Epistaxis

Epistaxis is a common ENT emergency, The estimated lifetime incidence of epistaxis is approximately 60%. Most episodes are minor in nature self-limiting and do not require intervention Minor bleeding episodes occur more frequently in children and adolescents, whereas severe bleeds requiring intervention often occur in individuals older than 50 years. Peaks in incidence are seen in those under 10 years of age and aged over 40 years.

Management:

Trotter’s manoeuvre: cartilaginous part of the nose should be compressed for at least 15 to 20 minutes most of the time the anterior pressure stops the nasal bleeding

Cauterisation of anterior nasal bleeding: if the source of the bleeding can be seen attempt should be made to cauterise it after local anaesthesia, silver nitrate cautery or the bipolar cautery both are effective to control the bleeding from the anterior nasal septum

Failure of cauterization or medical management leads a clinician to consider packing as the next treatment option. Many different types of packs have been developed over the years, including, no absorbable, anterior, and posterior packs

Nasal Packing: Oxidized cellulose (eg, Surgicel): it is local hemostatic agent which acts by pressure compression and promote the coagulation at the bleeding site.

Absorbable Gelatin foams (Gelform): acts by temponade effect and promote the platelet aggregation

Non Absorbable packs:

Carboxymethylcellulose sponge (Merocel):

Usually used as first line anterior nasal packs, they act by mechanical compression of the bleeding point, usually they are lubricated with antiseptic ointment for easy insertion and preventing the secondary infection, Once inserted they are left for 24 to 48 hours. they are inserted along the floor of the nose. Side effects include patient discomfort at the time of insertion and removal of pack.

Impregnated Gauze packing: This is a traditional way of nasal packing where impregnated gauze is used as layers for packing the nasal cavity , it caused significant pain to the patient

Posterior nasal packing: posterior packing are not as commonly used , it is used with anterior packing when anterior packing alone fails to stop the bleeding

A Foleys catheter of size 14 or 12 is used , catheter is inserted along the nasal floor into the choana , the position is confirmed after visualisation of the tip in the posterior pharyngeal wall through the oral cavity , 5 to 10ml of saline is used to fully inflate the balloon and catheter is pulled to hinge over the choana there by occupying the nasopharynx and putting a tamponade effect on posterior end of the nasal cavity

Surgical Management:

If the above management fail to control the bleeding surgical management is indicated

Preop preparation :

The control involves endoscopic control of major blood vessels in the nose.

1. The procedure is most of the time done as emergency procedure
2. 1 or 2 units of packed RBS (blood ) is kept standby, excess blood loss may need blood transfusion during the surgery
3. Most of the time it is possible to control the bleeding intranasally with endoscope , some times external incision next to the medial canthus is needed to control the bleeding
4. Some times packing is done for 24 to 48 hours post surgery.
5. If patient has other comorbidities like hypertertension , cardiac issues , or on anticoagulant medications like aspirin or warfarin there is always risk of rebleeding.

Procedure :

Endoscopic Sphenopalatine artery ligation:

Surgical management of epistaxis is typically only for those patients whose bleeding is refractory to more conservative therapies. Knowledge of the vascular anatomy and important landmarks is necessary to avoid intraoperative bleeding and to lower the risk of postoperative bleeding. The sphenopalatine artery can be exposed endoscopically by raising a posterolateral mucosal flap over the orbital process of the palatine bone. A maxillary antrostomy is done to visualise the posterior maxillary wall and palatine bone .A vertical incision is made inferior to the posterior portion of the middle turbinate, 1 cm anterior to its posterior tip. Raising the mucoperiosteal flap posteriorly and superiorly will expose the ethmoid crest. The ethmoid crest represents a significant landmark for locating the position of the sphenopalatine artery and is consistently anteromedial to the sphenopalatine foramen. Resection of the ethmoid crest enhances exposure of the sphenopalatine artery and helps identify its branches to ensure appropriate vessel ligation. As the flap is raised and ethmoid crest resected, the fibro neurovascular bundle including the SPA and nasopalatine nerve will be reachable at the sphenopalatine foramen. After isolating the artery and its branches, the next step is either cauterizing them with bipolar forceps, occluding with clips, or using a combination of both Upon attaining bleeding control, the mucoperiosteal flap is put back in place and covered with surgical.

Anterior Ethmoidal Artery ligation

The anterior ethmoidal artery ligation is considered in cases of refractory epistaxis when either the bleeding is seen coming from AEA or sphenopalatine artery ligation does not control the nasal bleeding. Embolization is not an option for AES bleed as there is high risk of blindness.

Traditionally ligation has been performed via an open approach using a Lynch-type incision(10) with the placement of the vascular clip on the AEA between the periorbital fascia and its entrance into the lamina papyracea. Now many endoscopic approaches have been described for ligation of AEA avoiding external scar.

Retraction of the AEA into the orbit can lead to permanent vision loss, hence in case of failed endoscopic approach external approach is used.

Complication of the procedure:

1. Rebleeding
2. Nasal septal necrosis
3. Crustations
   
4. Revision surgery
5. Blindness in case of anterior ethmoidal artery bleeding
6. Anosmia
7. Injury to the orbit
8. Diplopia

Post of Care:

1. Avoid blowing of the nose for 6 weeks
2. Avoid heavy exercises and exertion for 6 weeks post surgery
3. Control of blood pressure
4. Use of nasal saline washes and saline nasal drops
   

For detailed videos and images of this procedure, click here