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**Managing Epistaxis: Causes, Diagnosis, and Treatment**

Learn about the causes, diagnosis, and treatment of epistaxis (nosebleed) including local and general factors, systematic diseases, arterial pressure, treatment methods, foreign body in the nose, mucoclele, cysts, benign neoplasms, and malignant tumors.

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**Managing Epistaxis: Causes, Diagnosis, and Treatment**

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  1. Epistaxis (nosebleed) Etiology： 1、 Local causes： 1）Trauma：mucosa laceration blood vessel injury 2）Inflammation of nose and sinus 3）Diseases of septum 4）Tumor：nasal cavity tumor sinus tumor angiofibroma of nasopharynx

  2. 2、 General factors Systematic disease—— Ascension of arterial pressure and venous pressure， Dysfunction of coagulation, Change of blood vessel tension.

  3. 1） Acute epidemical diseases 2） Cardiovascular diseases 3） Hemological diseases 4） Nutrition defect：VitC、K、P or calcium 5） Liver, kidney diseases and rheumatic fever 6） Poison ：phosphorus, mercury, arsenic, benzene 7）Osler’s disease hemorrhagic familial telangiectasia 8） Endocrinic imbalance

  4. Treatment： 1、 Fundamental treatment Emergency: sedation estimate the bleeding amount keep proper posture No blood ingest 2、 Hemostatic methods 1）Identify the bleeding site pinch the nostrils

  5. 2）Cautery techniques • chemical • electrical • laser • radiofrequency • microwave • 3） Nasal packing • resorbable material, gel foam. • anterior • postorior • water or air balloon

  6. 3、Artery ligation anterior ethmoid artery posterior ethmoid artery internal maxillary artery external carotid artery 4、 Angiography and embolization submucous resection endoscopic cautery and ligation

  7. 5、 Systematic management. 1）sedative 2）hemostatic agent 3）Vitamine C, K. 4）sclerosant 5）anti-shock management 6）Traditional Chinese Medicine

  8. Foreign body in the nose Endogenic Dead bone, blood clot, rhinolith Extrogenic Plant seeds, insect, metals, stone, woods… Biologic Nonbiologic

  9. Etiology： 1、Children 2-3yrs old 2、Insects 3、Injury：wood, rocks, metals 4、Iatrogenic

  10. Metal in nasal cavity

  11. Rhinolith in nasal cavity

  12. Diagnosis： Unilateral purulent drainage with foul smell in children ——Foreign body in the nose? History；nasal examination； plain X-ray; CT scan Treatment： Remove foreign body in different ways Prevent foreign body in the nosein bronchi

  13. Mucocele and Cyst

  14. Cyst of nasal vestibule • Vestibule, maxillary dental alveoli, unilateral round/oval cyst • Diagnosis: palpation, punction X-ray • Treatment: resection of cyst

  15. Mucocele Benign neoplasms: Obstruction of sinus ostia and accumulation of fluid Etiology: chronic inflammation, allergic sinonasal disease, trauma, and previous surgery Pathology：retention of intrasinus secretion, progressive augmentation of internal pression, bony remodeling and erosion.

  16. Morbidity: China: ethmoid > frontal > sphenoid > maxillary Abroad: frontal > ethmoid > sphenoid > maxillary Symptoms & Sign： Orbital apex syndrome Facial protrude Rhinorrhea, nasal obstruction, hyposmia Diagnosis: History, symptoms and sign Punction, X-ray/CT scan Treatment: Operation: “open surgery”, marsupialization

  17. Diagnosis： X-ray and CT scanner. Treatment：surgical treatment: drainage, creation of vast communication with nasal cavity

  18. Tumor of nose and skull base Benign tumor in the nose — 40 kinds of benign tumor — nasal organ is small, difficult to identify the origin. —recurrence and malignant transformation Hemangioma Capillary hemangioma——nasal septum & anterior inferior turbinate Cavernous hemangioma——maxillary & nasal bone

  19. Papilloma in the nose Pathogenesis — unclear — humon papilloma virus (HPV) Pathology: 1) Keratotic papilloma simple cutaneous wart, exophytic with broad base, in the nasal vestibule or nasal septum.

  20. 2) Inverted papilloma Age>40ys，high morbidity: 50—60ys; M: F=3:1 Features：Hyperplastic epithelia with inverting pattern of growth. Epithelial inversion into underlying stroma. Basal membrane is intact. Malignant transformation : 5-15% . squamous cell carcinoma, adenocarcinoma.

  21. Symptoms & Signs： Nasal obstruction, rhinorrhea with blood staining, sometimes with headache and abnormalities of smell. Firm red or grey masses, unilateral, arising from lateral wall of the nose, extension into the ethmoid and maxillary sinuses.

  22. Treatment Complete excision Some times it is difficult. Recurrence: 28-74% Lateral rhinotomy. Endoscopic excision, with reasonable recurrence rates. Malignant transformation--radiotherapy

  23. Malignant tumor of nasal cavity and paranasal sinuses Morbidity in China: 2.05-3.66% of malignant tumors in all 21.74%-49.22% ofmalignant tumors in ORL Carcinoma:cancer=8.5:1 M: F=1.5-3.0:1 Cancer:---40-60ys，Sarcoma---younger

  24. — 2～4% of whole body carcinorna. — more frequently in sinus than nasal cavity maxillary 60～80% ethmioid 3.8% frontal 2.5% — for advanced case difficult to identify the original site. Squamous: 70～80% more in maxillary sinus Adenocarcinoma: 4～8% more in ethmoid sinus

  25. Adenoid cystic carcinoma 4% more in ethmoid sinus Sarcoma:10-20% malignant tumors in ORL More in nasal cavity and maxillary sinus. Malignant lymphoma>60%；

  26. — Malignant epithelia tumor. Carcinoma of nasal vestibule and Septum Carcinoma of the paranasal Sinus Melanoma Esthesioneuroblastoma

  27. — Malignant nonepithelial tumor. Rhabdomyosarcoma. Hemangiopericytoma lymphoma Extramedullary plasmacytoma.

  28. Symptoms & Signs： Nasal Cavity: — nasal obstruction. — epistaxis. — pain. — numbness of cheek.

  29. Paranasal sinus: — purulent drainage with blood — nasal obstruction (unilateral, progressive) — extrusion of cheek — extrusion of hard palate — Ophthalmologic symptoms: proptosis, epiphora, visual acuity decrease, orbital apex syndrome — cranial involvement

  30. Diagnosis: Caution! >40yrs, unilateral, progressive symptoms — increase doctor’s index of suspicion — nasal examination — nasal endoscopic examination — biopsy — CT、MRI — PET (positron emission tomograph)

  31. Treatment: • Radiotherapy: 5000-6000rad within 4-8w，6w after radiotherapy --- surgery • Surgery --- cornerstone • -lateral rhinotomy. • -midfacial degloving • -Maxillectomy • -Maxillectomy+orbital contents exenteration • -Craniofacial resection.

  32. 3. Chemotherapy --- unwilling or unsuitable for surgery Prognosis : —Survival advantage radiation and surgery. —The value of the chemotherapy undetermined. 5yr survival rate: 30-40% for maxillary sinus MT

  33. 复习与思考： 1、鼻出血的病因有哪些？如何处理鼻出血？ 2、鼻腔鼻窦恶性肿瘤的临床表现有哪些？ 3、鼻腔鼻窦恶性肿瘤的处理原则是什么？

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