Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany

BACKGROUND

Reports of a decrease in hospital admissions during the coronavirus disease 2019 (COVID-19) lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.

AIM

To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.

METHODS

A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period. This was done on a weekly basis before, during, and after the lockdown. An Interrupted Time Series was used as the analysis method.

RESULTS

In our analysis, we included 26183 patients. The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients (P < 0.05). This effect was most pronounced in the age group of 0-39 years, where the decrease was highly significant (P < 0.001). However, there was no change observed in patients aged 80 years and older (not significant). With the end of the lockdown period, the overall number of patients, especially in the youngest age group, increased abruptly and significantly (P < 0.01).

CONCLUSION

During the lockdown period, there was a decrease in hospital admissions for younger patients with epistaxis, possibly due to the fear of COVID-19 exposure. We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Endovascular intervention in treatment of refractory epistaxis

Objective

Angiographic embolization is an established method of treating intractable cases of posterior epistaxis. This study aimed to test the effectiveness and safety of this method in treating cases refractory to conservative methods.

Methods

A descriptive retrospective analysis of consecutive cases referred to the department of interventional radiology with refractory epistaxis from January 2001 to December 2018 and received a selective angiographic embolization of the sphenopalatine artery was done. Only epistaxis of idiopathic origin was included in the study.

Results

During this period, 98 embolizations were performed. The success rate reached 81.6%. Minor complications were registered in 5%, with no single major complication. The length of stay was 10.5 ± 5.6.

Conclusion

Selective angiographic embolization is an effective, safe, and minimally invasive method in treating refractory epistaxis.

Septoplasty Effect on the Enhancement of Airflow Distribution and Particle Deposition in Nasal Cavity: A Numerical Study

The surgery outcomes after fixing nasal airway obstruction (NAO) are sometimes not satisfactory in improving ventilations of airflow. A case study is presented in this paper with computational fluid dynamics applied to determine the key factors for successful septoplasty plans for a patient with a deviated nasal septum. Specifically, airflow, as well as particle transport and deposition were predicted in a pre-surgery nasal cavity model reconstructed from patient-specific Computer Tomography (CT) images and two post-surgery nasal cavity models (i.e., VS1 and VS2) with different virtual surgery plans A and B. Plan A corrected the deviated septal cartilage, the perpendicular plate of the ethmoid bone, vomer, and nasal crest of the maxilla. Plan B further corrected the obstruction in the nasal vestibule and caudal nasal septal deviation based on Plan A. Simulations were performed in the three nose-to-throat airway models to compare the airflow velocity distributions and local particle depositions. Numerical results indicate that the VS2 model has a better improvement in airflow allocation between the two sides than the VS1 model. In addition, the deposition fractions in the VS2 model are lower than that in both the original and VS1 models, up to 25.32%. The better surgical plan (i.e., Plan B) reduces the particle deposition on the convex side, but slightly increases the deposition on the concave side. However, the overall deposition in the nasal cavity is reduced.

Imaging to intervention: a review of what the Interventionalist needs to Know about Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is a disorder that affects 1 in 5000-10,000 people worldwide and can result in devastating complications such as cerebral abscess, stroke, massive hemorrhage, and even death. HHT is an autosomal dominant disorder that leads to the formation of abnormal communication between the arteries and veins with a resultant spectrum of vascular anomalies. The disorder affects many organ systems and thus requires a dedicated multidisciplinary approach. Interventional radiologists are vital members of this team providing expertise not only in disease management, but in complex embolotherapy, helping to maintain the health of these patients. This article reviews clinical manifestations, screening guidelines, diagnostic criteria, and endovascular management of HHT.

Skull Base Neurointerventional Techniques

Neurodiagnostic and neurointerventional radiology (NIR) play a central role in the diagnosis and treatment of skull base disorders. Noninvasive imaging modalities, including computed tomography and magnetic resonance imaging, are important in lesion localization, evaluation of lesion extent, and diagnosis, but cannot always be definitive. Image-guided skull base biopsy and percutaneous and endovascular treatment options are important tools in the diagnosis and treatment of head, neck, and skull base disorders. NIR plays an important role in the treatment of vascular disorders of the skull base. This article summarizes the imaging evaluation and interventional therapies pertinent to the skull base.

Success Rate of Endoscopic Sphenopalatine Artery Ligation for the Management of Refractory Posterior Epistaxis Patients in a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

Epistaxis is a common medical emergency with 5% to 15% of patients admitted for epistaxis will require surgical management as nasal packing has high failure rates. A modern endoscopic technique like Endoscopic Sphenopalatine Artery Ligation has increased in popularity for managing intractable posterior epistaxis. It has less complication and high success rate. The study conducted to estimate the success rate of Endoscopic Sphenopalatine Artery Ligation of refractory posterior epistaxis among admitted patients in a tertiary care hospital.

Methods:

This is a descriptive cross-sectional study conducted from June 2019 to June 2020 at the Department of Otorhinolaryngology, Nobel Medical College and Teaching Hospital among the patient with refractory posterior epistaxis with the help of retrospective data. Convenient sampling method was used. These patients underwent endoscopic sphenopalatine artery cauterization for recurrent/intractable posterior epistaxis. Ethical clearance was taken from the Institutional Review Board. Data were analyzed in Statistical Package for the Social Sciences.

Results:

Out of the total patient with refractory posterior epistaxis who underwent Endoscopic Sphenopalatine Artery Ligation, the overall success rate was 39 (95.12%). Among them, 25 (60.97%) males and 16 (39.02%) females underwent endoscopic sphenopalatine artery ligation. Twenty (48.78%) of them were unilateral whilst 21 (51.21%) were bilateral disease. About 2 (4.8%) case had re-bleeding within 48 hours which was managed conservatively. Hypertension was found to be the most common comorbid condition followed by diabetes, chronic kidney.

Conclusions:

From our study, we conclude that the success rate for Endoscopic Sphenopalatine Artery Ligation in a patient with refractory posterior epistaxis was high.

Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications

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.

Lasers in Rhinology-An Update

OBJECTIVES

A wide and evolving range of lasers and their applications often makes it difficult for a busy surgeon to choose the ideal laser for a specific indication. With this in mind, this article aims to summarize the most recent literature concerning laser application in rhinology.

METHODS

A literature search from 2000 to 2020 using the PubMed database was employed. Keywords used included "laser," "rhinology," "endonasal endoscopic surgery," "hereditary haemorrhagic telangiectasia," "rhinitis," "refractory rhinitis," "Inferior turbinate hypertrophy," "dacryocystorhinostomy," "septoplasty," "cartilage reshaping" and "choanal atresia." The most up to date studies published for each rhinology condition that could potentially be treated with laser surgery was included.

RESULTS

Rhinological conditions appropriate for laser applications are discussed. We identified articles related to a number of applications including hereditary hemorrhagic telangiectasia, rhinitis, turbinate surgery, dacryocystorhinostomy, septoplasty, choanal atresia, and sphenopalatine artery ligation, paying attention to the outcomes of the studies and their limitations.

CONCLUSIONS

There is currently no one-size-fits-all laser and therefore being up to date on the latest clinical application results can help the clinician decide which are the best treatments to offer their patients.

Clinical Practice Guideline: Nosebleed (Epistaxis)

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.

Usefulness of computed tomography in predicting ethmoidal arterial bleeding in refractory epistaxis

PURPOSE

Epistaxis that is refractory to conservative management can be treated with endoscopic sphenopalatine artery ligation (ESPAL). Although rare, ethmoidal artery (EA) bleeding can be a cause of rebleeding after successful ESPAL. EA bleeding is diagnosed by angiography and can also be identified during surgical exploration. However, since the angiographic embolization of the EA is contraindicated, surgical hemostasis is mandatory. This study investigated whether paranasal sinus (PNS) CT could provide information for predicting EA bleeding without angiography in patients with refractory epistaxis requiring ESPAL.

METHODS

Forty-seven patients, who were surgically treated [with ESPAL or EA ligation (EAL)] for refractory epistaxis from March 2010 to June 2019, were retrospectively analyzed. A positive PNS CT finding for EA bleeding was defined as the presence of soft tissue densities having continuity with the EA pathway, accompanied by a partially deficient surrounding bony canal. These findings as well as soft tissue densities in each paranasal sinus were compared between the ESPAL and EAL groups.

RESULTS

All patients in the EAL group had positive CT findings of EA bleeding, compared to only 12.2% in the ESPAL group (P < 0.001). The rate of soft tissue densities within the frontal and sphenoid sinuses were noted in 26.8% and 17.1% of patients in the ESPAL group, compared to 83.3% and 83.3% of patients in the EAL group (P = 0.013 and P = 0.003, respectively).

CONCLUSION

PNS CT might be useful for predicting EA bleeding in patients with refractory epistaxis requiring surgical hemostasis.

Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department

Background

The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation.

Methods

A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort.

Results

Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time.

Conclusion

Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.

Severe spontaneous epistaxis: retrospective study in a tertiary ENT centre

PURPOSE

To investigate the clinical profile and outcomes of different treatment strategies in patients hospitalized for spontaneous severe epistaxis.

METHODS

This is a retrospective descriptive study of a case series of patients hospitalized for epistaxis in the University Hospital of Ghent between 2005 and 2012.

RESULTS

124 patients with, respectively, 132 episodes were included. 64% were male. The mean age was 65 years. 73% had comorbidities of which arterial hypertension was the most common. 61% were taking one or more antithrombotics and in 25.7% a recent change in the medication schedule took place. 47% of the episodes necessitated a vascular intervention. The most performed surgery was endoscopic sphenopalatine artery ligation. The 1-year success rate of conservative treatment was 47% and of vascular intervention 81%. No significant difference between the recurrence rates and need for vascular intervention of the different comorbidities and medications was detected using Pearson chi-squared and Fisher's exact testing. The overall 5-year survival rate was 83.6%.

CONCLUSIONS

The typical pattern of a patient presenting with severe epistaxis was a patient in the sixth decade, male, suffering from comorbidities and taking one or more antithrombotic agents. Based on the above-mentioned success rates of the different treatment options, we think all centres treating epistaxis should apply a well-defined protocol to guide the decision when to proceed with surgery. Furthermore, prospective research needs to precisely investigate the role played by comorbidities and their treatment in the occurrence of epistaxis and to test the effectiveness of proposed algorithms.

Endovascular Embolization in the Treatment of Epistaxis

OBJECTIVE

The cost-effectiveness of endovascular embolization (EE) for intractable epistaxis has been questioned, especially as endoscopic surgical techniques have become standard of care at many institutions. Our objectives were to review the safety profile and effectiveness of EE for epistaxis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary care hospital.

SUBJECTS

There were 54 patients and 64 unique encounters. Patients were 66.7% male, with a mean age of 64.5 years. Bleeding disorders were present in 18.8%, hypertension was present in 71.7%, and 61.1% were on anticoagulant/platelet drugs.

METHODS

Charts of patients undergoing EE for epistaxis between 2005 and 2015 were retrospectively reviewed.

RESULTS

The immediate bleeding control rate was 92.6%. Three patients died within 1 week of EE and were excluded from further analysis. Overall, 64.7% of the remaining patients had no further episodes of epistaxis. Thirteen patients (25.4%) rebled within 1 week, 11 of whom required repeat EE or operative control. Five patients (9.8%) rebled more than 1 week following the procedure with 4 requiring repeat EE or operative control. The major complication rate was 7.4% and included transient stroke, diplopia, facial skin necrosis, and extraperitoneal hemorrhage.

CONCLUSION

While the immediate success rate of EE for epistaxis was comparable to the literature, the overall short- and long-term rebleed rate was high in this selected population. The results suggest that patients who are referred for EE represent a high-risk group with increased risk of repeat hemorrhage and morbidity. Patients who undergo EE for epistaxis should be carefully monitored for complications, including repeat hemorrhage.

To Pack or Not to Pack: Inpatient Management of Epistaxis in the Elderly

BACKGROUND

Epistaxis is common in elderly patients, occasionally necessitating hospitalization for the management of severe bleeds. In this study, we aim to explore the impact of nasal packing versus nonpacking interventions (cauterization, embolization, and ligation) on outcomes and complications of epistaxis hospitalization in the elderly.

METHODS

The 2008-2013 National Inpatient Sample was queried for elderly patients (≥65 years) with a primary diagnosis of epistaxis and accompanying procedure codes for anterior and posterior nasal packing or nonpacking interventions.

RESULTS

A total of 8449 cases met the inclusion criteria, with 62.4% receiving only nasal packing and 37.6% receiving nonpacking interventions. On average, nonpacking interventions were associated with a 9.9% increase in length of stay and a 54.0% increase in hospital charges. Comorbidity rates did not vary between cohorts, except for diabetes mellitus, which was less common in the nonpacking cohort (26.6% vs 29.0%; P = .014). Nonpacking interventions were associated with an increased rate of blood transfusion (24.5% vs. 21.8%; P = .004), but no significant differences in rates of stroke, blindness, aspiration pneumonia, infectious pneumonia, thromboembolism, urinary/renal complications, pulmonary complications, cardiac complications, or in-hospital mortality. Comparing patients receiving ligation or embolization, no differences in length of stay, complications, or in-hospital mortality were found; however, embolization patients incurred 232.1% greater hospital charges ( P < .001).

CONCLUSION

Nonpacking interventions in the elderly do not appear to be associated with increased morbidity or mortality when compared to nasal packing only but appear to be associated with increased hospital charges and length of stay. Embolization in the elderly results in greater hospital charges but no change in outcome when compared to ligation.

Comprehensive understanding of vascular anatomy for endovascular treatment of intractable oronasal bleeding

Oronasal bleeding that continues despite oronasal packs or recurs after removal of the oronasal packs is referred to as intractable oronasal bleeding, which is refractory to conventional treatments. Severe craniofacial injury or tumor in the nasal or paranasal cavity may cause intractable oronasal bleeding. These intractable cases are subsequently treated with surgical ligation or endovascular embolization of the bleeding arteries. While endovascular embolization has several merits compared to surgical ligation, the procedure needs attention because severe complications such as visual disturbance or cerebral infarction can occur. Therefore, comprehensive understanding of the head and neck vascular anatomy is essential for a more effective and safer endovascular treatment of intractable oronasal bleeding.

Economic Analysis of the Treatment of Posterior Epistaxis

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.

Endoscopic Anatomy of the Sphenopalatine and Posterior Nasal Arteries: Implications for the Endoscopic Management of Epistaxis

Background

Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity.

Methods

We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined.

Results

In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen.

Conclusion

Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.

An Endoscopic Study of the Greater Palatine Nerve

Background

Using an endoscopic approach, lateral sphenoid air cells and terminal branches of the internal maxillary artery often can be accessed through the pterygomaxillary fossa; however, injury to the greater palatine nerve (GPN) can occur if the anatomy of this region is not understood clearly. This study was undertaken to define the pathway of the GPN and to identify landmarks useful in preventing its injury.

Methods

Six cadaveric heads were used to endoscopically dissect and examine 11 pterygomaxillary fossae. An additional latex-injected cadaveric head was sectioned coronally and dissected bilaterally. The relationships between the vascular, neurological and bony structures and foramena were noted and described.

Results

All specimens studied maintained consistent relationships. The sphenopalatine and posterior nasal arteries cross nearly perpendicular and just superficial to the GPN. The GPN traveled anteriorly and inferiorly to reach the greater palatine foramen. The lateral wall of the canal ranged from a thin bony covering to complete dehiscence and was thinnest as it crossed the inferior turbinate and approached the foramen. The foramen rotundum was located lateral and superior to the sphenopalatine foramen near the roof of the maxillary sinus.

Conclusion

When surgically approaching the pterygomaxillary fossa, injury to the GPN is avoidable by thorough knowledge of anatomy and awareness of the described landmarks.

Management of Persistent Epistaxis Using Floseal Hemostatic Matrix vs. traditional nasal packing: a prospective randomized control trial

BACKGROUND

Epistaxis is the most common emergent consultation to otolaryngology-head & neck surgery (OHNS) and with 60% of the population having experienced an episode and 1.6 in 10,000 requiring hospitalization in their lifetime. In preliminary studies Floseal® (Baxter, USA) Hemostatic Matrix has shown efficacy in up to 80% of persistent anterior epistaxis. We sought to evaluate the clinical efficacy and cost-effectiveness of Floseal® (Baxter, USA) compared to traditional nasal packing for persistent epistaxis.

METHODS

A prospective, randomized controlled trial was conducted on all adult patients consulted to the OHNS service at the tertiary referral centers of the University of Alberta Hospital and Royal Alexandra Hospital for persistent epistaxis. Patients were randomized to the Floseal® (Baxter, USA) or traditional packing study arms. Our main clinical outcome measures were: 1) Hemostasis directly following treatment and at 48 h post-treatment, and 2) self-reported patient comfort at 48 h post-treatment. Further, trial data was used for a formal cost-effectiveness analysis to determine incremental cost-effectiveness ratio (ICER). Univariate sensitivity analysis and uncertainty analysis were performed.

RESULTS

There were no significant differences between groups for initial hemostasis (76.9% vs. 84.6%, p = 1.000) or, hemostasis at 48 h (76.9% vs. 69.2%, p = 1.000), requirement for admission (15.4% vs. 46.1%, p = 0.2016) or 30-day re-presentation rates (15.4% vs. 46.1%, p = 0.2016). Floseal® (Baxter, USA) was superior for decreased pain during placement (2.42 vs. 7.77, p = 0.0022), treatment (0.50 vs. 4.46, p = 0.0007) and removal (0 vs. 3.85, p = 0.0021). Floseal® (Baxter, USA) provides an average $1567.61 per patient savings from the single-payer system point of view and has an ICER of - $11,891 per re-bleed prevented (95% CI: -$37,658 to +$473). Uncertainty analysis shows that Floseal® has >90% chance of not only being cost-effective, but the dominant (preferred) treatment.

CONCLUSIONS

Floseal® (Baxter, USA) was demonstrated to be an effective, comfortable and cost-effective alternative treatment of persistent epistaxis when compared to traditional packing methods for patients referred to OHNS with a normal coagulation profile.

TRIAL REGISTRATION

Trial registration number: NCT02488135 . Date registered: June 26, 2015.

Surgical and interventional radiological management of adult epistaxis: systematic review

BACKGROUND

There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery.

METHOD

A systematic review of the literature was performed using a standardised published methodology and custom database search strategy.

RESULTS

Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73-100 per cent and 75-92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1-1.5 per cent). No articles directly compared the two techniques.

CONCLUSION

Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

Endovascular Treatment to Stop Life-threatening Bleeding from Branches of the External Carotid Artery in Patients with Traumatic Maxillofacial Fracture

Objective

The purpose of this study was to report our preliminary experience with endovascular treatment (EVT) for life-threatening bleeding from branches of the external carotid artery (ECA) in patients with traumatic maxillofacial fractures.

Materials and Methods

A total of 12 patients seen between March 2010 and December 2014 were included in this study. All subjects met the following criteria: 1) presence of maxillofacial fracture; 2) continuous blood loss from oronasal bleeding; and 3) EVT to stop bleeding. Various clinical factors were recorded for each patient and the correlations between those factors and clinical outcome (Glasgow Outcome Scale, GOS) were evaluated.

Results

Four patients were injured in traffic accidents, five in falls, and three by assaults. Mean initial Glasgow Coma Scale (GCS) was 6.9 ± 2.1 and the lowest hemoglobin measured was mean 6.3 ± 0.9 g/dL. GOS at discharge was 4 in five patients, 3 in three patients, and 1 (death) in four patients. GOS on follow-up (mean 13.7 months) was 5 in two patients, 4 in three patients, and 3 in three patients. Initial GCS (p = 0.016), lowest systolic blood pressure (p = 0.011), and lowest body temperature (p = 0.012) showed a significant positive correlation with good clinical outcomes. The number of units of red blood cells transfused (p = 0.030), the number of units of fresh frozen plasma transfused (p = 0.013), and the time from arrival to groin puncture (p < 0.001) showed significant negative correlation with good clinical outcomes.

Conclusion

It might be suggested that rapid transition to EVT could be preferable to struggling with other rescue strategies to stop life-threatening bleeding from branches of the ECA in patients with traumatic maxillofacial fractures.

Successful Implementation of a Clinical Care Pathway for Management of Epistaxis at a Tertiary Care Center

OBJECTIVE

We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost.

STUDY DESIGN

Single prospective analysis with historical control.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing.

RESULTS

Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented.

CONCLUSIONS

Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.

Inpatient management of epistaxis: Outcomes and cost

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.)

Sphenopalatine Artery Ligation for Epistaxis: Factors Influencing Outcome and Impact of Timing of Surgery

OBJECTIVE

Sphenopalatine artery ligation is a commonly employed surgical intervention for control of posterior epistaxis unresponsive to nasal packing. The objective of the present study was to evaluate the outcome of sphenopalatine artery ligation for control of epistaxis at our institution and the impact of timing and other factors on outcome.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary referral center.

SUBJECTS AND METHODS

Case notes were reviewed for 45 consecutive patients undergoing sphenopalatine artery ligation for control of epistaxis between October 2008 and October 2014.

RESULTS

Forty-one patients had nasal packing prior to sphenopalatine artery ligation, with 33 undergoing ≥2 packings. Postoperatively, 6 patients had rebleeding, which was treated with repacking (n = 4) and return to the operating room (n = 2). The overall success rate of sphenopalatine artery ligation was 87% (39 of 45). Rebleeding rate was not affected by concomitant septoplasty, anterior ethmoidal artery ligation, or postoperative nasal packing. Patients undergoing SPA ligation within the first 24 hours of admission had a significantly shorter hospital length of stay (3 vs 6 days, P = .02) and treatment cost (€5905 vs €10,001, P = .03). Length of stay was not influenced by sphenopalatine artery ligation after ≤1 nasal pack versus ≥2 packs. Timing of sphenopalatine artery ligation did not affect blood transfusion requirement (P = .84).

CONCLUSION

Sphenopalatine artery ligation is an effective management strategy for surgical control of refractory epistaxis. Early timing of sphenopalatine artery ligation may lead to reductions in length of stay.

Endoscopic endonasal greater palatine artery cauterization at the incisive foramen for control of anterior epistaxis

OBJECTIVES/HYPOTHESIS

To describe the anatomy of the incisive foramen and the transnasal endoscopic approach to the greater palatine artery at this foramen, and to evaluate the importance of the greater palatine artery as a cause of recurrent anterior epistaxis.

STUDY DESIGN

Anatomical dissection, radiographic study, and prospective case series.

SETTING

Academic Medical Center.

METHODS

Sixty-nine computed tomography scans were reviewed, and measurements were made of the incisive foramina's distance to the anterior nasal spine and subnasale. Twenty-two cadavers had sagittal split craniotomies performed prior to the measurements. The distance from the anterior nasal spine to the incisive foramen was documented. We also present an illustrative case series of patients who underwent endoscopic cautery of the greater palatine artery at the incisive foramen.

RESULTS

Radiographic review of the incisive foramen revealed a mean anterior nasal spine to incisive foramen distance on the right and left of 7.9 and 8.1 mm, respectively. The mean distance from the subnasale to incisive foramen on the right and left were 24.7 and 24.9 mm, respectively.

CONCLUSIONS

Endoscopic cauterization of the greater palatine artery at the incisive foramen is a safe and effective method to control recurrent anterior epistaxis. The incisive foramen can be predictively found within 1 cm of the anterior nasal spine. Our case series corroborates the above.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1033-1038, 2016.

Changing Trends in the Management of Epistaxis

Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment modalities including cautery, nasal packing, maxillary artery ligation, anterior artery ligation, and sphenopalatine artery ligation. The paper also proposes an algorithm for managing such cases.

Angioembolisation in Maxillofacial Trauma: An Initial Experience in a Tertiary Care Center

PURPOSE

To analyze the safety, efficacy and outcome of angio-embolization in the management of refractory oro-nasal bleeding in patients of severe maxillofacial trauma.

MATERIALS AND METHODS

It was a retrospective analysis of 21 patients who were managed by angio-embolisation to control refractory oro-nasal bleeding in severe maxillofacial trauma from December 2010 to December 2013. The patient population included 19 males and 2 females and the age ranged from 16 to 55 years (mean age of 29.6 years). Gelfoam pledgets and coils were used as embolising agents in branches of external carotid arteries. Embolising coils were preferably used to block actively bleeding vessels on angiography.

RESULTS

Road traffic accidents were the etiology in 17 patients and fall from height (two), assault (one) and gunshot injury (one) in the rest. Twelve (52 %) patients showed active contrast extravasation on angiography. Active arterial bleeding was observed from branches of internal maxillary [11], facial [2] and lingual arteries [4]. Gel foam embolisation alone was done in 16 patients, coil embolisation alone in two patients and both coil and gel foam embolisation in three patients. The procedures were technically successful in twenty (95 %) patients. None of the patients had procedure related complications. Nine patients (42 %) succumbed to their associated injuries later, in which five patients had severe head injuries and four patients had history of hemorrhagic shock and cardiac arrest prior to the procedure.

CONCLUSION

Angio-embolisation is a safe and effective technique in managing intractable bleeding in maxillofacial injuries.

Transcatheter embolization in the management of epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.

Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis

BACKGROUND

The advent of endoscopic sphenopalatine artery ligation (ESPAL) for the control of posterior epistaxis provides an effective, low-morbidity treatment option. In the current practice algorithm, ESPAL is pursued after failure of posterior packing. Given the morbidity and limited effectiveness of posterior packing, we sought to determine the cost-effectiveness of first-line ESPAL compared to the current practice model.

METHODS

A standard decision analysis model was constructed comparing first-line ESPAL and current practice algorithms. A literature search was performed to determine event probabilities and published Medicare data largely provided cost parameters. The primary outcomes were cost of treatment and resolution of epistaxis. One-way sensitivity analysis was performed for key parameters.

RESULTS

Costs for the first-line ESPAL arm and the current practice arm were $6450 and $8246, respectively. One-way sensitivity analyses were performed for key variables including duration of packing. The baseline difference of $1796 in favor of the first-line ESPAL arm was increased to $6263 when the duration of nasal packing was increased from 3 to 5 days. Current practice was favored (cost savings of $437 per patient) if posterior packing duration was decreased from 3 to 2 days.

CONCLUSION

This study demonstrates that ESPAL is cost-saving as first-line therapy for posterior epistaxis. Given the improved effectiveness and patient comfort of ESPAL compared to posterior packing, ESPAL should be offered as an initial treatment option for medically stable patients with posterior epistaxis.

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entively satisfactory because of morbidity, high failure rates, and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior existaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior & posterior nasal packing.

Internal maxillary artery ligation for idiopathic intractable epistaxis

Epistaxis though common, is rarely life threatening. Routinely nose pinching, anterior find posterior nasal packing and endoscopic cauterization of bleeding points is sufficient to control epistaxis in 99% of the cases. It is mandatory to rule out local and systemic causes before labeling a case as idiopathic by using a battery of investigative modalities. Here are two interesting cases of epistaxis which did not respond to conventional therapeutic modalities in which transantral internal maxillary artery ligation was attempted leading to complete cure.

Epistaxis: A retrospective clinical study

Epistaxis is a common otolaryngologic problem. A 2.5 years retrospective study (June 1998 December 2000) of patients attending outdoor or indoor services of Department of ENT with complaint of nasal bleeding was done. The study was conducted on 88 patients for the incidence, age and sex relation, etiological factors, clinical findings, and treatment methods for epistaxis.

Nasal packing aspiration in a patient with Alzheimer's disease: a rare complication

Nasal bleeding is a frequent problem for patients receiving anticoagulant agents. Most cases are successfully managed with anterior or posterior nasal packing. However, the complications of nasal packing should be always considered. We report the case of a 78-year-old man with Alzheimer’s disease who was treated for anterior epistaxis with anterior nasal packing using three pieces of antibiotic-soaked gauze. Two days later, the patient was admitted to the emergency department in respiratory distress. A chest x-ray demonstrated atelectasis of the right lung. During an examination of the nasal cavities, the nasal packing was removed, and one of the gauze pieces was missing. The patient underwent rigid bronchoscopy, and the missing gauze was found to be obstructing the right main bronchus. The patient’s respiratory function improved considerably after removal of the foreign body. It is assumed that gauze packs should be used with caution in patients with an impaired level of consciousness and neurodegenerative diseases.

Direct cauterization of the nasal septal artery for epistaxis

Emergency management of epistaxis may include the use of local pressure and vasoconstrictors, chemical or electric cautery, hemostatic agents, nasal packing, embolization, and surgical arterial ligation. There is no definitive protocol for the management of epistaxis, although various protocols have been proposed in the literature. As approaches to surgical ligation of the arterial supply of the nasal cavity have evolved from external carotid ligation to minimally invasive approaches, surgical management of epistaxis has become more effective than embolization and may be less risky. In the surgical management of epistaxis, arterial ligation immediately proximal to the bleeding site is preferred. We propose a simple variation of the endoscopic sphenopalatine artery ligation that may be used to manage epistaxis arising from the nasal septum and floor.

Endoscopically guided chitosan nasal packing for intractable epistaxis

BACKGROUND

The purpose of this study was to evaluate the effectiveness and safety of endoscopically guided chitosan packing in controlling intractable epistaxis. A prospective case series was performed.

METHODS

This is a prospective clinical study conducted in a tertiary rhinology fellowship training hospital between January 2009 and November 2009. The study population consisted of patients with intractable epistaxis that failed to respond to traditional anterior-posterior nasal packing using either a 10-cm Pope PVA Merocel or a Rapid-Rhino. The bleeding site was identified using a nasal endoscope and controlled using a pack made of a ChitoFlex chitosan dressing wrapped around a polyvinyl acetal nasal sponge.

RESULTS

The intent-to-treat population consisted of 20 severe epistaxis subjects (8 men and 12 women) who continued to bleed despite traditional anterior-posterior nasal packing. The mean age was 67 years (±19 years). Sixteen subjects were on antiplatelets and/or anticoagulants. Eleven subjects (55%) presented with anterior epistaxis, and 7 subjects (35%) presented with posterior epistaxis. Chitosan nasal packing was performed on an outpatient basis and resulted in effective and immediate hemostasis in 19/20 subjects (95%). One subject had persistent bleeding after the first packing attempt and was successfully repacked within 30 minutes. Time to complete cessation of bleeding was 3.6 ± 2.2 minutes in the 19 subjects; the pack was removed after 48 hours, without any evidence of rebleeding or any serious side effects.

CONCLUSION

Endoscopically guided chitosan packing is a safe, effective, and well-tolerated outpatient treatment for the management of intractable epistaxis.

Endoscopic management of recurrent epistaxis: the experience of two metropolitan hospitals in Italy

CONCLUSION

Endoscopic cauterization of the sphenopalatine artery and anterior ethmoid artery is a first-line standard of care in managing intractable epistaxis, after the failure of previous packing. Epistaxis occurs in 12% of the population. Treatment is often based on nasal packing that could be poorly effective in the treatment of severe posterior epistaxis.

OBJECTIVE

To evaluate the effectiveness of the endoscopic approach for posterior epistaxis.

METHODS

We report the experience of endoscopic cauterization in two metropolitan hospitals in Italy: 48 patients with at least one nasal packing in the 3 weeks before hospital admission. They underwent endoscopic cauterization of the sphenopalatine artery or of the anterior ethmoid artery.

RESULTS

The patients' mean age was 58.7 years; the mean hospital stay was 2.97 days. In 42 cases (87.5%), cauterization of the sphenopalatine artery was performed, and 6 (12.5%) were subjected to anterior ethmoid artery treatment. Epistaxis control was achieved in 93% of cases; 3 patients had a recurrent nasal bleeding, and were treated with anterior nasal packing. Minor complications occurred in 27.1%. We achieved a shorter hospital stay compared with patients who underwent anteroposterior packing.

Sphenopalatine artery ligation under local anesthesia: A report of two cases and review of the literature

Epistaxis is the commonest emergency in otorhinolaryngology. Over the last decade endoscopic sphenopalatine artery (SPA) ligation has become a popular treatment option for posterior epistaxis and has been shown to be the most effective and cost-efficient definitive treatment for posterior epistaxis. SPA ligation is usually performed under general anesthesia. The majority of epistaxis patients are elderly, frail and have multiple medical conditions. These patients are therefore not always amenable to general anesthesia. In this article we describe two cases where posterior epistaxis was successfully treated with sphenopalatine artery ligation under local anesthesia and should be considered suitable for patients with severe posterior epistaxis who are not fit for a general anesthetic.

Endovascular treatment of epistaxis

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.

[Current aspects in epistaxis]

A survey of current literature on the topic of epistaxis revealed only a circumscript number of publications with a high methodologic value. The analysis of these publications showed that there is a controversy on the necessity of routine coagulation tests in epistaxis patients. These tests should only be performed in cases with clinical evidence of a coagulation disorder. Also, there is an ongoing controversy on the value of local cooling with ice or cold packs. Nasal creams and decongestive nose drops have been found to be effective in uncomplicated epistaxis. Rhinoscopically and endoscopically targeted coagulation of bleeding vessels and nasal packing are recommended treatment options. There is a debate on discontinuation of anticoagulant therapy, if INR is within normal limits in Cumadin patients. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options. Recurrent epistaxis in hereditary syndromes remains to be a challenge, although some advances have been made in diagnosis and symptomatic treatment. Some new medical drugs, as Viagra or Cialis may have nosebleeds as side-effects.