EPISTAXIS

MANAGEMEN
T
DEPARTMENT OF OTORHINOLARYNGOLOGY-
HEAD AND NECK SURGERY
MEDICAL FACULTY UDAYANA UNIVERSITY
 EPISTAXIS
MANAGEMENT
Epistaxis
•  epi- and stazein  to drip on, to bleed at
the nose again (Greek)
• There are two main types of epistaxis:
• Anterior bleeds (90%) – originate
from ruptured blood vessels in Little’s
area (Kiesselbach’s plexus)
• Posterior bleeds (10%) –usually due
to bleeding from Woodruff's plexus
 • The initial management of epistaxis
is dependent on the volume of the
bleeding.
• All patients should be kept sit upright and
EPISTAXIS lean forward to protect the airway.
MANAGEME • Massive bleeding should be approached in
NT an A to E manner.
• Airway, Breathing, Circulation, Dissability,
Exposure
• This may include fluid resuscitation
 Manual Hemostasis
Cauterization
EPISTAXIS
MANAGEMEN Nasal Packing
T
Arterial Ligation
Embolization
 Manual Hemostasis
X
• Direct pressure  The nostrils are
squeezed together for 5-30 minutes
straight.
• Keep head elevated but not
hyperextended  may cause
√ bleeding into the pharynx and
possible aspiration.
Kiesselbach’s Plexus

anterior ethmoid artery, greater palatine

artery, sphenopalatine artery, and superior
labial artery
 anteroinferior nasal septum
Mouth breathing and spitting all blood or saliva Put an ice pack placed over the dorsum
into a bowl of the nose

Manual Hemostasis
• If direct pressure is not sufficient, gauze moistened with
epinephrine at a ratio of 1:100,000 or 1:200.000 may be placed
in the affected nostril to help vasoconstrict and achieve
hemostasis.
How to make a 1:100,000 epinephrine
solution from 1:1,000 epinephrine?

0.1 cc epinephrine 1:1,000

diluted with 10 cc of NaCl 0,9%
or sterile water for injection
(lidocaine can be added to
acquire anesthesia effect)
The equipment of nasal packing procedure
Head lamp

Gloves

Face mask
Anterior nasal dressing

Vaseline nasal dressing

Ribbon gauze

Merocel sponges
 Posterior nasal dressing

Bellocq nasal pack

Nasal balloon
Tied together tightly with two #1-0 silk sutures

The silk suture should be left long enough that it

can be brought out through the nose
 How to do nasal
anterior packing?
Preparation
Head lamp
A. Placing headlamp onto the head.
B. Lamp position is on glabella between the
eyes.
C. Adjusting the lamp to make 15 angle
from examiner’s eye axis.
D. Focusing the lamp
Personal Protective Equipment  mask, gloves
Equipments for anterior nasal packing
procedure
 • Use non-dominant hand to hold
nasal speculum
• Thumb  ‘joint’ of nasal
speculum
• Index finger  nasal tip
• The other finger  holding
nasal speculum
• Insert gently to nostril in closed
position  superior part of nasal
cavity

Holding nasal speculum

Local Anesthesia
• Insert cotton that already soaked with
lidocaine (with or without epinephrine)
into bleeding nostril using bayonet forceps
• Leave for 3-5 minutes
• To reduce pain
• To block the nasal-vagal reflex (apneu,
bradycardia, hypotension)
• Remove the cotton  Evaluate bleeding
point
• If bleeding stopped, no further
management needed
How to do Ribbon gauze packing ?

Pick the gauze, that already coated with antbiotic zalf,

using Bayonette forceps approximately 10–15 cm from
1 the tip

2 Pack the nasal cavity starting from the floor

upwards
 How to do Ribbon gauze packing ?
Continue to do so by layering the gauze until reach
3 the cavity roof
Nasal packing must not hit the columella  easy to damage

Pack the cavity tightly.

Both ends of the ribbon gauze should both protrude
4 from the nostril.
 If one end dangling down the nasopharynx causing
the patient to gag or eliciting laryngospasm
How to do Ribbon gauze packing ?

5 Secure the gauze with dressing tape

Apply a nasal bolster to control dripping and secretions
How to do posterior nasal packing ?

A Posterior nasal packing with silk suture

B Red rubber catheters are passed through the nose until visible in the oropharynx.

C The catheters are then tied with silk sutures or umbilical tape.
How to do posterior nasal packing ?

The catheters are pulled out through the nose. The silk sutures or the umbilical tapes are
D secured to the posterior pack. The posterior pack is pulled and manually pushed into place.

E An anterior pack is then placed.

The silk sutures or umbilical tape is secured over dental rolls to maintain forward pressure and
F protect the columella.
 All packings should be
removed in 48 hours

Administer prophylactic
Anterior nasal antibiotics to all patients with
packing packing
Avoid physical strain for 1
week
THANK YOU