Epistxis : Epistxis bleeding from inside nose History. a/ Hippocrates 5thcenturyBC b/Ail bIn Rabat AD 850(the Paradise of wisdom) c/Merging 1769AD(syringe the nose with cold water and wine d/ Mahomed 1880. Slide 2: Vascular Supply of Nose: Slide 3: Nasal Septum : Internal carotid(Anterior and posterior Ethmoidal) External carotid:Sphenopaltine and greater palatine. superior labial branch of fascial artery. Slide 5: Woodruff's plexus: is responsible for posterior bleeds. This area is located over the posterior end of the middle turbinate. The anastomosis here is made up of branches from the internal maxillary artery namely its sphenopalatine and pharyngeal branches ascending Phyrangeal Branches. pharyngeal branchesWoodruff's plexus: is responsible for posterior bleeds. This area is located over the posterior end of the middle turbinate. The anastomosis here is made up of branches from the internal maxillary artery namely its sphenopalatine and ascending pharyngeal branches Slide 6: Epistaxis from septum in vast majority.Littles area described by James Little. the bleeding from this area is Arterial. The Dynamics of Nasal circulation.(arterioarterial anastomosis and contribution from internal and external carotid.) Slide 7: Causes of Epistaxis : Local a/ Trauma, Acute facial trauma, nose picking,intranasal surgery. b/ Infections Acute/Chronic c/ Foreign Bodies, Rhinolith d/ Neoplasm, hemangioma,Oslers disease, malignant e/Septal deviations, f/Atmospheric Slide 8: General Causes, Hypertension, arteriosclerosis, Blood dyscrasia,hereditary telangiectasia(osler disease) Drugs NSAID,ASPIRIN, ANTICOAGULANTS..INR 2/ Nasopharynx. Juvenile Angiofibroma Slide 9: Vast majority of epistaxis is from Septum..Littles area, its arterial.(o h shaheen) In children epistaxis from retro columllerVein. Slide 10: Anterior bleeding, Its common,recurrent,mild to moderate,littles area. posterior bleeding, Its severe, spontaneous.occasional ,difficult to manage.old age and are hypertensive, Slide 11: Management: History, onset, how much blood lost, recurrent.side of the nose bleeding tendency ,hypertension,diabetes, if on anticoagulant ask about INR Which side is bleeding? Which side was bleeding initially? What is the estimated amount of blood loss? Is it recurrent? Is it in the pharynx? Has any trauma recently occurred? Are symptoms of hypovolemia present? What are the patient’s past medical history and current medications (eg, aspirin, warfarin)?  Slide 12: General care: patient in sitting position, IV cannula,Blood for Hb and Group and croos match and save. Explain to patient ,how you are going to stop bleeding. : In sever b leeding, clear clots, Local anaesthetic spray, Try to Visualize bleeder or Endoscopic examination And Cauterize with Silver nitrate if still bleeding,Merocele packing and Hospitalize and IV antibiotics Slide 14: 90% Nasal bleeding stops with Merocele Packing, its easy to insert, painless Anterior nasal Bipp Packing Slide 15: In very few cases may need Posterior packing or catheter or brighton baloon. Slide 16: Posterior nasal packing. Slide 17: SMR if bleeding persist when nasal packing removed. Ligation of blood vessels. 1/internal Maxillary artery, 2/ external carotid artery. 3/ Anterior ethmoidal artery Slide 18: Unusual causes of epitaxis; Oslers disease (hereditary haemorrhagic telangiectasia)red spots on lips,tongue,face and nose, may be in the gut and lungs. recurrent epistxis, difficult to treat. Harrison (1957) estrogen Slide 19: Saunders (1963) excise nasal mucous membrane from anterior septum and replace with skin..septodermoplasty. Application of laser. Slide 20: Nasopharyngeal Angiofibroma:It is benign yet aggressive tomour. origin Posterior nose and nasophyrnx. Histology endothelial lined spaces and fibrous tissue,,, Incidence and age, not common,adolescent,male Slide 21: Clinical featurs. nasal obstruction and epistaxis.less common eustachian tube dysfunction and conductive deafness, fascial swelling ,proptosis. Reddish purple nodular mass in posterior nares and nasopharynx. Spread by expansile growth throug natural fissures. Slide 22: diagnosis:age,sex history,and physical findings are often diagnostic. radiology CT/MRI Treatment: Surgery Slide 23: wagners granuloma ; autoimmune, non healing ulceration of septum with granulations and cause septal perforation. crusts form and can cause epistaxis. diagnosis by biopsy giant cell granuloma and polyartritis nodosa in grnulations. Treatment: high doses of steroid and prognosis monitored by ESR. Slide 24: Question enumerate causes of epistaxis and its management in detail.