Epistaxis-Nose bleeding

Epistaxis/Nose bleeding-What is nose bleeding?

Nasal bleeding (epistaxis), also known as epistaxis, is one of the common clinical symptoms, nasal bleeding due to nasal lesions caused by systemic diseases may also be caused, and occasional bleeding nasal outflow due to the nasal cavity adjacent lesions. Epistaxis, unilateral, can also be bilateral; intermittent recurrent bleeding, but also sustainable bleeding; number of different amount of bleeding, the light only blood in the nose, severe cases can lead to hemorrhagic shock; repeated bleeding can lead to anemia. Most bleeding can be self-only.

Epistaxis - OverviewNosebleeds are many reasons, but about half of the people can not find the reason. The distribution of the tiny blood vessels in the nasal mucosa is very dense, is a very sensitive and fragile, easily broken Erzhi bleeding. In the phenomenon of preschool children common nasal bleeding. Nosebleeds, most people are accustomed to head back, nostrils upward, think that it can effectively stop the bleeding, but they are wrong to do so just the sight of blood outflow, but in fact blood or continue in the inward flow.Nose bleeding - cause ofEpistaxis - partly due toA. Trauma. Nose their own digging. Two. Barotrauma. 3. Deviated nasal septum. The nasal septum perforation often the Epistaxis symptoms. 4. Inflammation: ① non-specific inflammation: dry rhinitis, atrophic rhinitis, acute rhinitis, acute maxillary go far, often for epistaxis reasons. ② specific infection: nasal tuberculosis, nasal diphtheria, nasal syphilis, prone to cause nasal bleeding due to mucosal ulceration. 5 Tumors. 6. Others: nasal foreign bodies, nasal leeches can cause repeated heavy bleeding. The plateau region, the relative humidity is too low, the extra risk of dry rhinitis, an important reason for the region epistaxis.Epistaxis - systemic reasonsA. Blood diseases: abnormal of ① platelet quantity or quality. ② clotting mechanism abnormalities. Two. Acute infectious diseases. 3. Cardiovascular disease: ① arterial pressure is too high: such as hypertension, atherosclerosis, nephritis, associated with hypertension, eclampsia, etc.. ② increased venous pressure: such as mitral stenosis, the great mass of the chest or mediastinum and neck, pulmonary emphysema, pulmonary edema and bronchial pneumonia. 4. Vitamin A deficiency: vitamin C, K, P, and trace elements calcium deficiency are prone to nose bleeding. 5 Chemicals and drug poisoning: phosphorus, mercury, arsenic, benzene poisoning can damage the function of the hematopoietic system causing epistaxis. Long-term use of salicylic acid drugs, can cause prothrombin to reduce the bleeding of obviousness. 6. Endocrine disorders: compensatory menstruation, threatened epistaxis often occurs in puberty, usually caused by estrogen in the blood content decreased, caused by nasal blood vessels to dilate. 7. Hereditary hemorrhagic telangiectasia, liver, chronic renal disease and rheumatic fever, etc., may be associated with nasal bleeding.

Nose bleeding - symptomsSigns: bleeding can occur in any part of the nasal cavity, but the anterior subventricular zone of the nasal septum is the most common, sometimes visible injection or pulsatile arterial bleeding. Response to nasal bleedingNasal cavity bleeding often rapidly into the pharynx, from out of the mouth. In general, nasal bleeding caused by local disease, and more limited to the side of the nasal cavity, caused by systemic diseases, may alternately or simultaneously on both sides of the nasal bleeding. Complications: epistaxis difficult to control, whether it is ferocious severe bleeding, or prolonged healing of the intractable bleeding, can cause serious harm to the body, effects: blood loss, anemia, acute hemorrhagic shock, the cardiovascular system complications, cerebrovascular accidents, asphyxia, fetal distress, severe cases can be life-threatening.Nose bleeding - hazards1, pregnant women, nosebleeds often involving the health of the fetus, severe nosebleeds can cause fetal distress, and even premature delivery or stillbirth. 2, causing blood loss, anemia, blood loss caused by acute blood loss anemia in the short term, long-term repeated small amount of nosebleeds caused by chronic blood loss anemia. 3, causing hemorrhagic shock, occurs mainly in the elderly and infirm, because of its heart, lung, kidney compensatory function, acute massive blood loss or nosebleeds sustained more than, easily lead to shock. 4, blood loss anemia is caused by inner ear ischemia and hypoxia, caused by presbycusis. The hazards of epistaxis5, resulting in a sudden drop in blood pressure, acute coronary insufficiency, more likely to promote the onset or worsening the original cardiovascular insufficiency. Frequent nosebleeds can also be induced congestive heart failure and pulmonary edema, severe anemia can also lead to myocardial infarction, is one of the frequent nosebleeds cause of death. 6, hypertension, atherosclerosis is the main reason of high blood pressure in patients with nosebleeds, such as abuse of the haemostatic and procoagulant agents and antihypertensive drugs, nosebleeds may cause cerebrovascular accidents. 7, frequent nosebleeds nasal blood into the maxillary sinus cavity, sinuses have potential foci of infection, the blood into the sinuses of the lesion core solidification, the formation of onion-like pale yellow tumor tissue, it is referred to as necrotic false tumor. Mass of its surrounding tissue, especially the long-term oppression of the medial wall of bone, enable the destruction of bone absorption, inflammatory necrotic tissue to stimulate the local but also cause bleeding. 8, frequent nosebleeds caused by asphyxia most direct reason is the aspiration of blood, the hypopharynx blood clots, larynx and hypopharynx mucosal surface of the blood dirty off. Frail, coma or throat mucosal surface anesthesia patients, nosebleeds are more prone to suffocation. 9, nosebleeds often can cause myocardial infarction, subarachnoid hemorrhage, cerebral hemorrhage, pneumonia and sepsis, small bowel infarction, osteosarcoma, liver cirrhosis, amyloidosis, and blood aspiration, which led to death. 10 children with nosebleeds often easy to anemia, cerebral insufficiency in children memory loss, decreased visual acuity, low immunity, meaning power is not concentrated, poor academic performance; nosebleeds excessive nutrient loss in the 12-16 year-old adolescent outstanding performance for short stature.Complication
Nasal bleeding should not be underestimated, except for nasal bleeding injury, for the cause can prevent avoid, while others need to pay attention. Because of the long-term nasal bleeding may cause the following complications: one, nasal bleeding due to blood loss anemia, acute, chronic, the former because of the short-term blood loss due to the latter is the long-term repeated occurrence of a small amount of nasal bleeding caused by chronic blood loss caused. Such hazards attention to the occurrence in a year older, the body is weak. Cardiovascular complications in case of a lot of nose bleeding, blood pressure dump, can lead to acute coronary insufficiency, more likely to promote the onset or worsening the original cardiovascular insufficiency. The occurrence of severe anemia also lead to the possibility of myocardial infarction, this is also a major cause of nose bleeding to death. If the situation is more serious, then also lead to congestive heart failure and pulmonary edema. Third, the ear of repeated epistaxis prone to age-related hearing loss, mainly due to blood loss anemia caused by inner ear ischemia and hypoxia. Necrotizing maxillary sinus inflammatory pseudotumor When nasal repeated bleeding, nasal blood through the natural maxillary sinus to open the door into the maxillary sinus cavity, sinuses potentially infected lesions of blood into the sinuses to the lesion core from the surrounding wrapped solidification, so repeatedly. Blood coagulation machine, the formation of onion-like pale yellow tumor tissue, it is called necrotic pseudotumor. Mass of its surrounding tissue, especially the long-term oppression of the medial wall of bone, can absorb bone destruction; inflammatory necrotic tissue to stimulate the local but also cause bleeding. The clinical manifestations are very similar to the sinus malignancies, often misdiagnosed. Fetal distress: pregnant women, severe nosebleeds, can affect the health of the fetus, severe cases can lead to fetal distress, and even premature birth or stillbirth. In the treatment of pregnant women, serious nosebleeds of Obstetricians and Gynecologists consultation, pay close attention to the safety of pregnant women and fetuses.InspectionBefore rhinoscopy can not find the bleeding site, such as bleeding does not play practicable after the nose or fiber-optic nasopharyngoscopy. Sinus bleeding, the blood often outflow from the meatus or olfactory cleft. In addition to finding the bleeding point, and make the necessary systemic examination (blood pressure measurement, blood tests, bleeding time and clotting time determination, capillary fragility test and platelet count, etc.). Fashion consultation with the departments concerned to find the cause. The diagnosis is based on: (1) due to local causes such as trauma, ulcers, foreign bodies, tumors, rhinitis, or systemic disease such as blood diseases, cardiovascular disease, poisoning, vitamin deficiency, endocrine disorders, acute infectious disease caused by. One side or both sides of the nasal cavity of a small amount or heavy bleeding, quantity often flow through the nose and mouth, bleeding for a long time accompanied by symptoms of shock and anemia. Check the site of bleeding, and more generally at the bottom of the anterior nasal septum of a vascular plexus or nasopharynx vascular plexus (more common in middle-aged over the age of 40 here). (4) Check the causes of bleeding, to rule out local causes, should pay special attention to the systemic causes and blood tests. Necessary when doing a sinus X-ray examination and sinus endoscope examination to rule out sinus lesions. Repeated severe head trauma bleeding, angiography should be done to exclude the internal carotid artery pseudoaneurysm.

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Nose bleeding - diagnosisPatients with epistaxis should be comprehensive and accurate check, because it relates to future treatment. (1) access to the history of epistaxis severe cases treatment is often bilateral the Jieyou asked to understand the side of the first bleeding, blood, through the history of the side is the bleeding nasal cavity, the primary understanding of the disease in the past is necessary. Quickly find the bleeding location containing 0.1% epinephrine piece of cotton placed on the bleeding nasal cavity, removed after one minute, looking for a bleeding site in the nasal. Branch from the anterior ethmoid artery, nose and palate artery, and upper lip arteries (1) anterior nasal septum below there nasal mucosa shallow match with each other into a mesh. The premises known as the Kiesselbach or Little, is a common site of bleeding. (2) the bottom of the nasal septum front-end where pulsatile bleeding finger compression of the lateral upper lip. If bleeding is to reduce or stop, indicating that the nasal septum supporting the upper lip artery rupture, the treatment should be considered in the upper lip artery ligation. (3) the nasal cavity at the top of the head and face trauma should pay attention to the nasal cavity at the top of inspection, the blood from the nasal cavity at the top of dirty, suggesting that the anterior ethmoid artery rupture. Anterior ethmoid artery running in the ethmoid air cell, ethmoid fractures can occur in severe bleeding. Epistaxis(4) occur in the future such as the number of head trauma severe epistaxis should check visual acuity, eye muscle function, wary of the middle cranial fossa fracture, internal carotid artery rupture of a pseudoaneurysm. Diagnosis is based on the internal carotid pseudoaneurysm: ① history of head injury. ② vision loss or blindness. ③ oculomotor nerve palsy. ④ through the incubation period, a large number of epistaxis. ⑤ intracranial vascular murmur. ⑥ intracranial angiography. (5), nasal sinus endoscopy, such as bleeding in the rear of the nasal septum deviation, nasal septum after the edge of the middle turbinate rear, side and nose before and after the end of the inferior turbinate, nasal wall can make use of nasal endoscopy to find the exact site of bleeding. (3) If time permits, should be held in the sinus X-ray photographs. Severe epistaxis, quickly understand their general condition. (1) body temperature, pulse, heart rate, blood pressure and blood laboratory tests. (2) to observe the whole body skin, conjunctiva, oral mucosa, etc. with or without bleeding or ecchymoses, clear whether the blood disease. (3) the consciousness of patients with epistaxis, shall observe whether the frequent swallowing action must be OK oropharyngeal examination to determine epistaxis whether to continue the flow into the stomach via the pharynx.Nose bleeding - treatmentShould be a temporary solution before and after cure, that is, first of all as soon as possible to stop the blood, and then subjected to the cause of treatment. From treatment to consider, epistaxis can be divided into a small amount of bleeding, sudden severe bleeding two categories.Epistaxis - a small amount of bleedingSuch epistaxis should first identify the bleeding point. Small amount of bleeding, to allow sufficient time to carefully find the bleeding point. General nose is found that the bleeding site, the treatment is as follows: a burning method: bleeding the Ministry of the nasal mucosa surface anesthesia coated with 50% silver nitrate or trichloroacetic acid in the Department of points, the use of its proteins coagulate small blood vessels rupture closed . Electrocautery of the Department, or the application of laser or cryotherapy. Two submucosal dissection: This method can be used for cases of recurrent bleeding of the anterior nasal septum mucosa bleeding. Method of operation is the same as with conventional nasal septum mucosa resection, if the septal cartilage of the septum should be removed, stripped range should be a little wide. Narwla (1987), based on a set of data research, believes that this method better than the ligation of the artery, the reason may be some cases actually have a deviated septum, or destruction of the submucosal vascular network so Scar formation: the nasal mucosa surface anesthesia, ophthalmology triangular knife to do three incisions in the nasal septum easy bleeding, long 1 ~ 1.5cm, cut the mucosa, cut off the expansion of the hair cells in blood vessels, the incision on both sides of 1 ~ 2mm wide submucosal dissection, the oppression of 24 hours. Fulguration under nasal endoscopy: former rhinoscopy difficult to find the bleeding point can be the nasal endoscopy, to detect the nose to the rear of the bleeding site, such as the nasal septum rear, posterior lateral wall of the inferior meatus the rear of the nasal floor and in the nasal passages, etc.. The introduction of endoscopic electrocautery device head burning, can also be imported by the optical fiber laser burning. C02 and YAG laser could easily cause a large area burns, the KTP laser is more appropriate. Should be burning around the bleeding point, and finally in the vascular stump at the burning.Epistaxis - sudden severe bleedingThis type of epistaxis and more menacing manner, quickly stop the bleeding is important, and then further to find the cause for treatment. Hemostatic measures are: 1. Nostril nasal packing method: This is the preferred measure of the treatment of severe epistaxis. Stuffing sterile vaseline, fill pressure should be pre-set a hard plastic nasal catheter, in order to maintain the minimum nasal airway is particularly important when the bilateral nasal packing. Nasal packing time is normally 24 hours to one or remove, in order to avoid the sinus or middle ear complications. For stuffing indwelling for several days or even weeks, the stuffing should be added to the antibiotic powder can also be applied iodoform gauze. Vaseline gauze in patients suffering existing modified as follows: 1.1 hemostatic tamponade France: finger coated with oil or rubber sleeve placed in the nasal cavity, and then the gauze packing kit. 1.2 airbag compression hemostasis: attached to the ventilator rubber membrane or silicone membrane balloon placed in the nasal bleeding site, comprising a gas injection so that the expansion to stop bleeding, and snorkel to maintain nasal breathing. Nose after hole filling method: if the blood still in the packing of the bleeding side of the nasal cavity through the anterior nostril into the pharynx or emission, suggesting that the bleeding site to the rear of the nasal cavity, should be OK nostrils filling from the contralateral nostril. Choanal stuffing can not be retained for too long, and should generally be removed within 24 to 36 hours, or easily cause a variety of complications, severe cases can cause skull base osteomyelitis, meningitis, so choanal fill Se You should pay attention to prevent infection. The main stuffing cone yarn ball. Now more in favor of switching to balloon tamponade with a snorkel, not only can significantly reduce patients' suffering, but also can greatly reduce the incidence of complications. First topical anesthetic spray the affected side of the nose and throat, and take fine catheter inserted into the nostril by anterior nostril to nostril along the nasal floor by the oropharynx, the first end with a hemostat, pull exports, leaving the end of anterior nostril. Sterile vaseline gauze ball (cone yarn ball and then prepare in advance a good, thicker in the thumb head) to take the wire in the catheter front end, the catheter end of the front nostril to the back to pull the yarn bulb stay back from the mouth in the throat, then speed of the yarn ball pushed back into the nasopharynx with a hemostat, and the end of the nostrils at the catheter out taut, so that the yarn ball blockage in the affected side after nostrils. Anterior nostril exposed pairs of silk can not be relaxed to continue before nasal packing, put Lord of the yarn ball again in the anterior nostril, pairs of silk knot in the gauze ball, so that the posterior nasal packing yarn ball without slippage down. Yarn ball on two-lane perpendicular to the pharynx from the oral argument to the cheek, fixed with adhesive tape, set aside two days later, remove the yarn ball downward traction purposes.Sudden epistaxis, repeatedly filling is bound to damage the nasal mucosa, resulting in bleeding increasingly heavier.

This applications can no longer remove the absorbent stuffing, a filling replacement, a week after the stuffing in the nasal liquefied absorption or self-discharge. Such substances as gelatin sponge, oxidized cellulose, fibrin sponge (fibrinfoam), the use of first immersed in a coagulant solution, squeeze out excess liquid after filling in the nasal.The nasal packing is still the main method for the treatment of epistaxis. Nostrils, filling the success rate of more than 90% after the nostrils, filling in between 48% and 80%, Monux (1990) reported 322 cases of nasal packing to stop bleeding 100% success rate. Filling method is better, but its complications can not be ignored, especially in older patients and heart and lung function misfits, serious reactions may occur such as myocardial infarction or death, it should be observed closely for such patients with nasal packing, heart, lung function changes. Vessel occlusion intraoperative nasal packing is still not effective to stop bleeding, vessel occlusion surgery should be performed. Generally divided into the extravascular treatment and vascular therapy. 3.1 the external carotid artery ligation: the nasal cavity of the middle turbinate below the level of blood vessels, the peripheral branch of the Department of the external carotid artery, after ligation of certain hemostatic effect. Patient supine, shoulder padded, head to the opposite side, along the the sternocleidomastoid leading edge of line infiltration anesthesia. The midpoint of the upper corner of the thyroid cartilage at the the sternocleidomastoid leading edge of skin incision and subcutaneous tissue, the sternocleidomastoid backward traction, revealed the two branches of the carotid artery and internal jugular neck, then up stripped of the external carotid artery, exposed to the separation of the superior thyroid artery and its top of the lingual artery, the upward traction of the abdominal incision above the digastric and hypoglossal nerve. Thyroid artery and lingual artery with the aneurysm needle to wear thick silk around the external carotid artery and ligation of the superficial temporal artery should stop pulsating, but also to determine the ligation of the success of a sign.Carotid artery abnormalities can lead to surgical difficulties, the following four special circumstances must be properly handled: 3.11 common carotid arteries branch at more than half of the thyroid cartilage on the edge of the flat above. General incision only carotid artery was exposed and can not find the external carotid artery, the line not to mistake the common carotid artery ligation. In this case should be to extend the incision, the abdomen after exposure digastric and stylohyoid muscles, parotid upward traction with a retractor, deep in the parotid gland to find the external carotid artery ligation. Careful not to damage the facial nerve in the parotid gland peeling and traction. 3.12 thyroid artery and sometimes directly to the separation of the common carotid artery. In this case required to peel, find the common carotid artery at the differences, the identification of the internal carotid and external carotid artery, the separation of the lingual artery for external carotid artery, no branch of the internal carotid artery, it can avoid the mistake thyroid artery above the carotid artery as the external carotid artery, but wrong to tie the common carotid artery. 3.13 carotid artery is sometimes located in the rear of the internal carotid artery. This case the position of judge should not walk the line alone who for the external carotid, what for the carotid, but should be strictly in accordance with whether the branch to determine. Only to distinguish the superior thyroid artery and lingual artery before ligation, so as to avoid the bar of internal carotid artery. 3.14 thyroid artery sometimes absent and sometimes for a merge with the lingual artery. This case the judgment of the carotid artery differences at to the ligation of the external carotid artery, correct tie in danger of the internal carotid artery. Separation of the common carotid artery branch office should be in the artery intrathecal instillation of 1% novocaine to prevent carotid sinus reflex. Carotid artery ligation and applies only to traumatic internal carotid aneurysm due to epistaxis. The surgery should avoid damage to the vagus nerve.

Common carotid artery ligation after all, make the brain tissue blood supply decreased, for safety's sake, the best in the ligation before an adaptive test, with digital compression of the carotid artery for 10 minutes, observed in patients with or without EEG changes and brain positive signs, this method is called Matas test, in the absence of adverse reactions to ligation.Clinical, external carotid artery collateral circulation after ligation of the rapid hemostatic effect is sometimes not consolidated, so the recent multi-advocate ligation of distal vessels. The internal maxillary artery ligation 3.2 because the nasal blood supply mainly from the internal maxillary artery, so the ligation should be the most effective. Can be taken to the maxillary sinus approach or the oral route. 3.21 maxillary sinus approach: the first was reported by Seiffert (1928), promotion by Chandler and other applications. The approach that the conventional maxillary sinus radical surgery approach, lips and gingival incision should be slightly longer, the anterior wall of the window should be slightly larger. Into the sinuses chisel to sinus posterior wall should be kept to the inside to expand. After incision of the posterior wall of the periosteum into the pterygopalatine fossa, stripping fat tissue, with a vascular clamp to see the vein of a rampant, its depths of 4 ~ 5mm to find the internal maxillary artery vascular folder folder jaw, and then placed in the following three the distal end of the artery, the descending palatine artery distal end and the beginning of nearly maxillary artery Department. 3.22 through the oral route: in the maxillary serious injury or tumor filled the maxillary sinus, acute maxillary sinusitis and maxillary sinus gasification bad, selectable via the oral route. The law Maceri (1984), the cut oral mucosa in the maxillary second and third molar, ramus across the buccal gingival sulcus, the appropriate separation to remove the cheek fat pad, slightly expanded.