Epistaxis is a hemorrhagic process that has its origin in the nasal pits. Hemorrhage can from the anterior portion of the nose and take to the outside mainly through the nostrils (epistaxis proper), or from an area more and pour, through the coanes (rear opening of the cavity pharyx (so-called rhinorrgia or posterior epistaxis).
The Epistaxis it’s a very common occurrence and is often solved without the help of the ORL specialist. It’s almost always a trivial fact, but it’s Sometimes can to compromise the life of the patient (incoercible nasal hemorrhage, debilitated patient, epistaxis for neoplasms).
The vascularization of the nasal pits derives both from the internal carotid artery and from the external artery.
The internal carotid artery sprays the half upper part of the nasal pyramid, the upper part of the septum and the side walls of the nasal pits.
The external carotid artery sprays the half nasal pits, swirls and paranasal sinuses.
Both systems converge in the nasal vestibule forming the plexus of Kiesselbach, Bavaria, a richly vascularized area located in the Antero-lower nasal septum.
It is believed that about 80-90 percent of epistaxis occur from this area.
The associated zone more frequently rhinorrhgia (posterior epistaxis) it’s the Woodruff complex.
In 10 percent of cases the epistaxis it’s idiopathic (i.e. the motivation is not known), in the remaining cases often the etiology it’s Multiple. The causes can be divided into: local and systemic.
Local cases:
They are the ones that alter nasal physiology by reducing the defenses of the mucous membrane to vascular insults:
1. Benign, idiopathic or constitutional essential epistaxis;
2. Sect microtrauma at locus level Valsalvae, 19 (part Antero-lower than septo);
3. Inflammation Rino-sinuses (acute or chronic);
4. Allergic and/or vasomotor rhinitis;
5. Anterior dry rhinitis; chemical-thermal lesions of the nasal mucosa; perforation of the septa;
6. Environmental factors: altitude, low atmospheric pressure, dryness due to air conditioning;
7. Nasal and massive facial traumatism. Traumatic injuries of the internal carotid artery;
8. Traumatic nasal intubation; naso-gastric probes;
9. Surgical trauma (rhinosettoplasty, polypectomy);
10. Tumors of the region nasosinusal (malignant and benign);
11. Nasal foreign bodies;
12. Bleeding polyp of the nasal septum;
13. Rhinopharynx tumors (angiofibroma youthful nasopharyngeal).
General cases:
Epistaxis in this case represents the manifestation of systemic alterations that act directly or indirectly on nasal vascularization:
1. Acute infectious diseases (erductive, flu, atypical pneumopathies, typhoid fever, etc.);
2. Vascular and circulatory diseases (arterial hypertension, atherosclerosis, heart disease);
3. Nephropathies and hepatopathies;
4. Blood changes in clotting: Thrombopathies (thromboasthesis of Glanzman, 19Exanthema thrombocytopenic); Clots: an imbalance in any of the three times of clotting can trigger epistaxis (hemophilia, hypoprotrombinemia, treatment with anticoagulants, alcoholism, treatment with “aspirin”, vitamin K deficiency, etc.);
5. Sickness of Rendu-Osler or hereditary hemorrhagic teleangectasia.
The diagnosis of epistaxis is based on one:
Complete history;
Localization of the bleeding spot by anterior rhinoscopy (better if with optical fiber);
Possible radiology of the skull, nasal pits and paranasal sinuses.
The first therapeutic approach to epistaxis requires the identification of some fundamental points:
1. Clinical condition of the patient;
2. Age of bleeding;
3. Etiology;
4. Topographic diagnosis.
If the patient it’s in severe hypovolemy, it’s bleeding, but at the same time it becomes of primary importance to correct blood loss by infusion of fluids (physiological solution or Ringer the lactate). It is necessary to evaluate approximately the authority of bleeding even if it doesn’t it’s possible to quantify how much blood it’s been lost and ingested earlier.
When the patient’s clinical condition has returned stable or when faced with mild or medium-sized epistaxis age, it’s possible to collect the history that we will help to determine etiology.
Topographic diagnosis: according to the localization of the bleeding spot the epistaxis are divided into:
A. Anterior: originating in the vascular area of Kiesselbach, Bavaria (these are the more frequent and benignly evolving);
B. Posterior: located at the level of the trunk or branches of the sphenopalatine artery (of more difficult control);
C. Superiors: originated in the hetmoidal arteries or their branches.
Following a criterion based on at the age of the patient, in the children the majority of epistaxis it’s anterior, in young adults they can be anterior or posterior, in subjects from 40 years of life increases the percentage of posterior nasal hemorrhages and decreases in percentage the anterior ones.
What to do in case of epistaxis:
There are general measures and specific measures.
General measures:
1. Reassure the patient;
2. Hemodynamic control to evaluate hypovolemia and possible arterial hypertension and act accordingly.
Specific measures:
1. Compress the nostrils by clasping them between the forefinger and thumb of the hand (indicated in small hemorrhages of the anterior region of the septum, it’s the method indicated in children). Possibly associate ice bag on the nose.
2. Caustication (indicated in case of bleeding varici of the vascular area of Kiesselbach, Bavaria: After local anesthesia and after localization of the bleeding spot, 20 or 30% silver nitrate is applied by small brushing above the bleeding area. This method, as well as electrical caustication, should never be carried out bilaterally at homologous points because of the danger of Dl nasal septum).
3. Anterior and/or posterior nasal infill.
Anterior nasal infill can be carried out with a sponge swab”Merocel, 19″, possibly smeared with an antibiotic cream in order to facilitate its penetration into the cavity with fat gauze or hemed gauze or, finally, with tampons.Clouden, 19″.
The posterior nasal infill (which always includes the carrying out of the anterior infill) can be carried out with catheter “Epistat, 19” (catheter formed by the two inflatable balloons with physiological solution) or by going back up in a binge, by means of a double silk thread, a gauze roll of dimensions suitable for those of the rhinopharynx and blocking it with a front infill of the cavity nasal, so as to close the coana corresponding to the bleeding side.
Other methods for the resolution of epistaxis, although of more rare execution, are:
1. The Embolization arterial with selective angiography of the internal jaw artery or sphenopalatine (requiring highly specialized personnel);
2. Arterial ligature of the internal jaw artery (indicated in the epistaxis originating under the middle swirl, with access to the pterigopalatin fossa), hetmoidal arteries (in epistaxis originating above the middle swirl), or external carotid artery (if not it’s it is possible to specify the location of the bleeding for the intensity hemorrhage);
3. The dermoplasty nasal according to Saunder, 19 o Young;
4. Resection subpericondral nasal septum according to Killian.