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Common ENT problems Suthee Ratanathummawat Department of Otolaryngology Phramongkutklao college of Medicine.

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งานนำเสนอเรื่อง: "Common ENT problems Suthee Ratanathummawat Department of Otolaryngology Phramongkutklao college of Medicine."— ใบสำเนางานนำเสนอ:

1 Common ENT problems Suthee Ratanathummawat Department of Otolaryngology Phramongkutklao college of Medicine

2 Case 1 “A 55-year old lady has come in with a severe nose bleed and we are getting vital signs.” “A 55-year old lady has come in with a severe nose bleed and we are getting vital signs.”

3 Epidemiology  Child and adult : anterior epistaxis  Elderly : posterior epistaxis  90% of epistaxis occur at anterior site  More common in winter Epistaxis anterior epistaxis posterior epistaxis

4 Two types of nosebleeds Anterior NB (most common) Posterior NB (less common, but more severe)

5 Kiesselbach’s plexus (Little’s area) Most common site of Most common site of anterior epistaxis anterior epistaxis Blood supply Blood supply 1. Anterior Ethmoidal a. 1. Anterior Ethmoidal a. 2. Superior Labial a. 3. Greater palatine a. 4. Sphenopalatine a. Little’s area

6 Causes of epistaxis Trauma Trauma Infection Infection Foreign body Foreign body Neoplasm Neoplasm Systemic disease Systemic disease Coagulation defect Coagulation defect

7 Systemic causes Systemic causes -Atherosclerotic vascular disease ( HT, old age) -Atherosclerotic vascular disease ( HT, old age) -Coagulation deficits -Coagulation deficits -Hereditary hemorrhagic telangiectasia (Osler-weber- Rendu) -Hereditary hemorrhagic telangiectasia (Osler-weber- Rendu) -Idiopathic cause (10%) -Idiopathic cause (10%) Etiology Hereditary hemorrhagic telangiectasia

8 Osler-weber-Rendu) an autosomal dominant an autosomal dominant mucocutaneous telangiectasia mucocutaneous telangiectasia insufficient smooth muscle contractile element insufficient smooth muscle contractile element arteriovenous malformations arteriovenous malformations

9 การรักษาพยาบาลเบื้องต้น วัด Vital sign นั่งก้มหน้าเล็กน้อย ไม่นอนราบเพื่อลด Venous pressure บีบจมูกแน่น 5-8 นาที Pack หรือพ่นจมูกด้วย Adrenaline 0.1 % or Ephedrine 1 % ( ห้ามในผู้ป่วย HT)

10 How to stop an anterior nosebleed...

11 5 minute pressure - correct Incorrect

12 การรักษาพยาบาลเบื้องต้น ( ต่อ ) Cold compress จี้ด้วยไฟฟ้า หรือ Trichloracetic acid 30% Anterior nasal packing ด้วย Gel foam หรือ Finger cot หรือ Vaseline gauze Mouth care and Rest งดการสั่งน้ำมูกแรงๆ

13 Visualization of the nose without topical anesthesia and decongestant will result not only in severe discomfort for the patient, but also possibly precipitate additional bleeding. Spending the extra several seconds or so to anesthetize and decongest the nose will dramatically decrease the discomfort experienced by the patient. Visualization of the nose without topical anesthesia and decongestant will result not only in severe discomfort for the patient, but also possibly precipitate additional bleeding. Spending the extra several seconds or so to anesthetize and decongest the nose will dramatically decrease the discomfort experienced by the patient.

14 Nosebleed Tray

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16

17 Merocel Expandable cellulose nasal pack

18 Finger cot

19 Anterior nasal packing

20 Anterior packing

21 After you place and expand an expandable methylcellulose nasal pack in her nose she continues to bleed. Blood is only oozing from her nose but she is still spitting out bright red blood and clots from her mouth. After you place and expand an expandable methylcellulose nasal pack in her nose she continues to bleed. Blood is only oozing from her nose but she is still spitting out bright red blood and clots from her mouth.

22 Posterior nasal bleeding สาเหตุ : มะเร็งของจมูก มะเร็งหลังจมูก JuvinileAngiofibroma โรคเลือด เลือดออก บริเวณจมูกส่วนหลัง ส่วนใหญ่จาก Sphenopalatine artery

23 Sphenopalatine artery

24 การรักษาพยาบาลเบื้องต้น วัด Vital sign, Pain นั่งก้มหน้าเล็กน้อย พ่นจมูกด้วยยาหดเส้นเลือด cold compress พ่นจมูกด้วยยาชา เตรียมทำ Posterior nasal packing

25 การรักษาพยาบาลเบื้องต้น ( ต่อ ) นอนพักนิ่งๆ ศีรษะสูง Cold compress ตรวจ Hematocrit สังเกต Bleeding ให้อาหารอ่อน mouth care ให้ยาแก้ปวด * งด Aspirin งดดื่มน้ำร้อน วัด Vital sign, Pain ดูแลให้พักเพียงพอ ให้คำแนะนำ

26 Posterior nasal packing

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28

29

30 Posterior Nose Bleed

31 She was admitted to the ICU, monitored and sedated. She was admitted to the ICU, monitored and sedated. Urgent referral to an ENT made for definitive treatment. Urgent referral to an ENT made for definitive treatment. Later that afternoon she is transferred to the otolaryngologist in the adjacent town. The following day you receive a call from him and are told that she rebled during the night. He is planning to take her to the operating room urgently to perform endoscopic clipping of the sphenopalatine artery. Later that afternoon she is transferred to the otolaryngologist in the adjacent town. The following day you receive a call from him and are told that she rebled during the night. He is planning to take her to the operating room urgently to perform endoscopic clipping of the sphenopalatine artery.

32 Endoscopic clipping of the sphenopalatine artery.

33 Later that day you receive another call from the otolaryngologist. Following uneventful endoscopic ligation of the sphenopalatine artery the bleeding continued so he clipped the anterior ethmoid artery as well. Later that day you receive another call from the otolaryngologist. Following uneventful endoscopic ligation of the sphenopalatine artery the bleeding continued so he clipped the anterior ethmoid artery as well.

34 Ligation blood vessel Anterior ethmoid a. Anterior ethmoid a. Posterior ethmoid a. Posterior ethmoid a. Internal maxillary a. Internal maxillary a. External carotid a. External carotid a.

35 Ethmoid artery ligation

36 Anterior Ethmoidal Artery Nasal Septum

37 Treatment Artery ligation External carotid artery ligation - Easy but high failure rate(45%) Internal maxillary ligation Failure rate 0-25%

38 Treatment Embolization Indication Indication 1. Fail from other treatment 2. Contraindication to surgery

39 conclusion Anterior epistaxis pressure cautery ant.packing fail Posterior epistaxis Post.packing ligation embolization


ดาวน์โหลด ppt Common ENT problems Suthee Ratanathummawat Department of Otolaryngology Phramongkutklao college of Medicine.

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