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Epistaxis :blowfish: (:green_heart: Mx (Choices of Mx:fish: (Cauterization…

- - - - CA Nasopharynx (! Can present with many CC)
      - Juvenile nasopharyngeal angiofibroma (JNA)
  - - - ‘Hereditary hemorrhagic telangiectasia’
      - AD inheritance
      - Epidemio: 90% pt เจอใน 40 y/o
      - Presentation
        
        Mucocutaneous telangiectasia
        at oral, nasal mucosa, nail bed
        
        Arteriovenous malformation (AVM) at Liver, Lung, CNS, spinal cord
        
        :star: Recurrent epistaxis
        
        GI bleeding
- - - - Eg VitE, Gingko, liver fish oil, ASA, Pravit
- - - - Usu. involves Kiesselbach’s plexus or Little’s area
        (found around Middle turbinate)
    - - Usu. involves Woodruff’s plexus
  - - - Nose squeeze
        
        Cold packing
        
        1-3%ephedrine,adrenaline packing
        
        Chemical/Electrical cauterization
    - - Anterior nasal packing (gel foam, merocel)
        
        Nasal balloon/Foley’s catheter for Post. Bleeding
        
        Whether use Absorbale or Non-absorbable packing for Ant. Nasal packing?
        ⇨ Depends on Pt & U/D of pt
    - - Resuscitation
        
        Ant & Post nasal packing
        
        Nasal balloon/Foley’s catheter
        
        Arterial ligation
        
        Angiogram with embolization
  - - - Epinephrine
      - Adrenaline
    - - Chemical
        
        30-50% Trichloroacetic acid (TCA)
        
        10% silver nitrate
      - Electrical
        
        Bipolar cauterization
      - Don’t จี้ at แผลจุด bleed โดยตรง ให้จี้รอบๆแผล
    - - Posterior nasal packing
        
        :bulb: Always do Anterior packing!!!
        
        Using Vaseline gauze with
        
        :one: Foley’s catheter 12-16 Fr + NSS 10 ml
        
        Pro
        
        Adequate control of bleeding
        
        Cons
        
        Uncomfortable to pt
        
        :arrow_up: bacteremia incident
        (as of FB)
        
        Hypoxia as can’tหายใจ
        ⇨Need admission
        
        :two: Nasal balloon
        
        Pro
        
        Easy to use
        
        Less traumatic
        
        Permit nasal breathing
        
        Con
        
        Can’t control bleeding in every case
        
        These two should check cuff/balloon before use
      - Anterior nasal packing
        
        :check:I/C: failed cauterization
        
        Pack 2-3 day or เอาออกเร็วสุดเมื่อsure ว่า stop bleed alrdy
        
        Uses Absorable or Non-absorable :question:
        
        Non-ab : Finger clot, Vaseline gauze,Merocele
        (finger clot will lubricate with ATBointment)
        
        Absorbable : Gel foam, Oxidized cellulose
        uses in
        
        Blood dyscrasia
        eg. ITP, low plt
        
        Children
        
        Little bleeding
        (as this kind of packing ⇨ pressure. ไม่มาก)
        
        Mix of absorable & non-Ab is Polyganics (nasospore)
      - Post-nasal packing care :rolling_on_the_floor_laughing:
    - - Internal maxillary ligation
        (recall Sphenopalatine a branch fr this)
        
        Transantral
        
        Transoral
      - Internal Carotid ligation + Ant. Packing
        
        :warning: may fails due to Collateral Circulation fr TCA at opposite side
    - - :check: I/C
        
        Recurrent/Refractory epistaxis
        
        Vessels anomaly: Osler-Weber-Rendu
        
        Attempt embolization
        
        Pre/post op evaluation: Juvenile angiofibroma
      - C/I :red_cross:
        
        Severe atherosclerosis
        
        Anormalous anastomosis of ECA & ICA
        
        Known allergy to angiographic contrast media
      - :warning:
        
        Success rate 80-90%
        
        Limitation of procedure in anterior ethmoid a.
        
        As it branches into Opthalmic a which supply eye
        
        Complication: Cerebrovascular inj. 4%