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Thangavelu K, Köhnlein S, Eivazi B, Gurschi M, Stuck BA, Geisthoff U. [Epistaxis-overview and current aspects]. HNO 2021; 69:931-942. [PMID: 34643746 DOI: 10.1007/s00106-021-01110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
Nosebleeds (epistaxis) are usually minor. Medical intervention is only necessary in about 6% of cases. The source of bleeding is frequently located in the anterior region of the nose (Kiesselbach's plexus). The estimated lifetime prevalence of epistaxis is 60%. Diffuse epistaxis is often a manifestation of systemic disease. Epistaxis is the leading symptom of Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia, HHT). If intervention is required, the first-choice of treatment is bidigital compression for several minutes. Common therapeutic measures include local hemostasis using electrocoagulation or chemical agents, e.g., silver nitrate. Resorbable anterior nasal tampons or tampons with a smooth surface are also frequently employed. In case of failed surgical closure of the sphenopalatine artery, angiographic embolization is the method of choice.
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Affiliation(s)
- Kruthika Thangavelu
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland.
| | - Sabine Köhnlein
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Behfar Eivazi
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
- MED-HNO, Schwerpunktpraxis für HNO-Heilkunde, Kopf-Hals-Chirurgie und Plastische Operationen am Alice Hospital Darmstadt, Darmstadt, Deutschland
| | - Mariana Gurschi
- Klinik für Neuroradiologie, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Marburg, Deutschland
| | - Boris A Stuck
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - Urban Geisthoff
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Gießen und Marburg GmbH, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg, Deutschland
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Simplified management of epistaxis. J Am Assoc Nurse Pract 2021; 33:1024-1029. [PMID: 33463979 DOI: 10.1097/jxx.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Primary care, urgent care, and emergency department providers periodically treat epistaxis, either as recurrent nosebleed or an acute persistent episode. Silver nitrate application to the decongested and anesthetized nasal mucosa addresses the former in most cases. The plethora of commercial nasal packing devices testifies to the discomfort, technical difficulty, and frustration associated with traditional gauze-packing methods. Inflatable anterior nasal balloon packs reliably control most nosebleeds. Addition of a Foley catheter nasopharyngeal balloon pack manages most posterior epistaxis. Cautery and the two packing techniques mentioned above should treat most cases not requiring otolaryngology consultation or interventional radiology. Appropriate anesthetic and analgesics lessen the unpleasantness for both the patient and the provider. Topical moisturizing facilitates mucosal healing. Oxymetazoline 0.05% nasal spray provides the patient means to address rebleeding after discharge from treatment.
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Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications. Radiol Res Pract 2020; 2020:5710313. [PMID: 32884844 PMCID: PMC7455835 DOI: 10.1155/2020/5710313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 11/21/2022] Open
Abstract
Today, there are still no uniform guidelines for the treatment of epistaxis. Furthermore, it is widely debated whether embolization or surgical approaches should be the first choice of treatment for intractable posterior epistaxis after conservative measures have failed. In several meta-analyses, it is reported that endoscopic sphenopalatine artery ligation and embolization have similar success rates, but embolization was associated with more severe neurological complications. Regarding existing literature, there are many comparative analyses of surgical methods but none for embolization protocols. Against this backdrop of a lack of uniform standards in embolization techniques, we present a retrospective evaluation of what has emerged to be best procedural practice for endovascular treatment of epistaxis in our department using microsphere particles and microcoils, in particular regarding precaution measures to avoid neurological complications. In our retrospective data analysis of 141 procedures in 123 patients, performed between 2008 and 2019, we find success rates very similar to those reported in other studies (95.1% immediate-stop-of-bleeding success and 90.2% overall embolization success) but did not encounter any major neurological complication opposed to other reports. We suggest some aspects of our protocol as precaution measure to avoid neurological complications. More generally and perhaps even more importantly, we make a strong case for standardization for embolization techniques to the level of details in surgical procedure standardization to enable an apples to apples comparison of embolization techniques to each other and of intervention vs. surgery.
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg 2020; 162:S1-S38. [PMID: 31910111 DOI: 10.1177/0194599819890327] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Abstract
Most anterior epistaxis originates primarily from the Kiesselbach plexus, whereas posterior epistaxis is less common and originates from branches of the sphenopalatine artery. Risk factors include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies. Assessment of airway, breathing, and circulation precedes identification of bleeding source, pain control, and achieving hemostasis. Management options include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention. Specialty consultation may be pursued if interventions fail. Disposition is typically to home unless posterior epistaxis or significant comorbidities exist that warrant admission.
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Affiliation(s)
- Neil Alexander Krulewitz
- Division of Emergency Medicine, University of Utah, 30 North 1900 East, Room 1C26, Salt Lake City, UT 84132, USA.
| | - Megan Leigh Fix
- Division of Emergency Medicine, University of Utah, 30 North 1900 East, Room 1C26, Salt Lake City, UT 84132, USA
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6
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Miller TR, Stevens ES, Orlandi RR. Economic Analysis of the Treatment of Posterior Epistaxis. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240501900114] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The aim of this study was to compare the economic impact of controlling posterior epistaxis by transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular embolization. Methods We conducted a retrospective chart review of patients undergoing treatment of posterior epistaxis by either TESPAL or embolization. International Classification of Diseases 9 code 784.7 (epistaxis) was the initial screen followed by common procedural terminology codes for TESPAL and angiography with embolization. The total charges and direct costs for TESPAL and endovascular embolization were determined. An unpaired Student's t-test was used to evaluate statistical significance. Results Analysis revealed 25 patients that met inclusion criteria. The mean total charge was $14,088 for embolization and $7561 for TESPAL. The differences were statistically significant (p < 0.00006). Costs, defined as reimbursement by third-party payers and direct payments, varied widely and their difference did not reach statistical significance in this sample. Conclusion Our data established no economic advantage for angiography and, in fact, show a trend toward this treatment being more expensive than TESPAL. TESPAL is a procedure that can be performed quickly and on an outpatient basis without the need for angiography equipment or expertise. Additionally, the procedure provides the advantage of a comprehensive endoscopic nasal evaluation for ruling out tumors or other intranasal lesions. With equal efficacy, at least equal costs and equal risk, and additional diagnostic advantages, TESPAL is a more rational treatment for posterior epistaxis.
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Affiliation(s)
- Timothy R. Miller
- Division of Otolaryngology–Head and Neck Surgery, Salt Lake City, Utah
| | - Edwin S. Stevens
- Department of Radiology, University of Utah, Salt Lake City, Utah
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Christensen NP, Smith DS, Barnwell SL, Wax MK. Arterial Embolization in the Management of Posterior Epistaxis. Otolaryngol Head Neck Surg 2016; 133:748-53. [PMID: 16274804 DOI: 10.1016/j.otohns.2005.07.041] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2004] [Accepted: 07/18/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES: Treatment of severe epistaxis can encompass many modalities. Control rates with all treatments are good. Morbidity among treatment groups varies. Angiographic embolization is one such method that has a very low complication rate. Over the last 10 years, it has become the preferred treatment at our institution. STUDY DESIGN: Tertiary medical referral centers: OHSU, Portland VAMC. MATERIALS AND METHODS: Retrospective review of 70 patients transferred or admitted with posterior epistaxis and treated with selective angiographic embolization from 1993 to 2002. RESULTS: Patients had bleeding for a median of 4.5 days prior to admission. 79% were unilateral. Etiology of bleeding was: idiopathic (61%), previous surgery (11%), anticoagulants (9%), trauma (7%), and other causes (12%). 30% required blood transfusions prior to admission to OHSU (average 4.4 units). No patient required a transfusion postoperatively following angiographic embolization or during their hospitalization. The internal maxillary artery (IMAX) was embolized in 94% (47% unilateral or bilateral IMAX only, 47% unilateral or bilateral IMAX in combination with other vessels, 6% other vessels besides the IMAX). Mean length of stay was 2.5 days. 86% had minor or no complications after the embolization and were discharged within 24 hours. 13% had a major rebleed that required surgical intervention within 6 weeks of the embolization. One patient had a serious neurological complication. Using the data available on 68 of 70 patients, the cost of hospitalization averaged $18,000 with direct costs of embolization averaging $11,000. CONCLUSIONS: Angiographic embolization is a clinically effective treatment for severe epistaxis.
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Affiliation(s)
- Nathan P Christensen
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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Gudziol V, Mewes T, Mann WJ. Rapid Rhino: A new pneumatic nasal tamponade for posterior epistaxis. Otolaryngol Head Neck Surg 2016; 132:152-5. [PMID: 15632931 DOI: 10.1016/j.otohns.2004.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES: Some of these measures to control posterior epistaxis cause loss of nasal respiration and put the patient on those related risks. STUDY DESIGN AND METHODS: The efficiency of a new pneumatic nasal tamponade (Rapid Rhino) was compared with a choanal balloon tamponade that has been used in our department for years in a prospective randomized study in patients with posterior epistaxis. The new pneumatic tamponade was used on the affected side only and nasal ventilation of the contralateral side was possible. RESULTS: Because of the successful use of the new pneumatic tamponade in most of the patients, epistaxis could be controlled without bilateral obstruction of nasal respiration. The use of the new pneumatic tamponade was evaluated to be less painful by the patients than choanal balloon tamponade. CONCLUSION: In an adapted therapeutic regime, the new pneumatic tamponade seems to have its place before using bilateral nasal respiration obstructing measures.
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Affiliation(s)
- V Gudziol
- Department of Otorhinolaryngology-Head and Neck Surgery, Mainz Medical School, Germany.
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Abstract
OBJECTIVE: Evaluate treatments for epistaxis. STUDY DESIGN AND SETTING: Retrospective review of Nationwide Inpatient Sample (1998-2000). RESULTS: A total of 9778 admissions with admitting diagnosis “epistaxis” were identified. Among admissions involving 1 treatment, 454 (9.6%) received arterial ligation, 94 (2.0%) embolization, and 4188 (88.4%) nasal packing. There were no differences in length of stay, transfusions, complications, or deaths between groups (all P >0.05). Mean total hospital charges were $6,282 for the packing group, $12,805 for the ligation group, and $17,517 for the embolization group; differences between ligation and packing groups, and embolization and packing groups demonstrated significance ( P >0.05). CONCLUSIONS: Nasal packing is used commonly for epistaxis that requires inpatient management. Although embolization and arterial ligation are associated with higher hospital charges, complications, transfusion rates, and lengths of stay are similar. Further studies are needed to quantify other outcome measures, such as recurrence rates and patient quality of life. SIGNIFICANCE: Nasal packing is associated with lower hospital charges and similar complication rates as arterial ligation or embolization. (Otolaryngol Head Neck Surg 2005;132:707-12.)
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Affiliation(s)
- John C Goddard
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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10
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Abstract
Epistaxis or nosebleed is relatively common in the general population. Depending on the location of the bleeding in the nasal cavity, epistaxis can be divided in two types: anterior or posterior type. The anterior type is far more frequent, often self-limiting and, if needed, is relatively easy treatable. Posterior type epistaxis is rare and more likely to require medical attention. The cornerstone of the conservative therapy of posterior epistaxis is nasal packing. Only in patients with persistent or recurrent epistaxis, endovascular intervention or surgery is indicated. Both treatment options have a similar success and complication rate, but endovascular treatment, if feasible, has several advantages above surgical treatment. The choice of procedure should be made on a patient-to-patient basis, taking several parameters into account. In this pictorial essay we present an overview of the relevant radiological anatomy and a review of various causes of epistaxis, with the emphasis on the endovascular treatment.
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Krajina A, Chrobok V. Radiological diagnosis and management of epistaxis. Cardiovasc Intervent Radiol 2015; 37:26-36. [PMID: 24232035 PMCID: PMC3895177 DOI: 10.1007/s00270-013-0776-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 10/04/2013] [Indexed: 11/30/2022]
Abstract
The majority of episodes of spontaneous posterior epistaxis treated with embolisation are idiopathic in nature. The angiographic findings are typically normal. Specific angiographic signs are rare and may include the following: a tumour blush, telangiectasia, aneurysm, and/or extravasation. Selective internal carotid artery (ICA) angiography may show rare causes of epistaxis, such as traumatic or mycotic aneurysms, which require different treatment approaches. Complete bilateral selective external and internal carotid angiograms are essential to evaluation. The images should be analysed for detection of central retinal blush in the external carotid artery (ECA) and anastomoses between the branches of the ECA and ICA. Monocular blindness and stroke are two of the most severe complications. Embolisation aims to decrease flow to the bleeding nasal mucosa while avoiding necrosis of the nasal skin and palate mucosa. Embolisation is routinely performed with a microcatheter positioned in the internal maxillary artery distal to the origin of the meningeal arteries. A guiding catheter should be placed in the proximal portion of the ECA to avoid vasospasm. Embolisation with microparticles is halted when the peripheral branches of the sphenopalatine artery are occluded. The use of coils is not recommended because recurrent epistaxis may occur due to proximal embolization; moreover, the option of repeat distal embolisation is lost. The success rate of embolisation therapy (accounting for late recurrence of bleeding) varies between 71 and 94 %. Results from endoscopic surgery are quite comparable. When epistaxis is refractory to nasal packing or endoscopic surgery, embolisation is the treatment of choice in some centres.
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Affiliation(s)
- Antonín Krajina
- Department of Radiology, University Hospital Hradec Kralove and Medical Faculty of Charles University, 500 05 Hradec Kralove, Czech Republic
| | - Viktor Chrobok
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove and Medical Faculty of Charles University, 500 05 Hradec Kralove, Czech Republic
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Corrales CE, Goode RL. Should patients with posterior nasal packing require ICU admission? Laryngoscope 2013; 123:2928-9. [PMID: 24114977 DOI: 10.1002/lary.23672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/23/2012] [Indexed: 11/09/2022]
Affiliation(s)
- C Eduardo Corrales
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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13
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Hettige R, Mackeith S, Falzon A, Draper M. A study to determine the benefits of bilateral versus unilateral nasal packing with Rapid Rhino ® packs. Eur Arch Otorhinolaryngol 2013; 271:519-23. [PMID: 23765062 DOI: 10.1007/s00405-013-2590-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/04/2013] [Indexed: 11/26/2022]
Abstract
There is little evidence to suggest that bilateral nasal packing increases intra-nasal pressures compared to a single pack (or is well tolerated) for uncontrolled unilateral epistaxis, but it is often performed and justified on those grounds. 15 volunteers were recruited according to strict criteria. Rapid Rhino(®) 5.5 cm anterior packs were inserted bilaterally following topical nasal preparation with co-phenylcaine. The first pack was inflated to a pre-determined pressure. The contralateral pack was inflated to match, and any intra-nasal pressure change on the first side was measured. The subject's level of discomfort was scored on a visual analogue scale. This procedure was repeated at incremental pressures. Higher ipsilateral intra-nasal pressures are achieved when additional contralateral nasal packs are inflated. This change in ipsilateral intra-nasal pressure is greater at higher total inflation pressures. At higher pressures, the subjects reported lower mean pain scores when bilateral packs were used compared to unilateral. This effect was only statistically significant at intra-nasal pressures of 140 mmHg and above (Wilcoxon Signed-Rank test, p < 0.02). It is possible to increase the ipsilateral nasal cavity pressure by inserting a contralateral nasal pack. Although this extra pressure may be enough to tamponade further venous bleeding without significantly increasing a subject's discomfort, the high levels of pack pressure required, make this unlikely to be of significant use in the clinical setting.
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Jindal G, Gemmete J, Gandhi D. Interventional Neuroradiology Applications in Otolaryngology, Head and Neck Surgery. Otolaryngol Clin North Am 2012; 45:1423-49. [DOI: 10.1016/j.otc.2012.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Emergency Otorhinolaryngolocal cases in Medical College, Kolkata-A statistical analysis. Indian J Otolaryngol Head Neck Surg 2012; 57:219-25. [PMID: 23120176 DOI: 10.1007/bf03008018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
At the round the clock entergency of the Deparment of Otorhinolaryngology, Medical College, Kolkata, different types of cases are managed everyday. The various emergency conditions encountered by us in last four years are gathered and analyzed in this study. The different problems and their modes of management are discussed here.
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Haroon Y, Saleh HA, Al-Azzazy MZ, Abou-Issa AH. Embolization for control of refractory posterior epistaxis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2012. [DOI: 10.1016/j.ejrnm.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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17
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Posttraumatic Severe Epistaxis and Its Safe Management. J Craniofac Surg 2012; 23:947-8. [DOI: 10.1097/scs.0b013e31824de10e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Park IK, Sir JJ, Jung HJ, Jo SY, Cho WH, Choi SK. Atypical takotsubo cardiomyopathy associated with nasal packing for paranasal sinus surgery. ACTA ACUST UNITED AC 2009; 11:186-8. [PMID: 20042420 DOI: 10.1093/ejechocard/jep174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Takotsubo cardiomyopathy (TC) is characterized by reversible left ventricular (LV) apical ballooning and no significant coronary artery stenosis. New variants of TC with localized wall motion abnormality or inversed pattern with hyperdynamic apex have been reported. We present the case of a 24-year-old female with atypical presentation of TC occurring in the setting of paranasal sinus surgery under local anaesthesia with post-surgical nasal packing. She did not demonstrate ST-segment elevation on electrocardiogram, but transient moderate LV systolic dysfunction and localized wall motion abnormality affecting basal to mid-ventricular anterior and anteroseptal wall. She rapidly and completely recovered without sequelae.
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Affiliation(s)
- Il-Kwon Park
- Department of Internal Medicine, Cardiovascular Center, Inje University Seoul Paik Hospital, Inje University College of Medicine, 85 Jeo-Dong 2-ga, Jung-Gu, Seoul, Republic of Korea
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Clinical outcome of patients with epistaxis treated with nasal packing after hospital discharge. Braz J Otorhinolaryngol 2009; 75:857-65. [PMID: 20209288 PMCID: PMC9446092 DOI: 10.1016/s1808-8694(15)30550-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 02/25/2009] [Indexed: 12/01/2022] Open
Abstract
Epistaxis is a common clinical condition and in most public hospitals these patients received nasal packing and were admitted to the hospital as initial management strategies. However, little is known about the follow-up of these patients after they leave the hospital. Aim To identify the clinical outcome of patients treated for epistaxis following discharge. Materials and Methods We analyzed the results of questionnaires from patients hospitalized for non-traumatic epistaxis between March 2006 and March 2007. Study design Cohort longitudinal. Results Fifty-four of eighty-seven patients answered (62%). Epistaxis recurred in 37% of the patients. Of the patients who had recurrent bleeding, 70% were hypertensive, 35% were chronic users of acetylsalicylic acid, and 55% used tobacco. Forty per cent of the recurrences occurred in the first week after discharge, and fifty per cent needed to return to the emergency room. Seventy per cent of those who returned to the emergency room required a second treatment. Conclusions Recurrence after epistaxis treatment is common and may occur soon after the initial discharge. Although our sample was small, this data suggests the need for a reevaluation of the current treatment mode of patients with epistaxis in the emergency rooms of public hospitals.
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Abstract
Epistaxis is a common condition that can be managed conservatively in most cases. When these measures, including anterior and posterior packing of the nasal cavity, are unsuccessful at controlling the bleeding, interruption of the blood supply to the sinonasal area can be performed, either by surgical ligation or by transarterial embolization. Embolization should be preceded by thorough diagnostic angiography. Aside from aiding with subsequent selective catheterization and embolization, such angiography may reveal significant anatomic anomalies, anastomoses, or an unsuspected cause of epistaxis. Taking these findings into account, the interventionalist may decide to refrain from embolization or adjust the technique to minimize the risk of adverse events, which are mostly related to inadvertent embolization of the internal carotid artery or ophthalmic artery. We present a review of the various causes of epistaxis and the treatment options, with emphasis on endovascular embolization. We also describe the protocol of our institution for endovascular management of this condition.
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Affiliation(s)
- P W A Willems
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada.
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Vergara Hernández J, Ordóñez Ordóñez LE. [Surgical versus non-surgical treatment of posterior epistaxis]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2006; 57:41-6. [PMID: 16503032 DOI: 10.1016/s0001-6519(06)78661-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A study was performed in order to compare the efficiency of surgical versus non-surgical treatment in patients hospitalized for epistaxis regarding the source of bleeding, and to identify failure-predicting factors related to specific treatments. 62 patients were included in the study, 36 (58%) of whom suffered from posterior epistaxis and 26 (42%) experienced anterior bleeding. The single factor associated with failure of the non-surgical treatment was the posterior source of the bleeding (p = 0.001). These patients were also hospitalized for a longer period (8, 17 days) than those with anterior epistaxis (4, 62 days) (p = 0.001). The percentage of success for the primary non-surgical treatment in patients with posterior epistaxis was 45% (14/31), significantly smaller (p = 0.0001) than the successful reached in the primary surgical procedure, 87% (13/15); endoscopic cauterization of the sphenopalatine artery. These results support endoscopic cauterization of the sphenopalatine artery as primary care in posterior epistaxis.
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Affiliation(s)
- J Vergara Hernández
- Servicio de Otorrinolarinigología, Hospital Universitario Clínica San Rafael, Bogotá, Colombia
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Shah AG, Stachler RJ, Krause JH. Endoscopic Ligation of the Sphenopalatine Artery as a Primary Management of Severe Posterior Epistaxis in Patients with Coagulopathy. EAR, NOSE & THROAT JOURNAL 2005. [DOI: 10.1177/014556130508400514] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe our experience with endoscopic ligation of the sphenopalatine artery in the treatment of severe posterior epistaxis in 2 patients with coagulopathy. Conservative treatment had failed in both cases. The key elements of this procedure are the identification of the branches of the sphenopalatine artery via an endoscopic endonasal approach and the application of two titanium clips under direct vision. This procedure was successful in both patients, and we recommend it in selected cases.
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Affiliation(s)
- Anand G. Shah
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit
| | - Robert J. Stachler
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit
| | - John H. Krause
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit
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Abstract
Epistaxis is a frequent complaint, and may often cause great anxiety in patients and clinicians. Epistaxis results from the interaction of factors that damage the nasal mucosal lining, affect the vessel walls, or alter the coagulability of the blood, and which may be categorized into environmental, local, systemic and medication related. The knowledge of the first aid treatment of epistaxis is very poor, amongst not only the public, but also health professionals. Immediate emergency department management of epistaxis depends on prioritized assessment and treatment, including resuscitation if necessary, together with the application of relatively simple otolaryngological techniques. There is little high quality evidence regarding routine, alternative or adjunctive treatments.
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Affiliation(s)
- Paul M Middleton
- Emergency Department, Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia.
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Affiliation(s)
- Hassan H Ramadan
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
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Klotz DA, Winkle MR, Richmon J, Hengerer AS. Surgical management of posterior epistaxis: a changing paradigm. Laryngoscope 2002; 112:1577-82. [PMID: 12352666 DOI: 10.1097/00005537-200209000-00008] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To demonstrate that surgery, as the initial treatment option for posterior epistaxis, can provide comparable success and complication rates to nonsurgical management with fewer associated costs. STUDY DESIGN A retrospective chart review and cost analysis. METHODS Two hundred three consecutive charts were reviewed for patient outcome, complications, and hospitalization time. Average costs were calculated from hospital department and physician fee schedules. RESULTS Average success rate of all surgical procedures performed for posterior epistaxis was 90%, anterior-posterior packing success was 62%, and embolization success was 75%. The packing-only group had a significantly greater mean hospitalization time (5.29 d) than patients who were treated either surgically (2.1 d) or with embolization (2.6 d). The average per-patient admission charges were, for successful posterior packing, $5136 per patient; for surgical treatment, $3851 per patient; and for embolization, $5697 per patient. Surgery offered a cost savings of $1846 per patient over traditional packing. There was no significant difference in complication rates between the groups. CONCLUSION The review suggests that a better success rate, a comparable complication rate, and a cost savings can be achieved with surgical intervention as the first-line treatment for intractable epistaxis when compared with traditional anterior-posterior packing and embolization.
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Affiliation(s)
- Darrell A Klotz
- Division of Otolaryngology, University of Rochester Medical Center, New York 14642, USA
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Kezirian EJ, Yueh B. Accuracy of terminology and methodology in economic analyses in otolaryngology. Otolaryngol Head Neck Surg 2001; 124:496-502. [PMID: 11337651 DOI: 10.1067/mhn.2001.114675] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Economic studies increasingly guide health care resource allocation decisions. Because rigorous adherence to accepted definitions and research techniques is critical to ensure accuracy, we evaluated the terminology and methods of otolaryngology economic analyses. STUDY DESIGN A total of 71 articles published from 1990 to 1999 in 6 peer-reviewed otolaryngology journals with terms such as "cost-effective" in their title or representing economic analyses were reviewed for terminology and use of established methodology guidelines. RESULTS Over half (35 of 66) of terms such as "cost-effective" were used incorrectly, and 60% of articles (39 of 64) confused "charge" and "cost" data. Eleven percent (7 of 64) of papers specified the perspective of their analysis. About half (17 of 30) reported a summary measure such as a cost-effectiveness ratio. Only one third (23 of 63) performed sensitivity analyses. CONCLUSION Adherence to accepted definitions and research methods is inconsistent, although we did note moderate improvements in making the distinction between costs and charges, defining of study perspective, and performing sensitivity analysis. SIGNIFICANCE Greater attention to both terminology and methodology can enhance the quality of economic analyses and ultimately improve certain resource allocation decisions.
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Affiliation(s)
- E J Kezirian
- University of Washington, Seattle 98195-6515, USA.
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