Epistaxis

4.4.1 Draw the vascular supply to the nasal mucosa, noting the vessels of origin. What is Kiesselbach’s plexus?

4.4.2 What are local causes of epistaxis (sino-nasal pathologies)? Where does epistaxis most commonly originate from?

4.4.3 Discuss systemic diseases that predispose to epistaxis. Also discuss the role of hypertension.

Page C, Biet A, Liabeuf S, Strunski V, et al. Serious spontaneous epistaxis and hypertension in hospitalized patientsEur Arch Otorhinolaryngol. 2011 Dec;268(12):1749-53. Epub 2011 Jun 9. PMID:21656167

4.4.4 Discuss topical nasal and systemic medications that increase risk of epistaxis.

Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009 Feb 19;360(8):784-9. PMID:19228621

Smith J, Siddiq S, Dyer C, Rainsbury J, et al. Epistaxis in patients taking oral anticoagulant and antiplatelet medication: prospective cohort study. J Laryngol Otol. 2011 Jan;125(1):38-4Epub 2010 Sep 16. PMID:20843406

4.4.5 What laboratory tests will you order in evaluating a patient with recurrent epistaxis? What is the role for radiologic studies?

4.4.6 Review the CT, endoscopic and histopathology images provided. What is your diagnosis?

http://portal.entnet.org/images/COCLIA/2011-2012%20updates/COCLIA%20Media/Epistaxis/Epistaxis-Q6.jpg

4.4.7 A patient presents to the ER with epistaxis. How do you proceed with history and examination?

4.4.8 In evaluating a patient with epistaxis, you find the origin of hemorrhage to be at the anterior septal mucosa. How will you manage this patient?

4.4.9 Discuss commercially available nasal packs and compare them. What is toxic shock syndrome? What absorbable nasal materials may also be used for hemostasis?

Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. 2007 Jun;15(3):180-Review. PMID:17483687

4.4.10 A patient with posterior epistaxis continues to bleed. Discuss and evaluate your options.

Soyka MB, Nikolaou G, Rufibach K, Holzmann D. On the effectiveness of treatment options in epistaxis: an analysis of 678 interventions. Rhinology. 2011 Oct;49(4):474-8. PMID:21991575

Miller TR, Stevens ES, Orlandi RR. Economic analysis of the treatment of posterior epistaxis. Am J Rhinol. 2005 Jan-Feb;19(1):79-82. PMID:15794080

4.4.11 Discuss construction of a posterior pack. What clinically significant issues must one consider when a posterior pack is placed (monitoring, duration and complications)?

4.4.12 Discuss steps in endoscopic sphenopalatine artery ligation and anterior ethmoid artery ligation.

Seno S, Arikata M, Sakurai H, Owaki S, et al. Endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis. Am J Rhinol Allergy. 2009 Mar-Apr;23(2):197-9. PMID:19401049

Pletcher SD, Metson R. Endoscopic Ligation of the Anterior Ethmoid Artery. Laryngoscope. 2007 Feb;117(2):378-81. PMID:17204990

4.4.13 What is hereditary hemorrhagic telangiectasia? What are medical and surgical options for its treatment?

Lund VJ, Howard DJ. A treatment algorithm for the management of epistaxis in hereditary hemorrhagic telangiectasia. Am J Rhinol. 1999 Jul-Aug;13(4):319-22. PMID:10485021

Karnezis TT, Davidson TM. Treatment of Hereditary Hemorrhagic Telangiectasia With Submucosal and Topical Bevacizumab Therapy. Laryngoscope. 2012 Mar;122(3):495-7. do~/images 10.1002/lary.22501. Epub 2011 Dec 6. PMID:22147664