、opalantine most importantRecurrence rate(failure rate)of 10-15%Complication rate of 25-30%(oa fistula,dental,n)Intraoral IMA ligationPosterior gingivobuccal incision beginning at second molarTemporalis mm split and partially dissectedIMAX visualized,clipped and dividedAdvantages:children/facial frac
30、turesDisadvantages:more proximal ligationComplications:trismus,damage to infraorbital n-class III(9%)Definitive treatment(severe disease)closure of noseTransnasal endoscopic bipolar cautery of sphenopalatine artery(7%failure in pts with obvious source of bleed)Middle agetumorscavernous sinusVascular
31、 natureICA AneurysmsNasal anomaly precluding packingTSSNugauze vs.Class 3:there are two separate opening into the superior and middle meatiComplications:trismus,damage to infraorbital nMerocels(2 or more)injected with cortisporin oticChildrenforeign body,nose picking,nasal diptheria(1/3 with chronic
32、 bleeds have coagulation d/o)Continuous cardiopulmonary monitoringInternal Carotid ArteryNasal packing(effective 80-90%of time)Patients s/p IMAX ligation still bleeding,superior nasal cavity epistaxis,or in conjunction when source unclearChildrenforeign body,nose picking,nasal diptheria(1/3 with chr
33、onic bleeds have coagulation d/o)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Local Factors-TraumaAnt./Post.Ethmoidal ligationPatients 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 Endosc
34、opic Sphenopalatine Artery ligationFollow Middle Turbinate to posteriormost aspectVertical mucoperiosteal incision 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-
35、13%Transnasal Spheno-palatine Artery ligationECA ligationEffectivenessAnterior border of SCMID ECA/ICALigation after clear that surrounding structures are safe.Septodermoplasty/LaserRemove mucosa from anterior septum,floor of nose,lateral wallSTSG vs.cutaneous,myocutaneous,microvascular free flaps v
36、s.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 authors(Wang and Vogel)showed surgical intervention to have lower failure rat
37、es(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 rates:posterior packs-25-40%,embolization 27%,IMAX ligation 28%Cost analysis:
38、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 packin
39、gH2O2Merocels(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 nitrateIntranasal pressureEstrogen cream to nasal septumTips and PearlsTra
40、nsnasal 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 hard-set outline.Do what is best for your particular patient典型录像下鼻道后端：鼻后外
41、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 supplyPhysiologyVascular natureMucosaAnatomy of the Lateral Nasal WallSPF-class I(35%)-class
42、 II(56%)-class III(9%)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/reve
43、rsal of anticoagulant/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 R
44、ecent modificationsAnt/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
45、 to surgery and showed 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 A
46、gNO3 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 sprayChildrenforeign body,nose picking,nasal diptheria(1/3 with chronic bleeds have coagulat
47、ion d/o)Non-surgical treatmentsPeriarteritis nodosa5-10%of the population experience an episode of epistaxis each year.Non-surgical treatments on d/cJuvenile nasopharyngeal angiofibromaPlatelet dysfunctionJuvenile nasopharyngeal angiofibromaClass 2:the SPF spans the ethmoidal crest(i.Cold water irri
48、gationLaboratory exam-Sphenopalatine A(IMAX)FFP or whole blood/reversal of anticoagulant/plateletsAnatomy/Physiology of EpistaxisHereditary Hemorrhagic Telangectasias(OWR)Amicar sprayNasogastric/nasotracheal intubationMild sedation/analgesiaEmbolization vs.Others compared all medical treatment to surgery and showed cost cut using medical management.vaseline gauze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
