鼻出血英文课件

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,Introduction and History,5-10% of the population experience an episode of epistaxis each year. 10% of those will see a physician. 1% of those seeking medical care will need a specialist.,Mythology: brown paper, nails, scissors, scarlet threads,“,lead that has never touched the ground,”,A condition with a long historyHippocrates to Henry Goodyear.,Introduction and History5-10%,1,Anatomy/Physiology of Epistaxis,Anatomy,Nasal cavity,Vascular supply,Physiology,Vascular nature,Mucosa,Anatomy/Physiology of Epistaxi,2,Why bleeding from the nose ?,Vascular organ secondary to incredible heating/humidification requirements,Vasculature runs just under mucosa (not squamous),Arterial to venous anastamoses,ICA and ECA blood flow,Why bleeding from the nose ?,3,Anatomy of the Lateral Nasal Wall,SPF,-class I (35%),-class II (56%),-class III (9%),Anatomy of the Lateral Nasal W,4,Sphenopalatine,fo,ramen (SPF) Class,Class 1: the opening of the SPF is purely into the superior meatus,Class 2: the SPF spans the ethmoid,a,l crest (i.e opens to both superior and middle meati,Class 3: there are two separate opening into the superior and middle meati,Sphenopalatine foramen (SPF) C,5,External Carotid Artery,-Sphenopalatine artery,-Greater palatine artery,-Ascending pharyngeal artery,-Posterior nasal artery,-Superior Labial artery,Internal Carotid Artery,-Anterior Ethmoid artery,-Posterior Ethmoid artery,External Carotid Artery,6,Pterygopalatine Vasculature,-Internal maxillary artery,Pterygopalatine Vasculature,7,Functional endoscopic sinus surgery,Nasal Fracture with Septal Hematoma,Cold, dry airmore common in wintertime,Maxillary sinus ostium,Nasal fracture,Anterior: younger, usually septal vs.,Woodruffs Plexus:,Reapproximate flap,Nasal packing (effective 80-90% of time),Electron microscopy,Temporalis mm split and partially dissected,Traditional,Adenocarcinoma,Avoid straining/bedrest,Indications for surgery/embolization,Anatomy of the Nasal Cavity and Vasculature,Functional endoscopic sinus su,8,Sphenopalatine AA,Ethmoid AA,Greater Palatine A,Sphenopalatine AA,9,鼻出血英文课件,10,鼻出血英文课件,11,Kesselbach,s Plexus/Little,s Area:,-Anterior Ethmoid (Opth),-Superior Labial A (Facial),-Sphenopalatine A (IMAX),-Greater Palatine (IMAX,),Woodruff,s Plexus:,-Pharyngeal & Post. Nasal AA of Sphenopalatine A (IMAX),Kesselbachs Plexus/Littles A,12,鼻出血英文课件,13,Anterior vs. Posterior,Maxillary sinus ostium,Anterior: younger, usually septal vs. anterior ethmoid, most common (90%), typically less severe,Posterior: older population, usually from Woodruff,s plexus, more serious.,Anterior vs. PosteriorMaxillar,14,Etiology,Local factors,Vascular,Infectious/Inflammatory,Trauma (most common),Iatrogenic,Neoplasm,Dessication,Foreign Bodies/other,EtiologyLocal factors,15,Etiology,Systemic factors,Vascular,Infection/Inflammation,Coagulopathy,EtiologySystemic factors,16,Local Factors - Vascular,ICA Aneurysms,extradural,cavernous sinus,Local Factors - Vascular,17,Local Factors - Infection/Inflammation,Rhinitis/Sinusitis,Allergic,Bacterial,Fungal,Viral,Local Factors - Infection/Infl,18,Local Factors - Trauma,Nose picking,Nose blowing/sneezing,Nasal fracture,Nasogastric/nasotracheal intubation,Trauma to sinuses, orbits, middle ear, base of skull,Barotrauma,Local Factors - TraumaNose pic,19,Anterior border of SCM,Still bleed, but not as bad,Ligation after clear that surrounding structures are safe.,ICA Aneurysms,Trauma (most common),cutaneous, myocutaneous, microvascular free flaps vs.,Nasal fracture,Introduction and History,Hematologic malignancies,Local Factors Dessication,Dont pack nose in unconscious person with suspected skull fractures.,Do what is best for your particular patient,Microscopic dissection and ligation of IMA -descending palatine & sphenopalantine most important,Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.,Vascular nature,Still bleed, but not as bad,Nasal packing (effective 80-90% of time),Indications for surgery/embolization,IMAX visualized, clipped and divided,Transnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed),-Greater Palatine (IMAX),Anterior border of SCM,Nasal Fracture with Septal Hematoma,Systemic disease (Uremia),Traditional,Recurrence rate (failure rate) of 10-15%,Nose picking,Lynch incision,Class 1: the opening of the SPF is purely into the superior meatus,Anatomy of the Lateral Nasal Wall,Nasal Fracture with Septal Hematoma,Anterior border of SCMStill bl,20,Local Factors - Iatrogenic nasal injury,Functional endoscopic sinus surgery,Rhinoplasty,Nasal reconstruction,Local Factors - Iatrogenic nas,21,Local Factors - Neoplasm,Juvenile nasopharyngeal angiofibroma,Inverted papilloma,SCCA,Adenocarcinoma,Melanoma,Esthesioneuroblastoma,Lymphoma,Local Factors - NeoplasmJuveni,22,鼻出血英文课件,23,Local Factors Dessication,Cold, dry airmore common in wintertime,Dry heatPhoenix and Death valley,Nasal oxygen,Anatomic abnormalities,Atrophic rhinitis,Local Factors ,24,Local Factors - Other,Self-inflicted (pedi) vs. traumatic foreign bodies,Intranasal parasites,Septal perforation,Chemical (cocaine, nasal sprays, ammonia, etc.),Local Factors - Other,25,Systemic Factors - Vascular,Hypertension/Arteriosclerosis,Hereditary Hemorrhagic Telangectasias (OWR),Systemic Factors - Vascular,26,Systemic Factors Infection/Inflammation,Tuberculosis,Syphillis,Wegener,s Granulomatosis,Periarteritis nodosa,SLE,Systemic Factors Infect,27,Systemic Factors Coagulopathies,Thrombocytopenia,Platelet dysfunction,Systemic disease (Uremia),drug-induced (Coumadin/NSAIDs/Herbal supplements),Clotting Factor Deficiencies,Hemophilia,VonWillebrand,s disease,Hepatic failure,Hematologic malignancies,Systemic Factors Coagulopath,28,Etiology and Age,Childrenforeign body, nose picking, nasal diptheria (1/3 with chronic bleeds have coagulation d/o),Adultstrauma, idiopathic,Middle agetumors,Old age-hypertension,Etiology and AgeChildrenforei,29,Initial Management,ABC,s,Medical history/Medications,Vital signsneed IV?,Physical exam,Anterior rhinoscopy,Endoscopic rhinoscopy,Laboratory exam,Radiologic studies,Initial ManagementABCs,30,suction,good light,anesthetic,silver nitrate,merocels,gelfoam,bacitracin,endoscopes,suction bovie/bipolar,Afrin,surgicel,epistat,bayonet forcepts,vaseline gauze,suctiongood lightanestheticsil,31,Non-surgical treatments,Control of hypertension,Correction of coagulopathies/thrombocytopenia,FFP or whole blood/reversal of anticoagulant/platelets,Pressure/Expulsion of clots,Topical decongestants/vasocontrictors,Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie),Nasal packing (effective 80-90% of time),Greater palatine foramen block,Non-surgical treatments Contro,32,Non-surgical treatments on d/c,Humidity/emolients,Discontinue offending meds,Nasal saline sprays,Avoidance of nose picking/blowing,Sneeze with mouth open,Avoid straining/bedrest,Non-surgical treatments on,33,Nasal packs,Anterior nasal packs,Traditional,Recent modifications,Posterior nasal packs,Traditional,Recent modifications,Ant/Post nasal packing,Nasal packsAnterior nasal pack,34,Pick a Pack, any pack,Pick a Pack, any pack,35,Pick a pack to pack with,Pick a pack to pack with,36,TSSNugauze vs. Merocel,Electron microscopy,TSSNugauze vs. Merocel,37,Posterior Packs Admission,Elderly and those with other chronic diseases may need to be admitted to the ICU,Continuous cardiopulmonary monitoring,Antibiotics,Oxygen supplementation may be needed,Mild sedation/analgesia,IVF,Posterior Packs Admission El,38,Indications for surgery/embolization,Continued bleeding despite nasal packing,Pt requires transfusion/admit hct of 72hrs (wang vs. schaitkin),Indications for surgery/emboli,39,Selective Angiography/embolization,Helps identify location of bleeding,Embolization most effective in patients who,Still bleeding after surgical arterial ligation,Bleeding site difficult to reach surgically,Comorbidities prohibit general anesthetic,Effective only when bleeding is .5 ml/min,90+% success rate, complication rate of 0.1%,Only able to embolize external carotid & branches,Complications: minor (18-45%)/major (0-2%),Contraindicated in bad atherosclerosis, Ethmoid bleed,Selective Angiography/emboliza,40,Surgical treatment,Transmaxillary IMA ligation,Intraoral IMA ligation,Anterior/Posterior Ethmoidal ligation,Transnasal Sphenopalatine ligation,External carotid artery ligation,Septodermoplasty/Laser ablation,Surgical treatment,41,Transmaxillary IMA ligation,Waters view,Caldwell-Luc,Electrocautery of posterior wall before removal,Microscopic dissection and ligation of IMA -descending palatine & sphenopalantine most important,Recurrence rate (failure rate) of 10-15%,Complication rate of 25-30% (oa fistula,dental, n),Transmaxillary IMA ligationWat,42,鼻出血英文课件,43,Intraoral IMA ligation,Posterior gingivobuccal incision beginning at second molar,Temporalis mm split and partially dissected,IMAX visualized, clipped and divided,Advantages: children/facial fractures,Disadvantages: more proximal ligation,Complications: trismus, damage to infraorbital n,Intraoral IMA ligationPosterio,44,Ant./Post. Ethmoidal ligation,Patients s/p IMAX ligation still bleeding, superior nasal cavity epistaxis, or in conjunction when source unclear,Lynch incision,Fronto-ethmoid,suture line,12-24-6,(14-18, 8-10, 4-6),Ant./Post. Ethmoidal ligationP,45,Transnasal Endoscopic Sphenopalatine Artery ligation,Follow Middle Turbinate to posteriormost aspect,Vertical mucoperiosteal incision 7-8mm anterior to post middle turb (between mid. and inf. turbs),Elevation of flapID neurovascular bundle at foramen,Ligation with titanium clip,Reapproximate flap,Complications few, Failures0-13%,Transnasal Endoscopic Sphenopa,46,Transnasal Spheno-palatine Artery ligation,Transnasal Spheno-palatine Art,47,Functional endoscopic sinus surgery,Laboratory exam,Vascular supply,Topical decongestants/vasocontrictors,Wegeners Granulomatosis,Antihistamines to prevent rebleeds,Anatomy/Physiology of Epistaxis,68), and shorter hospital stays (2.,-Greater Palatine (IMAX),traumatic foreign bodies,Others compared all medical treatment to surgery and showed cost cut using medical management.,Hypertension/Arteriosclerosis,Local Factors Dessication,68), and shorter hospital stays (2.,Non-surgical treatments on d/c,ECA ligation,Effectiveness,Anterior border of SCM,ID ECA/ICA,Ligation after clear that surrounding structures are safe.,Functional endoscopic sinus su,48,Septodermoplasty/Laser,Remove mucosa from anterior septum, floor of nose, lateral wall,STSG vs. cutaneous, myocutaneous, microvascular free flaps vs. Autografts,Neodymium-yttrium-garnet (Nd-YAG) laser or Argon laser + topical steroid best nonsurg rx for mild/mod disease,Still bleed, but not as bad,Definitive treatment (severe disease)closure of nose,Septodermoplasty/LaserRemove m,49,Statistically speaking,.,Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.,Others compared all medical treatment to surgery and showed cost cut using medical management.,Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%,Cost analysis: IMAX vs. Embolization vs. Surgical Cauteryabout equal,Failure rates: PP-30%, Sx-17%, Emb-4%,Statistically speaking,.Some,50,Tips and Pearls,Red rubber on suction in contralateral nasal cavity,AgNO3 x 30seconds or more (not on both sides of septum),Antihistamines to prevent rebleeds,Cautery does not work with no platelets/clotting,Glove packing,H2O2,Merocels (2 or more) injected with cortisporin otic,Amicar spray,Tips and PearlsRed rubber on s,51,Tips and Pearls,Hot water irrigation,Cold water irrigation,Salt Pork,Don,t pack nose in unconscious person with suspected skull fractures.,Antibiotic cream vs. silver nitrate,Intranasal pressure,Estrogen cream to nasal septum,Tips and PearlsHot water irrig,52,Tips and Pearls,Transnasal endoscopic bipolar cautery of sphenopalatine artery (7% failure in pts with obvious source of bleed),Submucosal supraperichondrial dissection of nasal septum,Not all hospitals have embolization-trained interventionalists,No hard-set outline. Do what is best for your particular patient,Tips and PearlsTransnasal endo,53,典型录像,下鼻道后端：鼻后外侧动脉出血,中鼻甲下端：鼻后外侧动脉中鼻甲支,下鼻甲上缘：鼻后外侧动脉分支,鼻中隔上端：筛前动脉,鼻中隔前端：筛前动脉末端等,典型录像下鼻道后端：鼻后外侧动脉出血,54,鼻内镜下止血,门诊止血成功率大约,95,需要鼻内镜手术并止血的：鼻中隔偏曲合并鼻出血，眶壁骨折合并鼻出血，鼻腔肿物或鼻窦肿瘤合并鼻出血,需要栓塞的：颈内动脉假性动脉瘤，颈内动脉海绵窦动静脉瘘,鼻内镜下止血门诊止血成功率大约95,55,Anatomy/Physiology of Epistaxis,Anatomy,Nasal cavity,Vascular supply,Physiology,Vascular nature,Mucosa,Anatomy/Physiology of Epistaxi,56,Anatomy of the Lateral Nasal Wall,SPF,-class I (35%),-class II (56%),-class III (9%),Anatomy of the Lateral Nasal W,57,Vascular nature,Anterior border of SCM,Maxillary sinus ostium,cutaneous, myocutaneous, microvascular free flaps vs.,Pt requires transfusion/admit hct of 38% (barlow),Wegeners Granulomatosis,Infectious/Inflammatory,Local Factors - Neoplasm,Anterior: younger, usually septal vs.,External carotid artery ligation,Not all hospitals have embolization-trained interventionalists,Mild sedation/analgesia,Microscopic dissection and ligation of IMA -descending palatine & sphenopalantine most important,VonWillebrands disease,下鼻甲上缘：鼻后外侧动脉分支,Local Factors - Trauma,Nose picking,Nose blowing/sneezing,Nasal fracture,Nasogastric/nasotracheal intubation,Trauma to sinuses, orbits, middle ear, base of skull,Barotrauma,Vascular natureLocal Factors -,58,Non-surgical treatments,Control of hypertension,Correction of coagulopathies/thrombocytopenia,FFP or whole blood/reversal of anticoagulant/platelets,Pressure/Expulsion of clots,Topical decongestants/vasocontrictors,Cautery (AgNo3 vs. TCA vs. Bipolar vs. Bovie),Nasal packing (effective 80-90% of time),Greater palatine foramen block,Non-surgical treatments Contro,59,Nasal packs,Anterior nasal packs,Traditional,Recent modifications,Posterior nasal packs,Traditional,Recent modifications,Ant/Post nasal packing,Nasal packsAnterior nasal pack,60,Statistically speaking,.,Some authors (Wang and Vogel) showed surgical intervention to have lower failure rates (14.3 vs. 26.2), decreased complications (40 vs. 68), and shorter hospital stays (2.2 less) than those w/posterior packs.,Others compared all medical treatment to surgery and showed cost cut using medical management.,Complication rates: posterior packs-25-40%, embolization 27%, IMAX ligation 28%,Cost analysis: IMAX vs. Embolization vs. Surgical Cauteryabout equal,Failure rates: PP-30%, Sx-17%, Emb-4%,Statistically speaking,.Some,61,Tips and Pearls,Red rubber on suction in contralateral nasal cavity,AgNO3 x 30seconds or more (not on both sides of septum),Antihistamines to prevent rebleeds,Cautery does not work with no platelets/clotting,Glove packing,H2O2,Merocels (2 or more) injected with cortisporin otic,Amicar spray,Tips and PearlsRed rubber on s,62,典型录像,下鼻道后端：鼻后外侧动脉出血,中鼻甲下端：鼻后外侧动脉中鼻甲支,下鼻甲上缘：鼻后外侧动脉分支,鼻中隔上端：筛前动脉,鼻中隔前端：筛前动脉末端等,典型录像下鼻道后端：鼻后外侧动脉出血,63,