Embolization in otolaryngology

The role of embolisation in ENT: an update

OBJECTIVE

To provide an update on the ever-increasing role that embolisation plays in the practice of otolaryngology.

METHOD

A literature search was performed during November 2008. The Medline, Embase, PubMed and Cochrane databases were searched. This resulted in 285 papers relevant for review.

CONCLUSION

The role of embolisation has expanded greatly to include the management of refractory epistaxis, pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

Life threatening epistaxis complicating extended maxillotomy for chordoma

Postoperative hemorrhagic complications of the "open-door" maxillotomy approach to the skull base and clivus are uncommon. We report a case of maxillary artery pseudoaneurysm and discuss the management of this condition.

From the archives of the AFIP. Paragangliomas of the head and neck: radiologic-pathologic correlation. Armed Forces Institute of Pathology

Paragangliomas of the head and neck are ubiquitous in their distribution, originating from the paraganglia or glomus cells within the carotid body, vagal nerve, middle ear, jugular foramen, and numerous other locations. The typical patient is middle-aged and presents late in the course of the disease, with a painless slow-growing mass. Clinical manifestations include hoarseness of voice, lower cranial nerve palsies, pulsatile tinnitus, and other neuro-otologic symptoms. The overall prognosis of patients with a cervical paraganglioma is favorable, whereas its temporal bone counterpart often results in recurrence, residual tumor, and neurovascular compromise when in the advanced stage. Pathologic examination reveals a characteristic biphenotypic cell line, composed of chief cells and sustentacular cells with a peripheral fibrovascular stromal layer that are organized into a whorled pattern ("zellballen"). Imaging hallmarks of paragangliomas of the head and neck include an enhancing soft-tissue mass in the carotid space, jugular foramen, or tympanic cavity at computed tomography; a salt-and-pepper appearance at standard spin-echo magnetic resonance imaging; and an intense blush at angiography. Imaging studies depict the location and extent of tumor involvement, help determine the surgical approach, and help predict operative morbidity and mortality. Surgical treatment is definitive. Radiation treatment is included as a palliative adjunct for the exceptional paraganglioma not amenable to surgery.

Hemorrhage following mandibular osteotomies: a report of 21 cases

Hemorrhage associated with mandibular osteotomies, especially to the extent that it becomes life threatening, is a rare occurrence and its risk is less than that following maxillary orthognathic surgery. Twenty-one cases of significant bleeding following mandibular sagittal split ramus osteotomies, vertical and oblique ramus osteotomies, and genioplasties are presented. Life-threatening hemorrhage associated with mandibular osteotomies is primarily an intraoperative problem and the incidence of major postoperative and recurrent hemorrhage is not as great as following maxillary osteotomies. Suggestions for the avoidance and treatment of these bleeding complications are discussed.

Major vascular complications of orthognathic surgery: false aneurysms and arteriovenous fistulas following orthognathic surgery

False aneurysms and arteriovenous fistulas are rare complications of orthognathic surgery. The vessel most commonly involved with false aneurysms following mandibular surgery is the internal maxillary artery, and this vessel, especially the sphenopalatine branch, may also be involved following maxillary surgery. An unusual factor in the presentation of false aneurysms following Le Fort I osteotomies is an initial episode of epistaxis occurring greater than 2 weeks postoperatively. Arteriovenous fistulas following orthognathic surgery are more apt to involve large vessels, especially the internal carotid artery. Embolization procedures are the treatment of choice for false aneurysms and arteriovenous fistulas in the maxillofacial region following orthognathic surgery.

Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies

Major intraoperative or postoperative bleeding associated with Le Fort I osteotomies can be venous and/or arterial in nature. Arterial hemorrhage generally involves the maxillary artery and its terminal branches. Arterial hemorrhage tends to be more persistent and can be recurrent, which makes it more difficult to manage. Postoperative bleeding following Le Fort I osteotomies generally presents as epistaxis and usually occurs initially within the first 2 weeks following surgery. Treatment modalities that have been used to successfully arrest postoperative hemorrhage include anterior and/or posterior nasal packing; packing of the maxillary antrum; reoperating with clipping or electrocoagulation of bleeding vessels, or the use of topical hemostatic agents in the pterygomaxillary region; external carotid artery ligation; and selective embolization of the maxillary artery and its terminal branches.

Superselective embolization for intractable epistaxis: experiences with 19 patients

Twenty-eight patients with intractable nose-bleeds were treated with either superselective embolization and/or surgery between 1983 and 1986. The follow-up time ranged between 6 months and 3 years. The results for the 2 groups were similar. The success rate for embolization was 74% and that for surgery 65%. Complications however, were more frequent after embolization, (i.e. facial nerve paralysis, soft tissue necrosis). Surgery is recommended as the treatment of choice in intractable nose-bleeds, until therapeutic embolization techniques have been further refined and the complication rate reduced.

Glomus vagale tumors

We present a case of a multicentric chemodectoma, with the unusual combination of a glomus vagale and a glomus tympanicum tumor. Multicentricity was suspected before selective carotid arteriography. Our patient, although asymptomatic, had elevated levels of urinary catecholamines preoperatively, which returned to normal postoperatively, suggesting biochemical activity of the tumor. Intraoperative hemostasis was assisted by the use of preoperative selective embolization of the tumor mass and the peripheral location of the injected Ivalon was confirmed histologically. The vagus nerve was anatomically spared and complete function was restored within 10 months. The asymptomatic small glomus tympanicum tumor was treated with embolization alone, as the patient chose to defer treatment at this time, but only time will reveal the effectiveness of this method of management.

Severe late-onset epistaxis following Le Fort I osteotomy: angiographic localization and embolization

Epistaxis following maxillofacial trauma or maxillofacial surgery is uncommon. It usually occurs within 24 hours of the injury and can usually be controlled by packing. Rarely internal maxillary artery ligation is necessary and embolization has been used in some cases of severe trauma. We present a case of severe late-onset epistaxis following Le Fort I osteotomy. The diagnostic approach and treatment are discussed.

Embolization for traumatic epistaxis. Adjuvant therapy in severe maxillofacial fracture

In a case of persistent traumatic epistaxis successful treatment by embolization therapy is reported. The method is described in detail and the advantages of the use of Digital Subtraction Angiography (DSA) are stressed.

Chemodectomas of the neck: the response to radiotherapy

In the 16 year period 1965-81, 12 patients with head and neck chemodectomas received radiotherapy. In only 1 patient did the tumour fail to respond, due to metastases, and 9 showed complete resolution of the tumour. As this form of treatment is associated with few complications, we conclude that it is the treatment of choice in those patients who are unfit for surgery and those whose tumours are technically unresectable.

An evaluation and clinical study of severe epistaxis treated by arterial ligation

Forty-three cases of intractable epistaxis treated by major arterial ligation are described, with follow-up in 41 cases of up to 11 years. It would appear that this treatment is effective in the control of epistaxis, and there was no evidence of any long-term detrimental effect on the nose, or of any significant mortality. External carotid artery ligation is advocated in the elderly and debilitated case, whilst internal maxillary artery ligation together with anterior ethmoidal artery ligation is indicated in the younger age group, or in the elective case. Evaluation of the results is discussed together with alternative methods of management.

Pre-operative embolization of juvenile nasopharyngeal angiofibromas with gelfoam

Two patients with juvenile nasopharyngeal angiofibromas are presented. Different haemorrhage-reducing operative methods were used. The cases illustrate the hazards of permanent ligation of the external carotid artery and the advantage of pre-operative embolization with absorbable Gelfoam.