Epistaxis is defined as bleeding of nasal origin irrespective of its expression.
The anterior nosebleeds are not a problem
recognition. The posterior epistaxis is sometimes more difficult to say as long as the blood has stopped flowing, and was swallowed and vomited. The bleeding usually externalize both forward and backward. In fact, we must especially distinguish the mild epistaxis, the most common by far, and severe epistaxis with hemodynamic consequences that require real taken into emergency care and hospitalization.
We must also distinguish essential epistaxis, corresponding to a single vascular erosion, often traumatic, or after exposure to heat, epistaxis indicative of more serious infections, such as general blood pressure or hémorragipares disease, tumor or local, benign or malignant.
The bleeding of the nose is because the nasal passages are very vascularized and is a meeting place and anastomosis between the external carotid system (internal maxillary and sphenopalatine, facial artery) and internal carotid system (ethmoid arteries).
Septum particularly present in his anterior inferior part a microartérielle anastomosis described as the vascular task name.
DIAGNOSTIC:
Recognize epistaxis is simple.
The anterior epistaxis has no differential diagnosis.
Posterior nosebleeds are objectified by examining the pharynx sunny with a tongue depressor, and well lit (mirror Clar).
An intermittent flow forced to repeat the examination. The presence of clots has the same meaning. The presence of blood “dried” on the wall does not always assert its origin.
Assessing the gravity is a key point since the subject’s condition appears troubling.
This gravity is assessed on the general signs, and emergency laboratory tests, keeping in mind the potential severity of some originally nasal bleeding.
This implies the establishment of an infusion with saline or macromolecules, and making arrangements for possible transfusion (group, Rh) should it become necessary clinical and especially biological monitoring (count, hematocrit).Resuscitation would be undertaken before any local maneuver sometimes traumatic and likely to result in decompensation.
Data from the patient interview and carers are often alarmist and not an important prognostic factor.
However, the examination can sometimes bring out the notion of repetition epistaxis, which is indeed a causative and prognostic significance.
ETIOLOGY:
The abundance, the anterior or posterior externalization does not constitute absolute orientation arguments. However a small anterior epistaxis, especially in children does not justify in any case of multiple examinations.
Anyway examination of the nasal cavity using a speculum or even endonasal perspective, is essential and allows in many cases to view the source of bleeding and its type (arterial bleeding the nasal septum, jet). Sometimes this examination reveals immediately small mucosal hemangiomas Osler Rendu disease. It can also highlight a tumor blocking the nasal cavity.
This examination if necessary faces two obstacles:
– Or the bleeding is too much and we see nothing in spite of aspiration;
– Or the bleeding has stopped and can not demonstrate its origin.
In fact we must distinguish local causes general causes.
Local causes:
Traumatic:
These are fractures of the nose and maxillofacial trauma in general, which is closer iatrogenic causes (rhinoplasty, surgery of the nasal septum and the turbinates).
Fractures of the facial bones, disjunctions orbitofrontal-naso-facial pose ethmoido addition, the control of bleeding which can be dramatic, the problem of their support for reduction and fixation, and the recognition of a leak associated CRL.
Ruptures of the internal carotid artery, traumatic or spontaneous, perfectly exceptional, can be revealed by epistaxis.They are often beyond any therapeutic resource.
Only arteriography with rise of a balloon may, in exceptional circumstances, allow to save the patient.
Tumor:
Malignant tumors of the sinuses:
Malignant tumors of the sinuses may be by epistaxis. These are squamous cell carcinomas or adenocarcinomas of ethmoid originally considered as an occupational disease among woodworkers.
Benign tumors of the sinuses:
Benign tumors match angiofibroma of the partition, which is closer to other angiomas nasal cavity or sinus.
Nasopharyngeal fibroma:
Nasopharyngeal fibroma is found among male adolescents. The endoscopic diagnosis.
Angiography can determine the dominant source of its blood supply and is, by the possibility of embolization, the first treatment.
General causes:
Hypertension:
The nosebleeds may indicate an unrecognized hypertension.
Warts:
We must especially remember the coagulation disorders:
– Iatrogenic: anticoagulants (++), aspirin and other antiplatelet agents;
– Thrombopathies and thrombocytopenia purpura with often: thrombocytopenia may be the consequence of chemotherapy treatment;
– Vascular disruption time, von Willebrand disease, some capillaries (HSP, immunoallergic diseases, infectious diseases);
– Coagulation disorders outside iatrogenic effect of drugs, such as hemophilia, etc.
Osler Rendu disease:
The epistaxis is the first mode of revelation of this hereditary telangiectasia. The presence of telangiectasia of fingers, lips or palate enough to confirm the diagnosis; but in the most difficult cases endonasal optics is highly suggestive.The review should be complete in particular looking for a pulmonary arteriovenous fistula or liver angiomatose.
Local treatment is difficult. Depending on the importance of epistaxis must appeal to a single cauterization or tamponade with, the use of adhesives, see embolization emergency (see below). In general, transfusions are necessary if the hemoglobin drops below 9 g / 100 mL, and iron therapy is indicated (per os or as Veinofer® IV day hospital). It is possible that COCs high-dose estrogen (30 to 50 micrograms of ethinyl estradiol) reduce the frequency and intensity of epistaxis.
TREATMENT:
Heavy bleeding:
If bleeding is abundant, the management does not differ from the care of any concern hemorrhage (treatment of shock, transfusion, etc.).
Mild or moderate epistaxis:
Benign earlier forms, often repetitive of the child are treated with simple digital compression of the nose wing on the partition (at least 10 minutes) followed if necessary by chemical cauterization (silver nitrate, chromic acid, etc. ).
If bleeding artery, must be selective electrocoagulation.
Most major bleeding are treated with anterior pack with fat wick, or better hemostatic plugs (Merocel®). These pads are left in place 48 hours under cover antibiotic (foreign body in the nose, sinus risk of infection or ear) and analgesic (paracetamol).
In a further degree, must be used to tamponade anteroposterior, usually carried today by using a double balloon catheter. The posterior balloon “tether” the probe at the posterior opening of the nasal cavities (choanal), the other balloon compresses within the nasal cavity by molding on the walls.
Buffering said later consists of a gauze pad is set up using a probe Nélaton to tow it with silk son, which was then docked with a previous buffer. Become quite exceptional because too traumatic, this technique must remain famous in the absence of more suitable equipment available.
Invasive approaches:
Invasive approaches are justified in the absence of control of bleeding and, in fact, facing iterative times “déméchage”.
It is :
– Essentially, “clipping” or coagulation of sphenopalatine artery, directed by endonasal route under video endoscopy.The first surgical transmaxillary became exceptional.
Sometimes the gesture must be supplemented by a direct approach of the ethmoid arteries (internal carotid system);
– Selective embolization femoral branches of the external carotid artery (facial, internal maxillary). This technique is not entirely without risk (risk of stroke, blindness).
Bleeding disorders:
Of course, coagulation disorders must be supported (stopping anticoagulants, aspirin, possible transfusion of platelet concentrate or administration of coagulation factors).
CONCLUSION:
In fact, keep in mind that most nosebleeds are benign and that apart from a few simple gestures, is knowing how to reassure the patient or his family, but some forms can be extremely serious (after trauma especially ) and require mobilization equivalent to that of any severe bleeding, particularly wary of unknown importance of blood swallowed in a tired subject, more or less shocked or comatose.
