ENT, Head & Neck Emergencies

A Logan Turner Companion

S Musheer Hussain

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138626423
• eBook ISBN: 9781351856676
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

ENT emergencies are a regular occurrence. This new book covers the full range of hospital emergencies seen  by ENT trainees and practitioners, and also by oral and maxillofacial surgeons and plastic surgeons. Succinct text and clear illustrations complement the sections on Rhinology,Head and Neck,Otology and Paediatrics.Practical and up to date, this book facilitates excellence in clinical practice.

1Emergencies in Rhinology

1Epistaxis

Iain Hathorn

2Acute severe rhinological infection

Wai Keat Wong and Salil Nair

3Acute CSF rhinorrhoea

Quentin Gardiner

4Management of acute nasal trauma

Richard Green and Peter Ross

5Management of orbital injury and expanding orbital haematoma

Bridget Hemmant and Carl Philpott

6Emergency management of the complications of infective sinusitis

Andrew C Swift

7Nasal foreign bodies and rhinoliths

Catriona M Douglas and Brian Bingham

1Epistaxis

Iain Hathorn

Introduction

Management

Primary epistaxis

Secondary epistaxis

Key learning points

Further reading

Introduction

Epistaxis is defined as bleeding from the nose and is one of the commonest emergencies dealt with by the otolaryngologist. The overall incidence of epistaxis in the general population is difficult to determine because most cases are unreported, minor, self-limiting episodes or those controlled with simple first-aid measures. Fewer than 10% of patients seek medical attention for epistaxis and fewer than 10% of those requiring hospitalisation require surgical intervention for control of bleeding.

Due to the fact that many cases involve the elderly population, epistaxis is a significant cause of morbidity and even mortality in general otolaryngology practice. In England there were 22,671 admissions in 2014/2015, with a mean stay of two days.

The nose has an excellent blood supply from both the internal and external carotid arteries, which anastomose extensively within the lateral wall of the nose and septum. The external carotid artery supplies the nose via the facial and maxillary branches. The maxillary artery supply is via the sphenopalatine and greater palatine branches and the facial artery supply is mainly via the superior labial artery. The sphenopalatine artery is the most important blood supply to the nose and it enters the nose via the sphenopalatine foramen before dividing into the posterior septal artery, which runs medially across the face of the sphenoid to the posterior septum and subsequently Little’s area, and the posterior lateral division, which supplies the inferior and middle turbinate. The internal carotid artery contributes the anterior and posterior ethmoid arteries via the ophthalmic artery, and supplies the superior part of the nasal septum and lateral wall.

Epistaxis can be classified anatomically into anterior (Kiesselbach’s plexus) (Figure 1.1) and posterior (Woodruff’s plexus) (Figure 1.2). Kiesselbach’s plexus (or Little’s area) is an arterial plexus on the anterior nasal septum and is a frequent site of bleeding. Woodruff’s plexus is an area of prominent blood vessels lying just inferior to the posterior end of the inferior turbinate. This is a common site of epistaxis in adults. Perhaps a more useful classification, which has the advantage of guiding management, is based on aetiology and whether the epistaxis is primary (80%) or secondary (Table 1.1). Twenty percent of cases will be classified as secondary epistaxis with a local or systemic cause identified. There are also aetiological associations with epistaxis. These include septal deviations and spurs that disrupt normal airflow, causing dessication, increased mucosal fragility and epistaxis. Septal perforations often result in the formation of granulation tissue and crusting, due to the lack of epithelium covering the margins, which can result in epistaxis. Alcohol can affect bleeding time, even when platelet counts and coagulation factors are normal. Epistaxis patients are more likely to consume alcohol than matched control patients and are also more likely to have hypertension. Long-standing hypertension may result in vascular fragility from long-standing disease; however, it is rarely a direct cause of epistaxis.

Figure 1.1The vascular supply of the nasal septum and locus Kiesselbach’s plexus.

Figure 1.2Endoscopic photograph of Woodruff’s plexus. WP-Woodruff’s Plexus, NP- Nasopharynx, IT-Inferior Turbinate.

Table 1.1Aetiology of epistaxis

Idiopathic	80% of cases
Trauma	Digital, external, nasal trauma, iatrogenic
Coagulopathy	Idiopathic thrombocytopaenia (ITP) Disseminated intravascular coagulopathy (DIC)
Drugs	Warfarin, aspirin, clopidogrel, apixaban, dabigatran, rivaroxiban
Chronic granulomatous disease	Granulomatosis with polyangiitis, sarcoidosis
Neoplastic	Angiofibroma, inverted papilloma, squamous cell cancer
Hereditary	Hereditary haemorrhagic telangiectasia (HHT), haemophilia, von Willebrand’s factor deficiency

Management

Primary epistaxis

Assessment and resuscitation

The patient presenting with epistaxis should be assessed as per Acute Life Support guidelines (Airway, Breathing, Circulation). They should be sitting up and leaning forward, with pressure applied to the anterior part of the nose by pinching continuously for 10 minu...

Table of contents

• Cover
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Contributors
• Section 1 Emergencies in Rhinology
• Section 2 Emergencies in Head and Neck
• Section 3 Emergencies in Otology
• Section 4 Emergencies in Paediatric ORL
• Index