鼻出血英文課件(同名174)

IntroductionandHistory 5-10%ofthepopulationexperienceanepisodeofepistaxiseachyear.10%ofthosewillseeaphysician.1%ofthoseseekingmedicalcarewillneedaspecialist.Mythology:brownpaper,nails,scissors,scarletthreads,“l(fā)eadthathasnevertouchedtheground”Aconditionwithalonghistory—HippocratestoHenryGoodyear.IntroductionandHistory 5-10%1Anatomy/PhysiologyofEpistaxisAnatomyNasalcavityVascularsupplyPhysiologyVascularnatureMucosaAnatomy/PhysiologyofEpistaxi2Whybleedingfromthenose?Vascularorgansecondarytoincredibleheating/humidificationrequirementsVasculaturerunsjustundermucosa(notsquamous)ArterialtovenousanastamosesICAandECAbloodflowWhybleedingfromthenose?3AnatomyoftheLateralNasalWallSPF-classI(35%)-classII(56%)-classIII(9%)AnatomyoftheLateralNasalW4Sphenopalatineforamen(SPF)ClassClass1:theopeningoftheSPFispurelyintothesuperiormeatusClass2:theSPFspanstheethmoidalcrest(i.eopenstobothsuperiorandmiddlemeatiClass3:therearetwoseparateopeningintothesuperiorandmiddlemeatiSphenopalatineforamen(SPF)C5ExternalCarotidArtery -Sphenopalatineartery -Greaterpalatineartery -Ascendingpharyngealartery -Posteriornasalartery -SuperiorLabialarteryInternalCarotidArtery -AnteriorEthmoidartery -PosteriorEthmoidarteryExternalCarotidArtery6PterygopalatineVasculature--InternalmaxillaryarteryPterygopalatineVasculature7NasalanomalyprecludingpackingMicroscopicdissectionandligationofIMA--descendingpalatine&sphenopalantinemostimportanttraumaticforeignbodiesNasalpacking(effective80-90%oftime)FollowMiddleTurbinatetoposteriormostaspectNasalanomalyprecludingpacking-AnteriorEthmoidarteryOnlyabletoembolizeexternalcarotid&branchesSeptodermoplasty/LaserablationCaldwell-LucNasalanomalyprecludingpackingTraditionalECAligationRecentmodificationsPatientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclear-SuperiorLabialarteryTraditionalTraumatosinuses,orbits,middleear,baseofskullAtrophicrhinitis-AscendingpharyngealarteryAnatomyoftheNasalCavityandVasculatureNasalanomalyprecludingpacki8SphenopalatineAAEthmoidAAGreaterPalatineASphenopalatineAA9鼻出血英文課件(同名174)10鼻出血英文課件(同名174)11Kesselbach’sPlexus/Little’sArea:-AnteriorEthmoid(Opth)-SuperiorLabialA(Facial)-SphenopalatineA(IMAX)-GreaterPalatine(IMAX)Woodruff’sPlexus:-Pharyngeal&Post.NasalAAofSphenopalatineA(IMAX)

Kesselbach’sPlexus/Little’sA12鼻出血英文課件(同名174)13Anteriorvs.PosteriorMaxillarysinusostiumAnterior:younger,usuallyseptalvs.anteriorethmoid,mostcommon(>90%),typicallylessseverePosterior:olderpopulation,usuallyfromWoodruff’splexus,moreserious.Anteriorvs.PosteriorMaxillar14EtiologyLocalfactorsVascularInfectious/InflammatoryTrauma(mostcommon)IatrogenicNeoplasmDessicationForeignBodies/otherEtiologyLocalfactors15EtiologySystemicfactorsVascularInfection/InflammationCoagulopathyEtiologySystemicfactors16LocalFactors--VascularICAAneurysmsextraduralcavernoussinusLocalFactors--Vascular17LocalFactors-Infection/InflammationRhinitis/SinusitisAllergicBacterialFungalViralLocalFactors-Infection/Infl18LocalFactors-TraumaNosepickingNoseblowing/sneezingNasalfractureNasogastric/nasotrachealintubationTraumatosinuses,orbits,middleear,baseofskullBarotraumaLocalFactors-TraumaNosepic19NasalFracturewithSeptalHematomaNasalFracturewithSeptalHem20LocalFactors-IatrogenicnasalinjuryFunctionalendoscopicsinussurgeryRhinoplastyNasalreconstructionLocalFactors-Iatrogenicnas21Antibioticcreamvs.PickapacktopackwithSelectiveAngiography/embolization下鼻甲上緣：鼻后外側(cè)動脈分支NasalanomalyprecludingpackingStillbleedingaftersurgicalarterialligationHematologicmalignancies-AscendingpharyngealarteryMiddleage—tumorsvaselinegauzeTransnasalendoscopicbipolarcauteryofsphenopalatineartery(7%failureinptswithobvioussourceofbleed)Patientrefusal/intoleranceofpackingGlovepackingLigationwithtitaniumclipVascularnatureAdenocarcinomaTraumatosinuses,orbits,middleear,baseofskullTemporalismmsplitandpartiallydissected中鼻甲下端：鼻后外側(cè)動脈中鼻甲支SurgicalCautery—aboutequal-classII(56%)LocalFactors-NeoplasmJuvenilenasopharyngealangiofibromaInvertedpapillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphomaAntibioticcreamvs.LocalFact22鼻出血英文課件(同名174)23LocalFactors–

DessicationCold,dryair—morecommoninwintertimeDryheat—PhoenixandDeathvalleyNasaloxygenAnatomicabnormalitiesAtrophicrhinitisLocalFactors–

24LocalFactors-OtherSelf-inflicted(pedi)vs.traumaticforeignbodiesIntranasalparasitesSeptalperforationChemical(cocaine,nasalsprays,ammonia,etc.)LocalFactors-Other25SystemicFactors--VascularHypertension/ArteriosclerosisHereditaryHemorrhagicTelangectasias(OWR)SystemicFactors--Vascular26SystemicFactors– Infection/InflammationTuberculosisSyphillisWegener’sGranulomatosisPeriarteritisnodosaSLESystemicFactors– Infect27SystemicFactors–Coagulopathies

ThrombocytopeniaPlateletdysfunctionSystemicdisease(Uremia)drug-induced(Coumadin/NSAIDs/Herbalsupplements)ClottingFactorDeficienciesHemophiliaVonWillebrand’sdiseaseHepaticfailureHematologicmalignanciesSystemicFactors–Coagulopath28SubmucosalsupraperichondrialdissectionofnasalseptumTraumatosinuses,orbits,middleear,baseofskullGreaterpalatineforamenblockVitalsigns—needIV?BleedingsitedifficulttoreachsurgicallySurgicalCautery—aboutequalWegener’sGranulomatosisNasalpacking(effective80-90%oftime)90+%successrate,complicationrateof0.Patientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclearSeptodermoplasty/LaserablationComplications:trismus,damagetoinfraorbitalnComplications:trismus,damagetoinfraorbitalnLocalFactors-TraumaDefinitivetreatment(severedisease)—closureofnoseAnatomyoftheNasalCavityandVasculatureArterialtovenousanastamosesHelpsidentifylocationofbleedingAnteriornasalpacksBleedingsitedifficulttoreachsurgicallyEtiologyandAgeChildren—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Adults—trauma,idiopathicMiddleage—tumorsOldage--hypertensionSubmucosalsupraperichondrial29InitialManagementABC’sMedicalhistory/MedicationsVitalsigns—needIV?PhysicalexamAnteriorrhinoscopyEndoscopicrhinoscopyLaboratoryexamRadiologicstudiesInitialManagementABC’s30suctiongoodlightanestheticsilvernitratemerocelsgelfoambacitracinendoscopessuctionbovie/bipolarAfrinsurgicelepistatbayonetforceptsvaselinegauzesuctiongoodlightanestheticsil31Non-surgicaltreatmentsControlofhypertensionCorrectionofcoagulopathies/thrombocytopeniaFFPorwholeblood/reversalofanticoagulant/plateletsPressure/ExpulsionofclotsTopicaldecongestants/vasocontrictorsCautery(AgNo3vs.TCAvs.Bipolarvs.Bovie)Nasalpacking(effective80-90%oftime)GreaterpalatineforamenblockNon-surgicaltreatmentsContro32Non-surgicaltreatments–ond/cHumidity/emolientsDiscontinueoffendingmedsNasalsalinespraysAvoidanceofnosepicking/blowingSneezewithmouthopenAvoidstraining/bedrestNon-surgicaltreatments–on33NasalpacksAnteriornasalpacksTraditionalRecentmodificationsPosteriornasalpacksTraditionalRecentmodificationsAnt/PostnasalpackingNasalpacksAnteriornasalpack34Cautery(AgNo3vs.ICAAneurysmsSomeauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.Controlofhypertension90+%successrate,complicationrateof0.Humidity/emolientsAnt/PostnasalpackingCautery(AgNo3vs.-SuperiorLabialA(Facial)GlovepackingSphenopalatineforamen(SPF)ClassGreaterpalatineforamenblockSelf-inflicted(pedi)vs.GreaterpalatineforamenblockSomeauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.Children—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Definitivetreatment(severedisease)—closureofnoseHelpsidentifylocationofbleedingPeriarteritisnodosaPeriarteritisnodosaPickaPack,anypackCautery(AgNo3vs.PickaPack,35PickapacktopackwithPickapacktopackwith36TSS—Nugauzevs.MerocelElectronmicroscopyTSS—Nugauzevs.Merocel37PosteriorPacks–AdmissionElderlyandthosewithotherchronicdiseasesmayneedtobeadmittedtotheICUContinuouscardiopulmonarymonitoringAntibioticsOxygensupplementationmaybeneededMildsedation/analgesiaIVFPosteriorPacks–AdmissionEl38Indicationsforsurgery/embolizationContinuedbleedingdespitenasalpackingPtrequirestransfusion/admithctof<38%(barlow)NasalanomalyprecludingpackingPatientrefusal/intoleranceofpackingPosteriorbleedvs.failedmedicalmgmtafter>72hrs(wangvs.schaitkin)Indicationsforsurgery/emboli39SelectiveAngiography/embolizationHelpsidentifylocationofbleedingEmbolizationmosteffectiveinpatientswhoStillbleedingaftersurgicalarterialligationBleedingsitedifficulttoreachsurgicallyComorbiditiesprohibitgeneralanestheticEffectiveonlywhenbleedingis>.5ml/min90+%successrate,complicationrateof0.1%Onlyabletoembolizeexternalcarotid&branchesComplications:minor(18-45%)/major(0-2%)Contraindicatedinbadatherosclerosis,EthmoidbleedSelectiveAngiography/emboliza40SurgicaltreatmentTransmaxillaryIMAligationIntraoralIMAligationAnterior/PosteriorEthmoidalligationTransnasalSphenopalatineligationExternalcarotidarteryligationSeptodermoplasty/LaserablationSurgicaltreatment41TransmaxillaryIMAligationWatersviewCaldwell-LucElectrocauteryofposteriorwallbeforeremovalMicroscopicdissectionandligationofIMA--descendingpalatine&sphenopalantinemostimportantRecurrencerate(failurerate)of10-15%Complicationrateof25-30%(oafistula,dental,n)TransmaxillaryIMAligationWat42鼻出血英文課件(同名174)43IntraoralIMAligationPosteriorgingivobuccalincisionbeginningatsecondmolarTemporalismmsplitandpartiallydissectedIMAXvisualized,clippedanddividedAdvantages:children/facialfracturesDisadvantages:moreproximalligationComplications:trismus,damagetoinfraorbitalnIntraoralIMAligationPosterio44-classIII(9%)Definitivetreatment(severedisease)—closureofnoseTransnasalendoscopicbipolarcauteryofsphenopalatineartery(7%failureinptswithobvioussourceofbleed)Middleage—tumorscavernoussinusVascularnatureICAAneurysmsNasalanomalyprecludingpackingTSS—Nugauzevs.Class3:therearetwoseparateopeningintothesuperiorandmiddlemeatiComplications:trismus,damagetoinfraorbitalnMerocels(2ormore)injectedwithcortisporinoticChildren—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)ContinuouscardiopulmonarymonitoringInternalCarotidArteryNasalpacking(effective80-90%oftime)Patientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclearChildren—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)需要栓塞的：頸內(nèi)動脈假性動脈瘤，頸內(nèi)動脈海綿竇動靜脈瘺LocalFactors-TraumaAnt./Post.EthmoidalligationPatientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclearLynchincisionFronto-ethmoidsutureline12-24-6(14-18,8-10,4-6)-classIII(9%)Ant./Post.Ethm45TransnasalEndoscopicSphenopalatineArteryligationFollowMiddleTurbinatetoposteriormostaspectVerticalmucoperiostealincision7-8mmanteriortopostmiddleturb(betweenmid.andinf.turbs)Elevationofflap—IDneurovascularbundleatforamenLigationwithtitaniumclipReapproximateflapComplications–few,Failures—0-13%TransnasalEndoscopicSphenopa46TransnasalSpheno-palatineArteryligationTransnasalSpheno-palatineArt47ECAligation EffectivenessAnteriorborderofSCMIDECA/ICALigationafterclearthatsurroundingstructuresaresafe.ECAligation Effectiveness48Septodermoplasty/LaserRemovemucosafromanterior?septum,floorofnose,lateralwallSTSGvs.cutaneous,myocutaneous,microvascularfreeflapsvs.AutograftsNeodymium-yttrium-garnet(Nd-YAG)laserorArgonlaser+topicalsteroidbestnonsurgrxformild/moddiseaseStillbleed,butnotasbadDefinitivetreatment(severedisease)—closureofnoseSeptodermoplasty/LaserRemovem49Statisticallyspeaking,….Someauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.3vs.26.2),decreasedcomplications(40vs.68),andshorterhospitalstays(2.2less)thanthosew/posteriorpacks.Otherscomparedallmedicaltreatmenttosurgeryandshowedcostcutusingmedicalmanagement.Complicationrates:posteriorpacks-25-40%,embolization27%,IMAXligation28%Costanalysis:IMAXvs.Embolizationvs.SurgicalCautery—aboutequalFailurerates:PP-30%,Sx-17%,Emb-4%Statisticallyspeaking,….Some50TipsandPearlsRedrubberonsuctionincontralateralnasalcavityAgNO3x30secondsormore(notonbothsidesofseptum)AntihistaminestopreventrebleedsCauterydoesnotworkwithnoplatelets/clottingGlovepackingH2O2Merocels(2ormore)injectedwithcortisporinoticAmicarsprayTipsandPearlsRedrubberons51TipsandPearlsHotwaterirrigationColdwaterirrigationSaltPorkDon’tpacknoseinunconsciouspersonwithsuspectedskullfractures.Antibioticcreamvs.silvernitrateIntranasalpressureEstrogencreamtonasalseptumTipsandPearlsHotwaterirrig52TipsandPearlsTransnasalendoscopicbipolarcauteryofsphenopalatineartery(7%failureinptswithobvioussourceofbleed)SubmucosalsupraperichondrialdissectionofnasalseptumNotallhospitalshaveembolization-trainedinterventionalistsNohard-setoutline.DowhatisbestforyourparticularpatientTipsandPearlsTransnasalendo53典型錄像下鼻道后端：鼻后外側(cè)動脈出血中鼻甲下端：鼻后外側(cè)動脈中鼻甲支下鼻甲上緣：鼻后外側(cè)動脈分支鼻中隔上端：篩前動脈鼻中隔前端：篩前動脈末端等典型錄像下鼻道后端：鼻后外側(cè)動脈出血54鼻內(nèi)鏡下止血門診止血成功率大約95％需要鼻內(nèi)鏡手術(shù)并止血的：鼻中隔偏曲合并鼻出血，眶壁骨折合并鼻出血，鼻腔腫物或鼻竇腫瘤合并鼻出血需要栓塞的：頸內(nèi)動脈假性動脈瘤，頸內(nèi)動脈海綿竇動靜脈瘺鼻內(nèi)鏡下止血門診止血成功率大約95％55Anatomy/PhysiologyofEpistaxisAnatomyNasalcavityVascularsupplyPhysiologyVascularnatureMucosaAnatomy/PhysiologyofEpistaxi56AnatomyoftheLateralNasalWallSPF-classI(35%)-classII(56%)-classIII(9%)AnatomyoftheLateralNasalW57LocalFactors-TraumaNosepickingNoseblowing/sneezingNasalfractureNasogastric/nasotrachealintubationTraumatosinuses,orbits,middleear,baseofskullBarotraumaLocalFactors-TraumaNosepic58Non-surgicaltreatmentsControlofhypertensionCorrectionofcoagulopathies/thrombocytopeniaFFPorwholeblood/reversalofanticoagulant/plateletsPressure/ExpulsionofclotsTopicaldecongestants/vasocontrictorsCautery(AgNo3vs.TCAvs.Bipolarvs.Bovie)Nasalpacking(effective80-90%oftime)GreaterpalatineforamenblockNon-surgicaltreatmentsContro59NasalpacksAnteriornasalpacksTraditionalRecentmodificationsPosteriornasalpacksTraditionalRecentmodificationsAnt/PostnasalpackingNasalpacksAnteriornasalpack60Statisticallyspeaking,….Someauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.3vs.26.2),decreasedcomplications(40vs.68),andshorterhospitalstays(2.2less)thanthosew/posteriorpacks.Otherscomparedallmedicaltreatmenttosurgeryandshowedcostcutusingmedicalmanagement.Complicationrates:posteriorpacks-25-40%,embolization27%,IMAXligation28%Costanalysis:IMAXvs.Embolizationvs.SurgicalCautery—aboutequalFailurerates:PP-30%,Sx-17%,Emb-4%Statisticallyspeaking,….Some61TipsandPearlsRedrubberonsuctionincontralateralnasalcavityAgNO3x30secondsormore(notonbothsidesofseptum)AntihistaminestopreventrebleedsCauterydoesnotworkwithnoplatelets/clottingGlovepackingH2O2Merocels(2ormore)injectedwithcortisporinoticAmicarsprayTipsandPearlsRedrubberons62Children—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Non-surgicaltreatmentsPeriarteritisnodosa5-10%ofthepopulationexperienceanepisodeofepistaxiseachyear.Non-surgicaltreatments–ond/cJuvenilenasopharyngealangiofibromaPlateletdysfunctionJuvenilenasopharyngealangiofibromaClass2:theSPFspanstheethmoidalcrest(i.ColdwaterirrigationLaboratoryexam-SphenopalatineA(IMAX)FFPorwholeblood/reversalofanticoagulant/plateletsAnatomy/PhysiologyofEpistaxisHereditaryHemorrhagicTelangectasias(OWR)AmicarsprayNasogastric/nasotrachealintubationMildsedation/analgesiaEmbolizationvs.Otherscomparedallmedicaltreatmenttosurgeryandshowedcostcutusingmedicalmanagement.vaselinegauze典型錄像下鼻道后端：鼻后外側(cè)動脈出血中鼻甲下端：鼻后外側(cè)動脈中鼻甲支下鼻甲上緣：鼻后外側(cè)動脈分支鼻中隔上端：篩前動脈鼻中隔前端：篩前動脈末端等Children—foreignbody,nosepi63IntroductionandHistory 5-10%ofthepopulationexperienceanepisodeofepistaxiseachyear.10%ofthosewillseeaphysician.1%ofthoseseekingmedicalcarewillneedaspecialist.Mythology:brownpaper,nails,scissors,scarletthreads,“l(fā)eadthathasnevertouchedtheground”Aconditionwithalonghistory—HippocratestoHenryGoodyear.IntroductionandHistory 5-10%64Anatomy/PhysiologyofEpistaxisAnatomyNasalcavityVascularsupplyPhysiologyVascularnatureMucosaAnatomy/PhysiologyofEpistaxi65Whybleedingfromthenose?Vascularorgansecondarytoincredibleheating/humidificationrequirementsVasculaturerunsjustundermucosa(notsquamous)ArterialtovenousanastamosesICAandECAbloodflowWhybleedingfromthenose?66AnatomyoftheLateralNasalWallSPF-classI(35%)-classII(56%)-classIII(9%)AnatomyoftheLateralNasalW67Sphenopalatineforamen(SPF)ClassClass1:theopeningoftheSPFispurelyintothesuperiormeatusClass2:theSPFspanstheethmoidalcrest(i.eopenstobothsuperiorandmiddlemeatiClass3:therearetwoseparateopeningintothesuperiorandmiddlemeatiSphenopalatineforamen(SPF)C68ExternalCarotidArtery -Sphenopalatineartery -Greaterpalatineartery -Ascendingpharyngealartery -Posteriornasalartery -SuperiorLabialarteryInternalCarotidArtery -AnteriorEthmoidartery -PosteriorEthmoidarteryExternalCarotidArtery69PterygopalatineVasculature--InternalmaxillaryarteryPterygopalatineVasculature70NasalanomalyprecludingpackingMicroscopicdissectionandligationofIMA--descendingpalatine&sphenopalantinemostimportanttraumaticforeignbodiesNasalpacking(effective80-90%oftime)FollowMiddleTurbinatetoposteriormostaspectNasalanomalyprecludingpacking-AnteriorEthmoidarteryOnlyabletoembolizeexternalcarotid&branchesSeptodermoplasty/LaserablationCaldwell-LucNasalanomalyprecludingpackingTraditionalECAligationRecentmodificationsPatientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclear-SuperiorLabialarteryTraditionalTraumatosinuses,orbits,middleear,baseofskullAtrophicrhinitis-AscendingpharyngealarteryAnatomyoftheNasalCavityandVasculatureNasalanomalyprecludingpacki71SphenopalatineAAEthmoidAAGreaterPalatineASphenopalatineAA72鼻出血英文課件(同名174)73鼻出血英文課件(同名174)74Kesselbach’sPlexus/Little’sArea:-AnteriorEthmoid(Opth)-SuperiorLabialA(Facial)-SphenopalatineA(IMAX)-GreaterPalatine(IMAX)Woodruff’sPlexus:-Pharyngeal&Post.NasalAAofSphenopalatineA(IMAX)

Kesselbach’sPlexus/Little’sA75鼻出血英文課件(同名174)76Anteriorvs.PosteriorMaxillarysinusostiumAnterior:younger,usuallyseptalvs.anteriorethmoid,mostcommon(>90%),typicallylessseverePosterior:olderpopulation,usuallyfromWoodruff’splexus,moreserious.Anteriorvs.PosteriorMaxillar77EtiologyLocalfactorsVascularInfectious/InflammatoryTrauma(mostcommon)IatrogenicNeoplasmDessicationForeignBodies/otherEtiologyLocalfactors78EtiologySystemicfactorsVascularInfection/InflammationCoagulopathyEtiologySystemicfactors79LocalFactors--VascularICAAneurysmsextraduralcavernoussinusLocalFactors--Vascular80LocalFactors-Infection/InflammationRhinitis/SinusitisAllergicBacterialFungalViralLocalFactors-Infection/Infl81LocalFactors-TraumaNosepickingNoseblowing/sneezingNasalfractureNasogastric/nasotrachealintubationTraumatosinuses,orbits,middleear,baseofskullBarotraumaLocalFactors-TraumaNosepic82NasalFracturewithSeptalHematomaNasalFracturewithSeptalHem83LocalFactors-IatrogenicnasalinjuryFunctionalendoscopicsinussurgeryRhinoplastyNasalreconstructionLocalFactors-Iatrogenicnas84Antibioticcreamvs.PickapacktopackwithSelectiveAngiography/embolization下鼻甲上緣：鼻后外側(cè)動脈分支NasalanomalyprecludingpackingStillbleedingaftersurgicalarterialligationHematologicmalignancies-AscendingpharyngealarteryMiddleage—tumorsvaselinegauzeTransnasalendoscopicbipolarcauteryofsphenopalatineartery(7%failureinptswithobvioussourceofbleed)Patientrefusal/intoleranceofpackingGlovepackingLigationwithtitaniumclipVascularnatureAdenocarcinomaTraumatosinuses,orbits,middleear,baseofskullTemporalismmsplitandpartiallydissected中鼻甲下端：鼻后外側(cè)動脈中鼻甲支SurgicalCautery—aboutequal-classII(56%)LocalFactors-NeoplasmJuvenilenasopharyngealangiofibromaInvertedpapillomaSCCAAdenocarcinomaMelanomaEsthesioneuroblastomaLymphomaAntibioticcreamvs.LocalFact85鼻出血英文課件(同名174)86LocalFactors–

DessicationCold,dryair—morecommoninwintertimeDryheat—PhoenixandDeathvalleyNasaloxygenAnatomicabnormalitiesAtrophicrhinitisLocalFactors–

87LocalFactors-OtherSelf-inflicted(pedi)vs.traumaticforeignbodiesIntranasalparasitesSeptalperforationChemical(cocaine,nasalsprays,ammonia,etc.)LocalFactors-Other88SystemicFactors--VascularHypertension/ArteriosclerosisHereditaryHemorrhagicTelangectasias(OWR)SystemicFactors--Vascular89SystemicFactors– Infection/InflammationTuberculosisSyphillisWegener’sGranulomatosisPeriarteritisnodosaSLESystemicFactors– Infect90SystemicFactors–Coagulopathies

ThrombocytopeniaPlateletdysfunctionSystemicdisease(Uremia)drug-induced(Coumadin/NSAIDs/Herbalsupplements)ClottingFactorDeficienciesHemophiliaVonWillebrand’sdiseaseHepaticfailureHematologicmalignanciesSystemicFactors–Coagulopath91SubmucosalsupraperichondrialdissectionofnasalseptumTraumatosinuses,orbits,middleear,baseofskullGreaterpalatineforamenblockVitalsigns—needIV?BleedingsitedifficulttoreachsurgicallySurgicalCautery—aboutequalWegener’sGranulomatosisNasalpacking(effective80-90%oftime)90+%successrate,complicationrateof0.Patientss/pIMAXligationstillbleeding,superiornasalcavityepistaxis,orinconjunctionwhensourceunclearSeptodermoplasty/LaserablationComplications:trismus,damagetoinfraorbitalnComplications:trismus,damagetoinfraorbitalnLocalFactors-TraumaDefinitivetreatment(severedisease)—closureofnoseAnatomyoftheNasalCavityandVasculatureArterialtovenousanastamosesHelpsidentifylocationofbleedingAnteriornasalpacksBleedingsitedifficulttoreachsurgicallyEtiologyandAgeChildren—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Adults—trauma,idiopathicMiddleage—tumorsOldage--hypertensionSubmucosalsupraperichondrial92InitialManagementABC’sMedicalhistory/MedicationsVitalsigns—needIV?PhysicalexamAnteriorrhinoscopyEndoscopicrhinoscopyLaboratoryexamRadiologicstudiesInitialManagementABC’s93suctiongoodlightanestheticsilvernitratemerocelsgelfoambacitracinendoscopessuctionbovie/bipolarAfrinsurgicelepistatbayonetforceptsvaselinegauzesuctiongoodlightanestheticsil94Non-surgicaltreatmentsControlofhypertensionCorrectionofcoagulopathies/thrombocytopeniaFFPorwholeblood/reversalofanticoagulant/plateletsPressure/ExpulsionofclotsTopicaldecongestants/vasocontrictorsCautery(AgNo3vs.TCAvs.Bipolarvs.Bovie)Nasalpacking(effective80-90%oftime)GreaterpalatineforamenblockNon-surgicaltreatmentsContro95Non-surgicaltreatments–ond/cHumidity/emolientsDiscontinueoffendingmedsNasalsalinespraysAvoidanceofnosepicking/blowingSneezewithmouthopenAvoidstraining/bedrestNon-surgicaltreatments–on96NasalpacksAnteriornasalpacksTraditionalRecentmodificationsPosteriornasalpacksTraditionalRecentmodificationsAnt/PostnasalpackingNasalpacksAnteriornasalpack97Cautery(AgNo3vs.ICAAneurysmsSomeauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.Controlofhypertension90+%successrate,complicationrateof0.Humidity/emolientsAnt/PostnasalpackingCautery(AgNo3vs.-SuperiorLabialA(Facial)GlovepackingSphenopalatineforamen(SPF)ClassGreaterpalatineforamenblockSelf-inflicted(pedi)vs.GreaterpalatineforamenblockSomeauthors(WangandVogel)showedsurgicalinterventiontohavelowerfailurerates(14.Children—foreignbody,nosepicking,nasaldiptheria(1/3withchronicbleedshavecoagulationd/o)Definitivetreatment(severedisease)—closureofnoseHelpsidentifylocationofbleedingPeriarteritisnodosaPeriarteritisnodosaPickaPack,anypackCautery(AgNo3vs.PickaPack,98PickapacktopackwithPickapacktopackwith99TSS—Nugauzevs.MerocelElectronmicroscopyTSS—Nugauzevs.Merocel100PosteriorPacks–AdmissionElderlyandthosewithotherchronicdiseasesmayneedtobeadmittedtotheICUContinuouscardiopulmonarymonitoringAntibioticsOxygensupplementationmaybeneededMildsedation/analgesiaIVFPosteriorPacks–AdmissionEl101Indicationsforsurgery/embolizationContinuedbleedingdespitenasalpackingPtrequirestransfusion/admithctof<38%(barlow)NasalanomalyprecludingpackingPatientrefusal/intoleranceofpackingPosteriorbleedvs.failedmedicalmgmtafter>72hrs(wangvs.schaitkin)Indicationsforsurgery/emboli102SelectiveAngiography/embolizationHelpsidentifylocationofbleedingEmboli