e.n.t. head & neck dept topical presentation · -positive family hx of epistaxis--takes...
TRANSCRIPT
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E.N.T. HEAD & NECK DEPT TOPICAL PRESENTATION
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EPISTAXIS
PRESENTERS: DR. OSISI
DR. AKPALABA
DR. EDIALE
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OUTLINE
• CASE PRESENTATION
• INTRODUCTION
• ANATOMY
• EPIDEMIOLOGY
• CLASSIFICATION
• CLINICAL FEATURES
• MANAGEMENT
• PROGNOSIS
• CONCLUSION
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Case 1
-Mr. O. S.
-57yr old Business man
-Resides in Benin city
-Christian
- Bini
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• P.C – Lt Nasal Recurrent bleeding x 1/12
• HPC
-Bleeding was spontaneous.
-Had about ten episodes, EBL - 50mls/Episode.
-No bleeding from other parts of the body
-No dizziness or fainting attacks.
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-No hx of trauma, nasal discharge or blockage
-No otologic symptoms
-Takes Ibuprofen periodically every other week.
-No neck mass, or abdominal swelling
-Recently diagnosed hypertensive on Nifedipine and Moduretic
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-No family hx of Epistaxis
-Does not take alcohol
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• O/E – Middle age man, calm, afebrile, not pale, anicteric, not dehydrated, no pedal edema.
CVS
-PR 80bpm, regular, good volume
-BP 130/80 mmHg
NOSE
-Blood clot, Lt nasal cavity
-Active bleeding
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ORAL CAVITY/OROPHARYNX
-Streaks of blood in posterior pharyngeal wall.
NECK
-No palpable mass
EAR
-Appeared normal
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• DIAGNOSIS – Recurrent Lt Nasal Epistaxis? cause
-FBC, Blood film
-Clotting profile
-E/U/Cr
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-Xray Paranasal sinuses
-Anterior nasal packing
-Tabs dicynone 250mg tds
-Tabs ciprofloxacin 500mg bd
-Presently on Follow-up
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Case 2
• Mr E. O.
• 35yr old Bricklayer/Welder
• Resides in Benin city
• Christian
• Esan
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• P.C. – Recurrent Lt nasal bleeding x 4/7
• HPC-
- Bleeding was spontaneous.
- Had about two episodes, EBL – 1.8litres.
- Similar episode 3yrs ago
- No bleeding from other parts of the body
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-Assoc dizziness, but no fainting attacks.
-No hx of trauma, nasal discharge or blockage
-No ear or throat symptoms
-Hx of prolonged bleeding from minor injuries.
-Positive family hx of epistaxis
-
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-Takes alcohol, 1 bottle/day for 15years
-No use of NSAIDs or Anticoagulant
-Not a known hypertensive
-Initially presented at Central Hosp B/city,
-Had nasal packing done
-Transfused with a unit of blood.
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-PMH-Not a known DM, PUDx
-FSHMarried with 3 children, monogamous settingDoes not smoke cigarette
-Drug Hx-Nil hx of drug allergy.
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• O/E-
Young man, anxious, febrile (38.3c), pale, anicteric, not dehydrated, no pedal edema.
CVS – P.R 120bpm, regular, good volume
B.P 140/90.
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• NOSE
-Patent bilaterally
-No petechial hemorrhages
-Hyperaemic spot on the septum
-Engorged inferior turbinates
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• ORAL CAVITY/OROPHARYNX
-Minimal streaks of blood in the posterior pharyngeal wall
NECK- No neck mass palpable
EAR – Appeared normal
OTHER SYSTEMS – Appeared normal
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DIAGNOSIS – Epistaxis ? Cause
r/o Bleeding Diathesis
-Urgent PCV – 17%
-GXM 3 units of blood
-Crude Clotting time – 2minutes
-FBC – Platelets 158,000, WBC 6,500
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-E/U/Cr - Ur 66mg/dl, others normal
-PT, PTTK - Normal
-LFT – Normal
-RVS - Negative
-Xray Paranasal sinuses
-Hematologist reviewed- Lassa fever screening (Negative)
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-IVF 5% Dext. Saline
-IV Dicynone 250mg bd
-Tabs Ciprofloxacin 500mg bd
-Tabs Flagyl 400mg tds
- Haematinics
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2nd DOA
- P.R 112bpm
- B.P -170/110mmHg
-Medical review
-commenced anti-Hypertensive.
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-Had Silver nitrate cauterization on 4th Day
-Bilateral Anterior nasal packing done on 5th Day
-Posterior nasal packing on same day
-Emergency Left External carotid artery ligation
done on 10th Day.
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Emergency EUA Nose, Nasopharynx with BellocqPosterior nasal packing on 11th DOA.
Findings at surgery:
-Multiple mucosal hemorrhages on the septum
and lateral nasal walls.
-Diffuse oozing of blood from the posterior wall of the nasopharynx
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- Bleeding subsided after surgery
- Blood transfusion
Had 13 units of blood transfused
-Discharged home on Anti-Hypertensives on 21st
DOA
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INTRODUCTION
- Bleeding from the Nasal cavity
- Commonest otolaryngological emergency.
- Affects up to 14% of the population in their lifetime.
- 6% of cases requiring medical attention.
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• The management include-
-resuscitation,
-through direct visualization and cautery,
-nasal packing,
-and surgery (both endoscopic and external)
-to embolization.
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RELEVANT ANATOMY
– Nasal cavity
– Vascular supply
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BLOOD SUPPLY
• External Carotid Artery
• -Sphenopalatine artery
• -Superior Labial artery
• -Greater palatine artery
• -Ascending palatine artery
• -Posterior nasal artery
• Internal Carotid Artery
• -Anterior Ethmoidal artery
• -Posterior Ethmoidal artery
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VENOUS DRAINAGE
• Pterygoid plexus
• Facial vein
• Ophthalmic veins
• Emissary vein superior saggital sinus
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SITES OF EPISTAXIS• Kiesselbach’s Plexus/Little’s Area:
• Above middle turbinate
• Below middle turbinate
• Posterior part of nasal cavity
• Diffuse
• Nasopharynx
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CLASSIFICATION OF EPISTAXIS
• PRIMARY OR SECONDARY
• CHILDHOOD OR ADULT
• ANTERIOR OR POSTERIOR
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CLASSIFICATION OF EPISTAXIS
• PRIMARY—IDIOPATHIC
• SECONDARY-KNOWN CAUSAL FACTOR
• CHILDHOOD-- <16yrs
• ADULT-- >16yrs
• ANTERIOR- anterior to piriform aperture
• POSTERIOR– posterior to piriform aperture
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CLASSIFICATION OF EPISTAXIS
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EPIDEMIOLOGY
• 2nd common cause of mortality
• All age groups
• Bimodal – childhood (common)
-- 6th decade (peak)
• 7- 14 % of population
• M:F = 1.25 : 1
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AETIOLOGY
• IDIOPATHIC (Most common)
• LOCAL
• GENERAL/SYSTEMIC
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AETIOLOGY
• Local factors– Trauma
– Infectious/Inflammatory
– Iatrogenic
– Neoplasm
– Foreign Bodies
– Vascular
– Dessication
– Deviated nasal septum
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LOCAL FACTOR -TRAUMA
• Nose picking
• Nose blowing/sneezing
• Nasal fracture
• Nasogastric/nasotracheal intubation
• Trauma to sinuses, orbits, middle ear, base of skull
• Barotrauma
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Local Factors - Infection/Inflammation
• Rhinitis/Sinusitis
– Allergic
– Bacterial
– Fungal
– Viral
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Local Factors - Iatrogenic nasal injury
• Functional endoscopic sinus surgery
• Rhinoplasty
• Nasal reconstruction
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Local Factors - Neoplasm
• Juvenile nasopharyngeal angiofibroma
• Nasopharyngeal carcinoma
• Inverted papilloma
• SCCA
• Adenocarcinoma
• Melanoma
• Esthesioneuroblastoma
• Lymphoma
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Local Factors –Dessication
• Cold, dry air—more common in wintertime
• Dry heat
• Nasal oxygen
• Anatomic abnormalities
• Atrophic rhinitis
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Local Factors - Others
• Self-inflicted (pedi) vs. traumatic foreign bodies
• Intranasal parasites
• Septal perforation
• Chemicals (cocaine, nasal sprays, ammonia, etc.)
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AETIOLOGY- CONT’D
• Systemic factors– Vascular
– Infection/Inflammation
– Coagulopathy
– Liver disease
– Kidney disease
– Drugs
– Vicarious menstruation
IDIOPATHIC-80%
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Systemic Factors -- Vascular
• Hypertension/Arteriosclerosis
• Hereditary Hemorrhagic Telangectasias(OWR)
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Systemic Factors –Infection/Inflammation
• Tuberculosis
• Syphillis
• Wegener’s Granulomatosis
• Periarteritis nodosa
• SLE
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Systemic Factors – Coagulopathies
Thrombocytopenia• Platelet dysfunction
– Systemic disease (Uremia)– drug-induced
NSAIDs/anticoagulantsAlcoholTobaccoCocaine
• Clotting Factor Deficiencies– Haemophilia– Von Willebrand’s disease– Hepatic failure
• Haematologic malignancies
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CLINICAL PRESENTATION
• Spontaneous
• Provoked
• Recurrent
• Scanty
• Profuse
• Post-nasal drip
• vicarious menstruation
• Haematemesis
• Fever / sore throat
• Headache
• Dizziness
• Syncope
• Pale
• Shock
• Features of liver disease, malignancy,
Kidney disease
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Management
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• History
- Onset, frequency, volume, Laterality
- Possible risk factors
• Examination
- P/E : Anxious
Pallor +/- , dehydration
Tachycardia
Blood pressure
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- Anterior rhinoscopy
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- Nasal endoscopy
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- Oropharynx:
- Neck:
- Ears:
- Other systems: Chest, Abdomen
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Investigations
• Haematology: Hb, Fbc & platelets, Gxm
- EUCr
- CCT, PT/PTTK
- VIII / IX assay
- LFT
- RVS , PCR (Lassa Fever)
• Radiology: - X-ray Paranasal sinuses
- CT-scan
- MRI
- Angiography
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X-ray paranasal sinuses
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CT-Scan Paranasal sinuses
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Investigation cont’d
• EUA nose & nasopharynx +/- biopsy
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Treatment
• Principles
1. Establish site of bleeding
2. Stop bleeding
3. Treat cause
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First Aid
A. Hippocrates Technique
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• Trotters Method
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• Modalities
A. Resuscitation(active/profuse bleed)
- Venous access
- Anterior rhinoscopy
- Suction toileting
- Topical decongestant/anaesthetic
B. Cauterization
- Chemical- silver nitrate
- Electrical- bipolar diathermy
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C. Nasal Packing
1. Anterior
- Ribbon gauze/BIPP, Gloved finger
- Bilateral
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Vertical/Horiz. Antr. Nasal packing
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2. Posterior Nasal Packing
- Bellocq (rolled gauze pack)
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- Inflatable balloons:
I. Brighton
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II. Foley's catheter
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D. Surgery
I. EUA +/- cautery or packing or septoplasty
II. Ethmoidal Artery Ligation
III. Endoscopic Sphenopalatine Artery Ligation
.
IV. Maxillary Artery Ligation
V. External Carotid Artery Ligation
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Arterial Ligation
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Ethmoidal Artery Ligation
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Sphenopalatine Artery Ligation
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Transantral approach –Maxillary ArteryLigation
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External Carotid Artery Ligation
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E. Embolization
- Angiography
- Polyvinyl alcohol, tungsten or steel microcoil
used to embolise vessels.
F. Laser Coagulation – Hereditary Haemorrhagic
Telangiectasia
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• Supportive measures
- Pharmacological Agents
- Blood Products : FFP/ Platelet concentrates
Aetiological factors identified & Treated
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Algorithm in the mgt of Epistaxis
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• Prognosis- Good:
• Prevention & Follow- up:
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Local Experience: Jan 2010 - Dec 2011
( U.B.T.H)
• Total Cases= 57
- Age: 23mths – 85years
- Mean Age= 42years
- M=29 , F=28: 1 : 1
- 17- Admissions
- 1 had ECAL
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• Aetiology:
Idiopathic - 24 (42%)
Infection - 18 (32%)
Atherosclerosis - 11 (19%)
Trauma - 3 ( 5%)
Bleeding diathesis - 1 ( 2%)
Total = 57 Patients
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Conclusion
- Epistaxis is a symptom and sign
- A cause of morbidity
- Evaluation - control bleeding & treat
cause
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THANK YOU