PANCE Blueprint EENT (9%)

Epistaxis (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

9 Year Old with Nosebleeds

9-year old with acute onset epistaxis and low platelet count (watch video)

Patient will present as → a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleed. In the ED a topical vasoconstrictor is tried but also fails to stop the bleeding.

Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds

  • Woodruff's Plexus is the most common site for posterior nosebleeds.
  • The sphenopalatine artery is generally the source of severe posterior nosebleeds causing bleeding from both nares and posterior pharynx.
  • Patients should always be asked about aspirin or ibuprofen use.

Majority do not require testing other than direct visualization

  • Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.
  • CT may be done if a foreign body, a tumor, or sinusitis is suspected.

Most nosebleeds are anterior and stop with direct pressure.

  • Apply direct pressure at least 10-15 minutes, seated leaning forward.
  • Short-acting topical decongestants (Afrin, phenylephrine, cocaine)
  • Anterior nasal packing.
    • Patients with nasal packing must be treated with antibiotics (cephalosporin) prevent toxic shock syndrome and patient has to return to take the packing out. 
  • If there is no packing in the nose, put a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days.
  • A posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated.
  • Recurrent epistaxis: Must rule out hypertension of hypercoagulable disorder (see video case above).
Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX) Woodruff’s Plexus: -Sphenopalatine A (IMAX)

Anterior Ethmoid (Opth) Superior Labial A (Facial) Sphenopalatine A (IMAX) Greater Palatine (IMAX) Woodruff’s Plexus: -Sphenopalatine A (IMAX)

Question 1
A 66 year-old male presents with epistaxis of two hours duration. He has been unable to stop the bleeding at home. He has a history of hypertension and cardiovascular disease. On exam the vital signs are T-38°C, P-74/minute, RR-20/minute, and BP-180/110 mmHg. Bleeding is noted from the right nare; the left is essentially clear with normal nasal mucosa. After applying pressure for 15 minutes, a bilateral anterior pack is placed. You note persistent bleeding, with blood in the posterior oropharynx. Of the following, the most appropriate treatment is to remove the packing and
A
replace with Gelfoam packing
Hint:
Gelfoam packing, cauterization of Kiesselbach's plexus, and topical lidocaine and epinephrine are helpful in treating an anterior bleed, but not in a posterior bleed.
B
cauterize Kiesselbach's plexus
Hint:
See A for explanation.
C
insert a posterior balloon pack
D
apply topical solution of lidocaine and epinephrine
Hint:
See A for explanation.
Question 1 Explanation: 
A posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated.
Question 2
A 13 year-old boy with leukemia presents with epistaxis for 2 hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is
A
electrocautery of the bleeding site.
Hint:
Cautery is not used because the edges of the cauterized area may begin to bleed.
B
silver nitrate application
Hint:
Silver nitrate is not used in children because it increases the risk for nasal septal perforation.
C
posterior nasal packing
Hint:
Posterior nasal packing is indicated for posterior bleeds in the inferior meatus.
D
intranasal petrolatum gauze
Question 2 Explanation: 
Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.
Question 3
What is the most common location of anterior nasal epistaxis?
A
Middle turbinate
Hint:
See D for explanation.
B
Posterior ethmoid artery
Hint:
See D for explanation.
C
Kiesselbach's triangle
D
Inferior turbinate
Hint:
The inferior turbinate is the most common location for posterior epistaxis.
Question 3 Explanation: 
90% of all cases of anterior epistaxis originate from Kiesselbach's triangle.
Question 4
An elderly patient with a history of hypertension presents with epistaxis. On examination you note blood from both nares and down the posterior oropharynx. Examination of the nasal cavity with an ENT headlamp does not show an area of bleeding. Which of the following is the treatment of choice in this patient?
A
Electrical cautery
Hint:
Cautery and direct pressure are effective in anterior, not posterior epistaxis.
B
Direct pressure on the nose
Hint:
See A for explanation.
C
Petroleum jelly application
Hint:
Petroleum jelly application is not indicated in posterior epistaxis.
D
Posterior nasal packing
Question 4 Explanation: 
Posterior epistaxis is more common in elderly patients, especially with hypertension. Posterior nasal packing is the treatment of choice.
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