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

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

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

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

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

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

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

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

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

How to stop an anterior nosebleed...

5 minute pressure - correct Incorrect

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

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.

Nosebleed Tray

Merocel Expandable cellulose nasal pack

Finger cot

Anterior nasal packing

Anterior packing

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.

Posterior nasal bleeding สาเหตุ: มะเร็งของจมูก มะเร็งหลังจมูก JuvinileAngiofibroma โรคเลือด เลือดออกบริเวณจมูกส่วนหลัง ส่วนใหญ่จาก Sphenopalatine artery

Sphenopalatine artery

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

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

Posterior nasal packing

Posterior Nose Bleed

She was admitted to the ICU, monitored and sedated. 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.

Endoscopic clipping of the sphenopalatine artery.

Later that day you receive another call from the otolaryngologist 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.

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

Ethmoid artery ligation

Anterior Ethmoidal Artery Nasal Septum

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

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

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