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 、 General factors

Systematic disease——

Ascension of arterial pressure and venous pressure ，

Dysfunction of coagulation,

Change of blood vessel tension.

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

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

2 ） Cautery techniques• chemical• electrical• laser• radiofrequency• microwave3 ） Nasal packing

• resorbable material, gel foam.• anterior• postorior• water or air balloon

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

5 、 Systematic management.1 ） sedative2 ） hemostatic agent3 ） Vitamine C, K.4 ） sclerosant5 ） anti-shock management

6 ） Traditional Chinese Medicine

Foreign body in the nose

Endogenic

Dead bone, blood clot, rhinolith

Extrogenic

Plant seeds, insect, metals, stone, woods…

Biologic

Nonbiologic

Etiology ：1 、 Children 2-3yrs old

2 、 Insects

3 、 Injury ： wood, rocks, metals

4 、 Iatrogenic

Metal in nasal cavity

Rhinolith in nasal cavity

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 nosein bronchi

Mucocele and Cyst

Cyst of nasal vestibule

• Vestibule, maxillary dental alveoli, unilateral round/oval cyst

• Diagnosis:

palpation, punction

X-ray

• Treatment:

resection of cyst

Mucocele

Benign neoplasms: Obstruction of sinus ostia and

accumulation of fluid

Etiology: chronic inflammation, allergic sinona

sal disease, trauma, and previous surgery

Pathology ： retention of intrasinus secretion,

progressive augmentation of internal pression, bo

ny remodeling and erosion.

Morbidity: China: ethmoid > frontal > sphenoid > maxillaryAbroad: frontal > ethmoid > sphenoid > maxillarySymptoms & Sign ：Orbital apex syndromeFacial protrude Rhinorrhea, nasal obstruction, hyposmia Diagnosis:History, symptoms and signPunction, X-ray/CT scanTreatment:Operation: “open surgery”, marsupialization

Diagnosis ：

X-ray and CT scanner.

Treatment ： surgical treatment: drainage, creatio

n of vast communication with nasal cavity

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

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.

2) Inverted papilloma

Age>40ys ， high morbidity: 50—60ys;

M: F=3:1Features ： Hyperplastic epithelia with inverting pattern of growth. Epithelial inversion into underlying stroma. Basal membrane is intact. Malignant transformation : 5-15% .

squamous cell carcinoma, adenocarcinoma.

Symptoms & Signs ：

Nasal obstruction, rhinorrhea with blood staining,

sometimes with headache and abnormalities of sm

ell.

Firm red or grey masses, unilateral, arising from lateral wall of the nose, extension into the ethmoid and maxillary sinuses.

Treatment

Complete excision

Some times it is difficult.

Recurrence: 28-74%

Lateral rhinotomy.

Endoscopic excision,

with reasonable recurrence rates.

Malignant transformation--radiotherapy

Malignant tumor of

nasal cavity and paranasal sinusesMorbidity in China:

2.05-3.66% of malignant tumors in all

21.74%-49.22% of malignant tumors in ORL

Carcinoma:cancer=8.5:1

M: F=1.5-3.0:1

Cancer:---40-60ys ， Sarcoma---younger

— 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

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% ；

— Malignant epithelia tumor.

Carcinoma of nasal vestibule and Septum

Carcinoma of the paranasal Sinus

Melanoma

Esthesioneuroblastoma

— Malignant nonepithelial tumor.

Rhabdomyosarcoma.

Hemangiopericytoma

lymphoma

Extramedullary plasmacytoma.

Symptoms & Signs ：Nasal Cavity:

— nasal obstruction.

— epistaxis.

— pain.

— numbness of cheek.

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

Diagnosis:

Caution! >40yrs, unilateral, progressive symptoms

— increase doctor’s index of suspicion

— nasal examination

— nasal endoscopic examination

— biopsy

— CT 、 MRI

— PET (positron emission tomograph)

Treatment:

1. Radiotherapy: 5000-6000rad within 4-8w ，6w after radiotherapy --- surgery

2. Surgery --- cornerstone

-lateral rhinotomy.

-midfacial degloving

-Maxillectomy

-Maxillectomy+orbital contents exenteration

-Craniofacial resection.

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

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？