post nasal pack

Post nasal pack is made of gauze which is two finger breadth long and one finger breadth wide.Three threads are suspended from this pack.

Epistaxis - treatment

Endoscopic cautery -

Nasal endoscopes have revolutionarised the treatment of epistaxis. Patients used to suffer with the agony of post nasal packs many times in intractable cases. Now we can examine the nasal cavity with an endoscope and pin point the area of bleeding. This area can now be cauterized by either biolar cautery or with an insulated metallic suction tube whose tip is non insulated. When connected with monopolar diathermy, the tip coagulates the bleeding area.

Epistaxis - treatment

Another method of posterior nasal packing is with the foley's catheter. Introduce the foley's catheter along the floor of the nasal cavity into the nasopharynx. When the tip is visible in the oropharynx, inflate the catheter with 10-15 ml of distilled water and pull the catheter till it tightly fits the posterior choanae. Put the anterior nasal pack and clamp t yhe foley's catheter with a umbilical cord clamp after putting a gauze piece inbetween clamp and nose to prevent necrosis of columella.

Double ballooon catheters can also be used in which there is a bloon fof posterior part of nose and choanae and a separate balloon for nasal cavity. These are inflated with distilled water to give optimum pressure.

Epistaxis - treatmant

Posterior nasal bleed - If the bleeding is posterior, a post nasal pack is required. Post nasal pack is made of gauze which is two finger breadth long and one finger breadth wide.Three threads are suspended from this pack.A catheter is passed from the nasal cavity into the oropharynx and taken out from the mouth. The two threads are fixed with this end and the catheter is pulled from the anterior nares thus taking the pack in the oral cavity, then oropharynx and lastly in the nasopharynx and posterior choana. In this procedure the pack is directed by the index finger of right hand. Once in the posterior choana, the nasal cavity is packed by anterior nasal packing and two threads are secured keeping a dental roll or a piece of gauze between the thread and columella to prevent columellar scarring.The third thread is taken out of the oropharynx and secured with adhesive tape on the cheek. This thread helps in taking out of the post nasal pack after 48 to 72 hours. The procedure can be repeated on the other side also if needed.

Epistaxis - treatment

Anterior nasal packing - If the bleeding point on the septum is not found then one has to pack the nasal cavity. For this following packing materials can be used -

1. Ribbon gauze impregnated with BIPP (bismuth iodoform pyro phosphate) or any antibiotic ointment.The ointment acts as lubricating and moistening agent as well as an antiseptic.The ribbon gauze can be layered in the nasal cavity in two ways, either layer on layer horizontally or vertically. Most of the time this anterior packing is enough to control the bleeding by tamponading effect. This is taken out mostly after 48 hours.

2. Readymade packs like merocel can be used which are less traumatising on nasal mucosa. After placing the pack in the nasal cavity, it is made wet by putting saline on it. The pack swells and controls bleeding by pressure effect.

3. Catheters are available with an inflatable baloon which is infatted after inserting the catheter in nasal cavity.

4.Nasal packs are also available with an inner airway for the patient to breathe through it.

Epistaxis - treatment

If all the general measures fail, then the patient should be taken to the operation theatre.The following procedures can be carried out as per the situation demands.

The nasal cavity of the patient should be examined using a sharp head light and a good suction. If the bleeding point is localised, it should be cauterized with a chemical agent like trichlor acetic acid or silver nitrate.

If the bleeding does not stop,the heat cautery or bipolar diathermy is used to cauterize the bleeder.

If the bleeding point can not be localised and the bleeding is not heavy, the bleeding area can be localised using a nasal endoscope (Hopkin's rod lens) and then bipolar diathermy can be used to cauterize it. If bipolar cautery is not available, then an insulated suction tip can be used that has an uninsulated tip to cauterize the area using monopolar diathermy.

Epistaxis-treatment

To treat epistsaxis, first some general measures are used. The patient is asked not to panic as this will raise the blood pressure and aggravate the situation.The nose is tightly pinched. This will control epistaxis from the little's area. Pressure should be firm and be applied for at least 10 minutes while keeping the head in the neutral position and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head backwards or forwards. Swallowing excess blood can irritate the stomach and cause vomiting.

Ice should be applied over the nose to promote vasoconstriction.

The use of local vasoconstrictor drops like oxymetazoline, xylometazoline or phenyepherine instilled in the nose in the form of drops or spray can help in simple bleeds. On can also use calcium alginate mesh to promote coagulation.

Epistaxis -investigations

In a case of epistaxis following investigations are needed -

1. Haematological investigations -

i) Hb, PCV - to see the amount of haemoglobin in blood and packed cell value helpful in acessing the general condition of the patient and to see need for any blood transfusion.

ii) Platelet count - to find any platelet deficiency state.

iii) PTI (prothrombin time index) - access the coagulatory mechanism.

iv) Total and differential leucocytic count - to see for any infection

v) Perepheral blood film - to see any immature cells and deficiency states.

vi) Bleeding and clotting time

2. Radiological investigations -

i) X-ray PNS water's view - to see any sinus pathology, fractures but does not give much information.

ii) CT scan and MRI - In cases of carcinoma and angiofibroma

3. Angiography - To see the vessel which is bleeding.

epistaxis

Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.

Causes of EPISTAXIS

Epistaxis -

Nasal bleeding can be of two types depending upon the site of nasal bleed.Anterior bleeding mostly originates from the septum from its anteroinferior area called Little's area or Kisselbach's plexus.Posterior bleeding is from the so called artery of epistaxis i.e.sphenopalatine artery.

Causes -

1.Idiopathic - In most of the cases no cause can be identified.

2.Traumatic causes -

Nasal picking - It is the commonest cause of epistaxis in children.Nasal picking can cause injury to the Little's area causing bleeding from nose.

Nasal blows and road side traffic accidents causing facial injuries, nasal injuries and fractures cause nasal bleeding.

Iatrogenic causes like nasogastric and nasotracheal intubation.

Surgical causes like in septoplasty, submucus resection and endoscopic sinus surgery.

3.Anatomical deformities such as DNS,septal spurs or Osler-Weber-Rendu Syndrome

4.Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants.

5.Chronic granulomatous diseases like tuberculosis,lupas vulgaris , syphilis, leprosy, rhynoscleroma etc

6. Foreign bodies

7.Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)

8.Midline granulomas - wegener's and stauwart's granuloma

9.Nasal sprays, particularly prolonged or improper use of nasal steroids

10.Chemical inhalants like mercury and chromic acid fumes, cocaine snuff

11.Barotrauma - Atmospheric changes such as sudden movement to high altitudes.

Systemic causes -

1.Drugs - Aspirin, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others

2.Hypertension - There is relationship between hypertension and epistaxis . In adults epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction.

3.Vascular abnormalities - like sclerosed vessels, A-V malformations, hereditary haemorrhagic telengeactasia.

4.Bleeding tendencies - thrombocytopenia, liver disease, coagulopathies.

5.Alcohol (due to vasodilation)

6.Heart failure (due to an increase in venous pressure)

7.Hematological malignancy

8.Systemic infections such as AIDS,typhoid, pneumonia, malaria, dengue fever, measles etc.

9.Pregnancy

10.Menstruation (vecarious menstruation)

Epistaxis-causes

Systemic causes -

1. Drugs - Aspirin, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others
2. Hypertension - There is relationship between hypertension and epistaxis . In adults epistaxis is more common in hypertensive patients, and patients are more likely to be acutely hypertensive during an episode of epistaxis. Hypertension, however, is rarely a direct cause of epistaxis, and therapy should be focused on controlling hemorrhage before blood pressure reduction.
3. Vascular abnormalities - like sclerosed vessels, A-V malformations, hereditary haemorrhagic telengeactasia
4. Bleeding tendencies - thrombocytopenia, liver disease, coagulopathies.
5. Alcohol (due to vasodilation)
6. Heart failure (due to an increase in venous pressure)
7. Hematological malignancy
8. Systemic infections such as AIDS,typhoid, pneumonia, malaria, dengue fever, measles etc.
9. Pregnancy
10. Menstruation (vecarious menstruation)

Epistaxis

Local Causes continuing -

3.Anatomical deformities, such as DNS,septal spurs or Osler-Weber-Rendu Syndrome

4.Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants.

5. Chronic granulomatous diseases like tuberculosis,lupas vulgaris , syphilis, leprosy, rhynoscleroma etc

6. Foreign bodies

7.Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)

8.Midline granulomas - wegeners and stauwarts granuloma

9.Nasal sprays, particularly prolonged or improper use of nasal steroids

10.Chemical inhalants like mercury and chromic acid fumes, cocaine snuff

11.Atmospheric changes such as sudden movement to high altitudes.

Epistaxis

Nasal bleeding can be of two types depending upon the site of nasal bleed.Anterior bleeding mostly originates from the septum from its anteroinferior area called Little's area or Kisselbach's plexus.Posterior bleeding is from the so called artery of epistaxis i.e.sphenopalatine artery.

Causes -

1. Idiopathic - In most of the cases no cause can be identified.

2. Traumatic causes -

• Nasal picking - It is the commonest cause of epistaxis in children.Nasal picking can cause injury to the Little's area causing bleeding from nose.
• Nasal blows and road side traffic accidents causing facial injuries, nasal injuries and fractures cause nasal bleeding.
• Iatrogenic causes like nasogastric and nasotracheal intubation.
• Surgical causes like in septoplasty, submucus resection and endoscopic sinus surgery.

Epistaxis - Little's area

Little's area or Kiesselbach's plexus is named after Wilhelm Kiesselbach (1839-1902) a German otolaryngologist.Most of the nasal bleeds especially in children arise from this area because this area is highly exposed to trauma due to nasal picking and dry air and moreover due to its rich blood supply because of anastomosis between different vessels.Anastomosis occur between the septal branches of sphenopalatine artery, greater palatine artery, superior labial artery and the anterior ethmoidal artery.Among the vessels taking part in the anastomosis, the anterior ethmoidal artery is the branch of ophthalmic artery from the internal carotid system while the other vessels are from the external carotid system. The main artery of epistaxis known as sphenopalatine artery and also the greater palatine artery are the branches of internal maxillary artery which is a terminal branch of external carotid artery. Superior labial is a branch of facial artery which is a branch of external carotid.

Epistaxis

Bleeding from the nose is known as epistaxis.Nose is a very vascular organ .Nasal mucosa has a rich blood supply.It gets blood supply from branches of internal carotid artery as well external carotid artery.In children the common cause of bleeding from nose is nasal picking and in adults it is hypertension.The commonest area for nasal bleeding is Little's area or Kasselbach's plexus. Second common area is Woodruf's area which lies posterior to inferior turbinate....

Changing tracheostomy tube

After performing tracheostomy, the tube should not be taken out for next 72 hours unless there is emergency like blockage of tube by thick mucus plug which can not be cleaned by doing suction.After the 72 hours tracheostome is fully formed and there are less chances of missing the tract.During this period ,it is necessary to fix the tube properly by tightly securing the tapes and additionally suturing the tube to the skin. When the tube is taken out for the first time, tracheal wound dilator should be there to keep the tracheostome open and to prevent it from collasping.Always keep another tracheostomy tube ready in cases of emergency when there is no time to clean and reinsert the tube.

Tracheostomy - post operative care

After surgery following things are to be taken care of -

1. As the trachea is suddenly exposed to dry air of the atmosphere, there is need to do suction through the tracheostomy tube after every half an hour to clear the secretions produced due to this insult.It is advised to keep the suction catheter in for minimum period of time. The catheter is pinched while taking in and the pressure released as the catheter is taken out. Care is taken not to insert too deep so as not to touch carina and produce spasms of cough due to irritation in trachea.
2. Secondly the trachea has to be moistened with saline,so saline is put in the tracheostome every half an hour and a single layer of wet gauze is placed over the tracheostome.
3. Mucolytic agents and sodium bicarbone can be instilled to decrease viscosity and reduce crusting.
4. A pen,paper anb bell have to be placed near the patient for the patient to communicate as the patient is unable to speak for some time after surgery.

Tracheostomy - complications

One of the immediate complication of tracheostomy is surgical emphysema.This is presence of air in subcutaneous tissue and its main cause in tracheostomy is

1. Tight sutures
2. Tight packing around tube
3. Wrong placement of tube in subcutaneous tissue in a false passage

The tight sutures act as ball valve. Air gets sucked into subcutaneous tissue but cannot comes out. So it gets collected under skin. If not checked, there can be pneumothorax and pneumomediastinum.

On examination ,on palpation creps can be felt under skin which can also be auscultated.

Treatment - Open the tight sutures. If extensive surgical emphysema is there oh face, neck and shoulders, then small nicks can be given to release air. If there is pnemothorax and pneumomediastinum, they are treated actively.

Tracheostomy

Tracheostomy is of two types according to time when it is done

1. Elective tracheostomy - done electively in some surgeries as in surgery of TM joint when the patient is not able to open the mouth for intubation,before planning for laryngectomy, in long standing medical diseases like CVA for tracheobronchial toilet etc
2. Emergency tracheostomy - done in patients who come in respiratory distress.

In emergency tracheostomy, vertical skin incision is preferred. After incision, the larynx is fixed with one hand and the incision is deepened not bothering about isthmus of thyroid or anything in the way direct to the trachea and then after identifying it, the trachea is opened,wound dilated and the tracheostomy tube inserted. As soon as the airway is made patent most of the bleeding stops automatically. Rest of the bleeders are secured and skin wound is stitched with silk.

Tracheostomy-complications

One of the most common problem is decanulation in a patient with long standing tracheostomy.This is particularly in kids. One of the causes of this is the emotional dependence on the tracheostomy tube. Other cause is the formation of granulation tissue in the trachea.As the tracheostomy tube is removed,the patient feels uncomfortable and suffers from respiratory difficulty.In such patients direct laryngoscopy should be done to look for any granulation tissue in trachea.For decanulation in such cases the size of the tube is gradually reduced and decanulation done by 72 hours or more.

Tracheostomy complications

1.Obstruction of the tracheostomy tube due to -

a) any clot in the tube

b) Any mucus plug in the tube

c) impingement on the posterior tracheal wall

d) partial displacement into the mediastinum or in a false passage

2. Wound infection

3. Tracheal injury and granulation tissue formation.

4. Fatal haemorrhage due to injury to inomanate artery due to continuous irritation and injury causing a tracheo-inominate fistula leading due massive haemorrhage and death.

5. Tracheo-oesophageal fistula.

6. Scar formation and tracheal tug.

7.Difficult decanulation.

Tracheostomy Complications

The immediate complications of tracheostomy are -

1. Haemorrhage - Bleeding can occur from anterior thyroid vein which can be easily avoided. Secondly bleeding can be from isthmus of thyroid.
2. Apnoea - Apnoea can occur on opening the trachea due to sudden wash out of carbon dioxide from lungs which causes loss of respiratory drive. In such cases a mixture of oxygen and carbon dioxide which is called carbogen is given for inhailation.
3. There can be injury to pleural apices, recurrent laryngeal nerve,oesophagus.