Epistaxis
Bleeding per nose
Aetiology
A idiopathic---------from little`s area
B Trauma
Nose picking
F.B
Maxillofacial trauma
Itrogenic
C infection acute or chronic.viral or bacterial
D Inflammatory
Rhinosinusitis
Nasal polyp
E Neoplasm
Benign angiofibroma, papilloma
Malignant sq.cellcarcinoma,adenocarcinoma, lymphoma
F Drug induced
Cocaine abuse
Rhinitis medicamentosa
medicamentosa,asprin,anticoagulant.chloramphinicol,immunosuppressant,alcohol
G inhalant
Tobacco
H endocrine
2 General
A atherosclerosis
B bleeding disorder
A coagulopathy
1inhereted coagulation factors deffeciancy like factor vii,factor ix
2acquired :anticoagulant,liver disease,vitamin k defficiancy
B platelate disorders
●thrombocytopenia
●●platelate disfunction
►congenital like vonwillbrand disease
►► acquired like leukemia,uremia,drugs as asprin & NSAID
C blood vessel disorders
●congenetal----osteogenesis imperfecta
●●acquired-----amyloid,vasculitis,vit.K defeciancy
D hyperfibrinolysis
●congenital------αantitrypsin deficiency
●● acquired------malignant DIC
Classification
Anterior epistaxis
Incidence more common
Site---------mostly from little`s area or anterior area of the nose
Age---------mostly occur in children or young adult
Cause------mostly trauma
Bleeding---usually mild,can be easily controlled by local pressure or anterior pack
posterior epistaxis
Incidence less common
Site---------mostly from posterosuperior part of the nasal cavity,often difficult to localize the
bleeding point
Age---------mostly occur after 40 yerars of age
Cause------spontanous,often due to hypertention or atherosclerosis
Bleeding---bleeding is sever,requires hospitalization,post nasal packing often
required
manegment
Arrest the haemorrhage
Nostril pinched together,sitting position,compession of boney bridge is of no value,upright
position is to lower the blood pressure
Assessment of blood loss
Blood pressure
Pulse
Sign of shock
IV line may be equired
So IV line should be inserted
Blood taken for cross-matching
Blood or other plasma expander may be required
Determination of the cause
A detailed history required
Determination of the site
Whether it is anterior or posterior,all clots should be removed,nasal endoscope may be required
Control of bleeding
Anterior epistaxis:
Bleeding point on the anterior septum can usually be controlled with cauterisation after
anaesthetizing the nasal mucosa,a cotton wool soaked in 5-10% cocaine with equal amount of
1:1000 adrenalin & squeezed out is very useful technique & often bleeding stopped as aresult of
vasoconstriction effect of cocaine & adrenalin
A search then done in dry clean nose for the responsible vessel
Cauterization then done by silver nitrate or electrical cautary
A nasal pack may be needed
there are different type of packs needed
vasaline gauze,bismuth iodoform paraffin paste BIPP
Commertially produced sponge(tampons)
Anterior nasal pack are usually left for24 hr it is uncomfortable for the patient
Posterior epistaxis
Continues bleeding despite anterior pack is propably aresult of bleeding from the posterior
branch of sphenopalatine artery and will need insertion of posterior pack.
A simple postnasal pack is a Foley cathter which if inflated once correctly positioned.
If bleeding continue
need examination under anaesthesia
if bleeding continue
Deal with any septal deviation as it may hide bleeding point or prevent packing(septoplasty or
SMR),obvious bleeding point can be controlled with diathermy,nasal endoscopy is helpful to
locate the offending vessel
if bleeding continue
Ligation of ant ethmoid artery
Ligation of posterior ethmoid artery
Ligation of external carotid artery
Angiography and embolization
Nasal trauma
Skeletal injury of the head and neck are not unusual and may arise from
►personal insult :blow to the nose from the side or infront
►►personal accident
►►►sport injury
►►►►RTA
Aetiology
Pathogenesis
◙ no fracture
Just oedema and bleeding.this occur in low velocity trauma but could lead to septal deviation
due to displacement of maxillary crest
◙ Class 1 fracture
Usually due to frontal or fronto-lateral blow result in vertical fracture of the septum-chevallet
fracture- with depressed or distal portion of the nasal bone
◙ Class II fracture
It is nearly always due to lateral trauma,result in horizontal fracture of the septum-Jarjavay
fracture- or C shape fracture of the septum involving the perpendicular plate of ethmoid and
septal cartilage with fracture of upper nose or frontal process of maxilla,here the velocity is
more than class I
◙ Class III fracture
The force is foreward ,the velocity is very high like RTA and here all facial bones could be
involved even ethmoid labrynth,cribriform plate of ethmoid, can lead to CSF rhinorrhea,this
fracture produce a pig like nose,i.e elevation of the nostrils and suddeling of nose with widening
of nasal bridge so increase space between eyes(telecanthus)
All types of fractures could be seen and in addition to soft tissue damage like nasalacrimal duct
damage.
Management
How and when the injury was sustained-- time and mechanism of trauma
Other injuries may also be present and may have been overlooked
There will be certain degree of nasal obstruction
Diplopia,visual disturbance and epiphora suggest orbital trauma
Loose teeth and altered bite or trismus indicate the need of dental opinion
Watery rhinorrhea ,loss of smellthough uncommon,signall possible skull base damage and need
more detailed evaluation
Examination may be difficult in the acute situation when swelling may hide an underlying
abnormality ,a second inspection afew days later 5-7 days may be necessary
Gently palpate the nasal bones for a step deformity ,any surgical emphysema that could suggest
a more serious injury.
Look if there is any soft tissue laceration.
Inspect the nasal cavities and check for the presence of septal haematoma or deviation
Then don’t forget to make a thorough general ENT /head &neck examination.
Treatment
If no fracture or deformity just conservative like manage the epistaxis properly ,analgesia and
reassurance
If fracture seen early and there is nooedema and swelling so do close reduction under LA or
short acting GA disimpaction & realignment can usually be achieved with digital pressure or
walsham`s forceps : elevation of fractured bones then packing and P.O.P splint for one week
If fracture seen later then will be much swelling ,so manipulation should be delayed for 5-7 days
,manipulation should never be delayed more than 2 weeksbecause the bones should be fixed
,calus formation and reduction should be difficult if not impossible
There are two treatment modalities for the broken nose ,the closed reduction method which
involves repositioning the dislocated parts of the nasal bone&can be achieved under local or
general anaesthesia as mentioned above
Or
Open reduction in which the the septum is also explored and injuries corrected
After 2 weeks reduction is difficult ,so leave until the condition is settled then do
septorhinoplasty after 6 months
☻you have to distinguish between recent trauma and old deformity especially in patient with
frequent injury likr sportman and frequent fighters
Nasal polyp
It is around ,smooth,translucent,soft,yellow or pale structure results from prolapsed lining of
ethmoid sinus
Aetiology
1 bernouilli phenomenon
If there is constriction the pressure will drop result in prolapse of mucosa
2 polysaccride changes in ground substance
3vasamotor imbalance when patient is not atopic
4 infection
5 allergy 90% or more of polyps have eosinophil and threr is association with asthema,and the
nasal finding mimic allergy(rhinorrhea,sneezing &nasal obstruction)
Incidence
It is a disease of adult,male predominance.
If present below 2 year think of maningocele
If present below 10 year think of cystic fibrosis
Any child with nasal polyps should be regarded as having cystic fibrosis until proved otherwise
Unilateral nasal polyp need histopathological study
Sign and symptoms
Polyp seen by anterior rhinoscopy occasionally seen normal externally
Mouth breathing due to nasal obstruction which is constantly present but of varying degree
depending on the size of polyp
Watery rhinorrhea
Post nasal drip
Anosmia
Hyponasal voice
Hypertelorism may develop if patient develop polyp befor fusion of facial bone
Management
Aneroir rhinoscopy is enough to diagnose nasal polyp
Plain x-ray
CT scan
Nasal polyp treated either medically by short course of systemic steroid or intranasal
steroid(betamethasone) or steroid nasal drops for one month this depend on the extent of the
polyposis.
Surgical treatment
1 simple polypectimy
2 intranasal ethmoidectomy which done endoscopically
3 external ethmoidectomy
Antrochoanal polyp
Antrchoanal polyps are a separate entity,this polyp has two components,a solid nasal one and a
cystic maxillary one
It is less common arise from maxillary antrum and prolapsed through the ostium of the sinus to
the nasal cavity and nasopharynx
It is common in adolescence
Ther is no place of medical treatment in antrochoanal polyp
Septal haematoma
It is due to collection of blood beneath the mucoprechondrium of the nasal septum this
collection interfere with the vitality of the cartilage ,the cartilage remain viable for 3 days more
than 3 days the chondrocyte die lead to absorption of the cartilage
Clinical pictures
Nasal obstruction---complete bilateral nasal obstruction
Discomfort
Septal swelling soft red in colour
Complication
Septal abcess
Cartilage necrosis
Nasal suddle deformity
Treatment
Simple aspiration ---if haematoma is small
Incision and drainage
Packing to obliterate dead space with or without quilting suture
Systemic AB
Septal abcess
Mostly due to trauma 75%
Infective –measle,scarlet fever,furenculosis,AIDS.
Complicate ethmoid and sphenoid sinus infection
Complication
Spread infection to orbit,meningies,brain,cavernous sinus
Clinical pictures
Sever pain
Septal swelling
Nasal obstruction
Pyrexia
Treatment
Immediate drainage
Systemic AB
Reconstruction of the defect in the acute phase will reduce growth impactionies
Foreign bodies in the nose
More common in the children 2-3 years
It is either
Organic
Paper,nuts,woods,pears,beans
Inorganic
Stones,plastic from toys,buttn
Clinical pictures
History of induction
Unilateral nasal obstruction
Unilateralnasal discharge & foul smell
Pain at nose disappear soon
Treatment
Nasal foreign body usually removed by hook,avoid clamps and artery forceps for not making
foreign body to escape posteriorly
Cupped forceps are preferable for removal of thin objects like buttons and piece of cotton
In every case the nasal cavity must be examined afterwards for another FB most posteriorly
Septal perforation
More common in the anterior cartilaginous part except that cause by syphilis which involve
posterior boney part
Aetiology
Trauma
Itrogenic –septoplasty,SMR,nasal cautary,self inflicted -----nose picking,injury,assult,RTA ۩
Infection-syphlis,TB۩
Inflammatory ۩
Inhalation or irritanteither by drugs like cocaine or occupational like arsenic or alkaline dust۩
idiopathic ۩
clinical pictures
majority are asymptomatic
epistaxis
dryness
crustation
nasal obstruction
the severity of symptom depend on the position and size of perforation,the lerger perforation
and more anterior position ---the worse symptom
very small perforation may cause whistling or nasal breathing
treatment
it treated ususlly when there is symptom like crustation or bleeding if asymptomatic only
reassurance
medical treatment
perforation never heal spontaneously
1cicatrin cream twice daily by tip of the finger
2 nasal douch
Surgical treatment
Split skin graft
Buccal flap
Sublabial flap
Septal mucoprechondrium flap
Composit flap from pinna or moving septal cartilage to fill the defect plug by silastic button if
small and cause whistle so -----enlarge