[ENT] Epistaxis

Question 1

where do most epistaxes occur?

Answer 1

anteriorly in Little’s area (90-95%)

Question 2

what are the two age peaks of incidence?

Answer 2

children (2-15)

adults (>45)

Question 3

what are the risk factors for epistaxis?

Answer 3

• alcohol intake/excess
• anticoagulant/antiplatelet use
• bleeding/clotting disorders
• topic drugs (decongestants, cocaine)
• nasal polyps
• chronic sinusitis

Question 4

what are the signs of a posterior bleed?

Answer 4

• profuse bleeding
• bleeding from both nostrils
• no bleeding points can be found
• suspected anterior bleed has not resolved with rx

Question 5

what are the localised causes of epistaxis?

Answer 5

1. trauma (nose picking, FBs)
2. inflammation (sinusitis, recent URTI)
3. vascular (Telangiectasia)
4. tumours (angiofibroma, SCC)
5. dry membranes (air conditioning, nasal cannulae)
6. post-op bleeding
7. topical drugs (decongestants, cocaine)

Question 6

what are the generalised causes of epistaxis?

Answer 6

1. atherosclerosis
2. raised venous pressure (e.g. mitral stenosis)
3. haematological disorders (von Willebrand disease, haemophilia, leukaemia)
4. systemic drugs (anticoagulants, antiplatelets)
5. alcohol excess

NOT arterial HTN (no link!)

Question 7

what is nasopharyngeal carcinoma?

Answer 7

• common cancer of the nasopharynx

- a form of SCC

Question 8

what does nasopharygeal carcinoma present with?

Answer 8

a progressive disease presenting with nasal obstruction and neuropathies of CNs III, IV, V and VI

Question 9

what are the risk factors for nasopharyngeal carcinoma?

Answer 9

• Chinese
• male
• EBV exposure
• smoked fish consumption (nitrosamines)
• smoking

Question 10

how is nasopharyngeal carcinoma managed?

Answer 10

• radiotherapy

- systemic chemotherapy

Question 11

what can be done for residual disease in nasopharyngeal carcinoma?

Answer 11

nasopharyngectomy

Question 12

what can be done for metastatic disease in nasopharyngeal carcinoma?

Answer 12

neck dissection

Question 13

how do you manage epistaxis?

Answer 13

1. identify and control any risk factors e.g. anticoagulants:
   - nasal pressure 15 mins
   - tranexamic acid
2. assess location of bleeding

Question 14

what can be done for anterior bleeding?

Answer 14

silver nitrate cautery

Question 15

pt gets silver nitrate cautery for anterior bleeding and bleeding resolves. what next?

Answer 15

discharge with topical Naseptin

Question 16

pt gets silver nitrate cautery for anterior bleeding and bleeding does not resolve. what next?

Answer 16

‘rapid rhino’ unilateral anterior packing

Question 17

pt gets ‘rapid rhino’ unilateral anterior packing and bleeding resolved. what next?

Answer 17

discharge with packing and for ENT review the following day

Question 18

pt gets ‘rapid rhino’ unilateral anterior packing but bleeding persists. what next?

Answer 18

admit to hospital:

• bilateral posterior packing
• abx
• surgery if indicated
• replace blood and reverse coagulation if needed

Question 19

what is the mx for posterior bleeding?

Answer 19

admit to hospital:

• bilateral posterior packing
• abx
• surgery if indicated
• replace blood and reverse coagulation if needed

Question 20

Chinese ethnicity, facial pain, double vision and persistent lymphadenopathy. dx?

Answer 20

nasopharyngeal carcinoma

Question 21

young child with recurrent epistaxis and purpuric lesions on the fingertips and tongue. dx?

Answer 21

hereditary haemorrhagic telangiectasia

Question 22

evolving sunburn-like erythema and confusion >48 hours nasal packing. dx?

Answer 22

toxic shock syndrome

Question 23

what is the 1st line ix for epistaxis?

Answer 23

nasal speculum examination

Question 24

how often should nasal packing be changed and why?

Answer 24

every 48 hours to reduced risk of toxic shock syndrome