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Epistaxis and Retropharyngeal Spaces Xavier Haworth-CollinsLearningObjectives 1. Bonyanatomy,functionand divisionsof thenasal cavity,as well as the important principlesof its neurovascularsupply,including Kiesselbach’splexus (Little’s Area) 2. Recallthe bonyanatomy,functionand divisionsofthenasal cavity,as well as the important principlesof its neurovascularsupply,including Kiesselbach’splexus (Little’s Area) 3. Understand the anatomicalprinciplesbehindthe pathologyand managementof epistaxis and septal haematoma 4. Explainthe gross anatomyof the oral cavity andtonsils, includingthe retropharyngealspace 5. Understand referral criteria,surgical managementand complicationsof tonsillitis, as well as the red flags and managementof retropharyngealabscess 6. Appreciatethe anatomyof theparanasalsinuses 7. Describethe relevanceof theparanasal sinusesto transsphenoidalsurgery,and complications ofsinusitis NasalCavity-BonyAnatomy Roof:Ethmoid(cribriformplate), frontal, sphenoid Floor: Maxilla (palatine process), palatine bone Medialwall (NasalSeptum): Perpendicular plate of theethmoid, vomer,septal cartilage Lateralwall: Maxilla, palatine, ethmoid (superior & middle lacrimalbone, sphenoidl concha, Innervation Sensory: • Ophthalmic (V1)- Anterior ethmoidal nerve • Maxillary (V2) - Nasopalatine &greater palatine nerves Autonomic: • Parasympathetic: Secretomotor to mucosal glands (via pterygopalatine ganglion) • Sympathetic: Vasoconstriction (via superior cervical ganglion) Arterial/VenousSupply Kiesselbach’s plexus(Little’s Area): A rich anastomosis on the anterior nasal septum, common site of epistaxis. Contributions from: Sphenopalatineartery (maxillary) Greaterpalatine artery(maxillary) Anteriorethmoidal artery (ophthalmic) Posteriorethmoidal artery (ophthalmic) Superiorlabial artery(facial) Woodruff’sPlexus: Located in the posterior part of the nasal cavity, associated with posterior epistaxis. Venous Drainage: via the pterygoid venous plexus, facial vein, and cavernous sinus, creating a potential route for infection spread (cavernous sinus thrombosis)Divisions Vestibule: Contains hair for filtration Respiratory Region: Mucosa-lined for air conditioning Olfactory Region: Contains olfactory epitheliumNasalConchae(turbinates)andMeatus The main function of the nasal concha is to increase the surface area of the nasal cavities in order to provide warming and humidificationof air as it passes to the lungs.Function Respiration: Warms, humidifies, and filtersair Olfaction: Houses olfactory receptors in the superiorpart of the nasal cavity Defense: Mucociliary clearance and immune function VoiceResonance: Contributes to phonationEpistaxis(Nosebleed)EpistaxisPathology/RiskFactors Epistaxis occursdue to ruptureofnasal blood vessels, typicallyinthe richlyvascularizednasal septum. RiskFactors • Anticoagulants, coagulopathies,trauma,dryair,hypertension,cocaineuse,nasal infections, nasal septal perforations,nosepicking/blowing,insertionof foreignbodies,juvenile angiofibroma,hereditary haemorrhagic telangiectasia Pathology • Morecommonand usually self-limiting.esselbach’splexus (Little’s Area) on the anterior septum. • Posterior epistaxis (10%):Involves Woodruff’splexus (posterior sphenopalatineartery).Less commonbut canbe severe,requiring intervention.EpistaxisManagement Management • First-line: Pinch the cartilaginous (soft) area of the nose firmly (20 mins), keephead in neutral position and breathe through mouth (topical vasoconstrictors may alsobe used. • Cauterization: Silver nitrate (chemical) or electrocautery should be used initially if local anaesthetic spray (e.g. Co-phenylcaine) and waitfor 3-4 minutes.se with topical • Nasal Packing: Anterior (eg. merocel, rapid rhino) or posterior packing may be used if cautery is not viableor the bleeding point cannot be visualised. • Surgical Intervention: Ligation of sphenopalatine artery (via endoscopic approach) or embolization in severe casesthat have failed allemergency management. For patients in extremis, the external jugular vein can be tied off in the neck. • Creduce crusting and the risk of vestibulitis. Cautions to this include patients that have peanut (previously contained peanut oil), soy or neomycin allergies SeptalHaematomaPathology nasal septum andmucoperichondrium(specialized layere oftissue thatcovers the cartilageofthe nasal septum), oftendue to trauma (eg. nasal fracture) Pathology • the septal cartilage, disruptingblood supply -> riskof cartilagenecrosisand saddle nose deformity. • In infection-> abscessformation,increasingrisk of intracranialspread (eg. cavernoussinusthrombosis). • Bilateral, red swelling arising fromthe nasal septum SeptalHaematomaManagement Management • Urgent incision& drainage (I&D) to prevent necrosis. • accumulation.toprevent re- • Antibioticsif infected. • Long-termfollow-up for nasal deformity assessment. OralCavity Oral vestibule: Space between lips/cheeks and teeth/gums. Oral cavity proper: Space inside the dental arches, bounded by: • Roof: Hard & soft palate • Floor: Mylohyoid, geniohyoid, tongue • Walls: Buccinatormuscle • Posteriorly: Opens tooropharynx ContentsoftheOralCavity Tongue: Divided into anterior 2/3 (oral) and posterior 1/3 (pharyngeal). Salivary glands: Major (parotid, submandibular, sublingual) and minor glands. Teeth & gingivae: 32 permanent teeth (adults). T onsils lymphoid tissue ring guarding the upperring, a airway. Palatine tonsils: Located in the tonsillar fossa arches. the palatoglossal & palatopharyngeal Lingual tonsils: At the base of the tongue. nasopharynx (enlargement can cause nasal obstruction). Tubal tonsils: Near the opening of the Eustachian tube.RetropharyngealSpace The retropharyngeal space is apotential space between the: Buccopharyngealfascia (coveringthe pharyngeal constrictormuscles) vertebrae &deep muscles)eringcervical super inferior axis of the larynx,pharynx, and oesophagus in relation tothe cervicalspine TonsillitisReferralCriteria Inflammationof thepalatinetonsils: oftenviral (eg. EBV)or bacterial (eg. GroupA Strep). T onsillitisManagement/Complications Surgical Management (Tonsillectomy Indications) • Recurrenttonsillitis:≥7 episodes in 1year, ≥5 per year for 2years, life (missing school/work), or recurrent quinsyive impact on quality of Complications of Tonsillitis • Suppurative:Peritonsillar abscess (quinsy), retropharyngeal abscess, parapharyngeal abscess. • glomerulonephritis.eumatic fever, post-streptococcal • Surgical complications(tonsillectomy): • Phaemorrhages should be assessed by ENT. Managed by immediate return to theatre. • Secondary haemorrhage 5–10 days post-op: Treatment is usually with admission and antibiotics RetropharyngealAbscess RedFlags A life-threatening deep neck space infection behind the pharynx,commonin children. RedFlags (Suggestiveof Retropharyngeal Abscess) • Severe sore throat,dysphagia, odynophagia • Neckstiffness, torticollis(difficultyturning head) • Stridor,respiratory distress • Muffled voice • Bulging posterior pharyngeal wall A lateralx-raydemonstratingprevertebralsofttissueswelling (marked bythearrow)as seenin apersonwitharetropharyngealabscess. RetropharyngealAbscessManagement Management • Urgent airway assessment (riskof obstruction) • IV broad-spectrumantibiotics(eg. ceftriaxone +metronidazole). • CT neck with contrasttoconfirmdiagnosis. • Surgicaldrainage via transoralorexternal approach if large or airway-compromising.ParanasalSinuses AnatomyoftheParanasalSinuses MaxillarySinuses: The paranasalsinusesare air-filledcavities that • Largest,locatedin the cheekbones. reduce skullweightandenhanceresonance. • Drain into themiddle meatus. FrontalSinuses: • Located in the forehead, above the eyes. • Drain into themiddle meatus. EthmoidSinuses: • Located between theeyes, in the ethmoid bone. • Drain into themiddle (anterior), superior (posterior) meatus. Clinical Relevance SphenoidSinuses: • Located behind the ethmoid sinuses,in the sphenoid • Sinusitis: Commonlyaffects maxillary andethmoid bone. sinuses. • Drain into thesphenoethmoidalrecess. • Anatomical Variations:Affect drainageand susceptibility to infection. ComplicationsofSinusitis 1. OrbitalComplications: • Orbitalcellulitis:Infectionspreadsto eye tissues,causingpainand swelling. • Abscesses:Mayrequiresurgicaldrainage. 2. Intracranial Complications: • Meningitis:Infectionspreadsto the meninges. • Brainabscess:Requiresdrainageandantibiotics. • Cavernoussinusthrombosis:Can leadto visionlossorcranialnerve damage. 3. Chronic Sinusitis: • Polyps:Mayobstructsinuses,worseningsymptoms. • Osteomyelitis:Chronic boneinfection. 4. Mucoceles: • Blocked sinusesleadingto cystformationand pressureonadjacent structures. TranssphenoidalSurgery Transsphenoidalsurgeryis used to accessthe pituitarygland throughthe sphenoidsinusvia thenasal cavity. • surgeons to accessit with minimaldisruptiontond, allowing surroundingstructures. • AnatomicalConsiderations: The optic nervesand internal carotidarterieslie near the sphenoid sinus,makingcareful navigationcrucial. • PreoperativeImaging: CT/MRIscans assesssinus anatomy for surgicalplanning. • Sinus Variations: Asymmetriesin the sphenoidsinuscan affectsurgicalaccessand increasecomplications.