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Angiographic Embolization for Epistaxis: A Review of 114 Cases
Abstract
Angiography with selective embolization has become an accepted method of treating posterior epistaxis that is not controlled with conservative measures. The authors reviewed 112 cases of patients who had received selective angiographic embolization for refractory epistaxis from January 1990 to December 1995. There were 114 embolizations over this 5-year period. The immediate success rate was 93%, with long-term success achieved in 88% of patients. The overall complication rate was 17%, with the long-term morbidity rate less than 1%. Selective angiographic embolization is a safe and effective method that should be considered in the treatment of refractory epistaxis.
... The procedure was successful in all 14 patients in our series, with a low rate of complications. In our study, the success rate of endovascular treatment was quite high (100%; 14/14), which is consistent with the findings of other studies reporting success rates ranging from 93% to 100% (7)(8)(9)(10)(11)(12). ...
... In previous studies, the success of unilateral internal maxillary artery embolization was reported to be 74% (7,13,14). The reason for continuing nosebleeds despite successful embolization is anterior ethmoid artery bleeding and/or mucosal tears caused by nasal packing (8,(15)(16)(17). ...
... In the literature, major complications, such as blindness, ipsilateral facial paralysis, cerebrovascular accidents, necrosis of the soft tissue of the cheek or nose, have been reported (6,8,14,15,18). In our study, temporary local dental, oral, nasal pain reported in one-third of patients, was the major complaint, and also one patient suffered from transient hemiparesis after unilateral embolization of the internal maxillary artery. These complications were thought to be caused by the powerful injection of the embolic agent and the backflow of particles into the internal carotid artery (7). ...
... Für die idiopathische posteriore Epistaxis liegt die Quote für eine erfolgreiche Embolisation in der Literatur bei 93-100 % [19][20][21][22][23][24]. Werden die frühen Nachblutungen mit berücksichtigt, sinkt die Erfolgsrate auf 77,3-94,6 % [19,21,22,25,26]. ...
... Für die idiopathische posteriore Epistaxis liegt die Quote für eine erfolgreiche Embolisation in der Literatur bei 93-100 % [19][20][21][22][23][24]. Werden die frühen Nachblutungen mit berücksichtigt, sinkt die Erfolgsrate auf 77,3-94,6 % [19,21,22,25,26]. Verspätete Nachblutungen, die i. d. ...
... Verspätete Nachblutungen, die i. d. R. mit symptomatischen Ursachen einher-gehen, weisennocheine Erfolgsquote von 71-89,2 % auf [19,[21][22][23][24]26]. ...
Die Diagnose Nasenbluten (Epistaxis) ist häufig, führt aber nur selten zur stationären Aufnahme. Bei Patienten, die einer stationären Behandlung zugeführt werden, liegt meist eine rezidivierende posteriore Epistaxis vor. Trotz HNO-ärztlicher Maßnahmen wie Nasentamponade oder operative Methoden kann es zu Blutungsrezidiven kommen, oder die Blutungsquelle ist chirurgisch nicht angehbar. Dann bietet die endovaskuläre Behandlung eine echte, oft die einzige Therapieoption. Neben idiopathischen Ursachen für die posteriore Epistaxis kommen auch symptomatische Ursachen vor, diese gilt es nachzuweisen und die Therapie anzupassen. Hilfreich ist die Durchführung einer Computertomographie der Nasennebenhöhlen (NNH-CT), ggf. mit CT-Angiographie. Damit können auch unerwartete Ursachen und die Lokalisation der Blutung eingegrenzt sowie Gefäßvarianten und -anomalien nachgewiesen werden. Insgesamt ist die endovaskuläre Therapie bei posteriorer Epistaxis unter Kenntnis der gefährlichen Anastomosen als sicher einzuschätzen. Gravierende Komplikationen sind selten.
... Alternatively or in addition to surgical therapy, selective endovascular embolization of nasal arteries is used, mostly in branches of the internal maxillary or facial artery, and by application of polyvinyl alcohol (PVA) microparticles, gelatin sponge or microcoils; for reviews, see [9, 10]. Most authors prefer gelfoam or microparticles as embolic agents [11][12][13][14][15][16][17][18]; coils as the sole embolic agent are applied in only a few studies and only in part of the patients, respectively [19][20][21][22][23][24]. In this paper, we analyze the treatment of 12 patients with severe refractory epistaxis by sole microcoil embolization; no other embolic agents were used, with the aim of avoiding typical embolic complications as seen in particle embolization (e.g., tissue necrosis, visual or neurological impairment) [9, 10, 19]. ...
... Merely one percent of our epistaxis inpatients were submitted to interventional endovascular therapy due to repeated failure of previous conservative and/or surgical treatments, which is quite a small fraction when compared to other case series. For example, Tseng et al. [15] describe 114 embolizations in 107 patients during a study period of 6 years (1990–1995), with a total of 436 epistaxis inpatients this time. This is about one-third of our epistaxis inpatients, but with an embolization rate of approximately 25 percent. ...
... Merely in one case, the facial artery of one side was embolized additionally, with the aim of better control of recurrent bleeding [11], but nevertheless, embolization and re-embolization were not successful in this patient. All procedures were carried out under general anesthesia and with nasal packings left in place, although some authors favor embolization in awake patients [15, 19, 20, 25]. In our opinion, the advantages of general anesthesia are better controllability in uncooperative patients, lower stress exposition, effective airway protection [9, 11], and a possible synergistic effect of embolization and nasal packing [10]. ...
From 2006 to 2013, 12 patients with severe epistaxis refractory to prior conservative and surgical therapy were treated by superselective embolization of nasal arteries. Supersoft platinum microcoils with smallest diameters were used as the sole embolic agent in all cases. Coils were applied far distally in a stretched position for obtaining ideal target vessel superselectivity. The objective of this study is to evaluate efficacy and complications of superselective coil embolization for treatment of severe intractable epistaxis and to discuss results from an otorhinolaryngologic and an interventional neuroradiologic point of view. Retrospectively, all epistaxis inpatients between 2006 and 2013 were identified and subdivided by form of treatment: conservative, surgical and interventional therapy. Medical records of interventionally treated patients were reviewed for demographics, medical history, risk factors, clinical data, complications and short-term success, and patients were followed up for long-term success. Mean follow-up was 37 months. In 12 patients, 14 embolizations were carried out, with short-term success in 9 patients (75 %), while early post-interventional rebleeding occurred in 3 patients (25 %). Of 9 patients with short-term success, 1 died during stay, 1 was lost to follow-up and 1 had minor re-bleeding after 30 months. Six patients had short-term and long-term success. Before the first embolization, 3 ± 1 conservative and/or surgical procedures had been undertaken. Length of stay was 12.8 ± 3.6 days. 8 patients (67 %) received red cell concentrates. Most frequent complications were mucosal damage and nasal pain, but these were related to repeated packing and surgery. Typical embolic complications as neurological or visual impairment or soft tissue necrosis were not observed in any patient. From the otorhinolaryngologic point of view, surgery is the treatment of choice in severe refractory epistaxis, but in case of repeated failure, superselective microcoil embolization is a valuable addition to the therapeutic spectrum. From the interventional neuroradiologic point of view, superselective microcoil embolization is an effective, well tolerable and safe procedure and complications may be reduced in comparison to microparticle embolization. Modern supersoft microcoils with smallest diameters enable ideal superselectivity of the target vessels.
... [11][12][13] Examples include tissue necrosis of the face or palate, stroke, hemiplegia, and blindness with the latter complications possibly due to retrograde embolic migration. [14][15][16] Minor complications occur far more often and consist of facial pain, headaches, confusion, paresthesia, facial edema, and numbness. 14 Permanent side effects of embolization are seldom reported with most complications resolving in less than a week. ...
... [14][15][16] Minor complications occur far more often and consist of facial pain, headaches, confusion, paresthesia, facial edema, and numbness. 14 Permanent side effects of embolization are seldom reported with most complications resolving in less than a week. ...
Objectives:
Endovascular embolization has emerged as an effective treatment for intractable epistaxis. This systematic review and meta-analysis aimed to calculate the rates of success, rebleeds, and complications and to identify the etiologies and complications of patients who undergo endovascular embolization.
Methods:
This systematic review and meta-analysis was conducted per the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were extracted from Scopus, PubMed, Web of Science, and Cochrane Central and were filtered by a systematic review process using Rayyan software. A random-effects model was used to quantify the rates success, rebleeds, and complications.
Results:
Forty-two studies were included, totaling 1660 patients. The pooled success rate was 89% (95% confidence interval [CI] 86%-92%) and the pooled rebleed rate was 19% (95% CI 16%-22%). The pooled minor complication rate was 18% (95% CI 11%-27%). The most common major complication was soft tissue necrosis followed by stroke. The most common minor complication was facial pain. No minor complications were reported to be permanent. Of the patients who failed initial embolization, 42% underwent repeat embolization and 34% underwent surgical arterial ligation.
Conclusions:
Endovascular embolization is an effective treatment for intractable epistaxis. The decision to perform embolization should be carefully weighed given the rare but significant major complications.
... These cases were not further elucidated in our investigation, but, since CT is also capable to detect trauma sequelae, not only of the paranasal sinuses, but also of adjacent bones forming the midface or portions of the skull base [23,24], in these terms, it may to be superior to rhinoscopy alone. Moreover, CT has been demonstrated to improve the diagnostic performance, especially when massive arterial bleeding is suspected and PE envisaged [6,10,25,26]. ...
... PE enables selective interruption of the blood supply to the sinonasal area, especially if the bleeding originates from the posterior nasal cavity [26]. In these cases, advanced medical imaging including non-contrast CT and CT angiography depicting the intracranial vessel status may be indicated prior to treatment [25,26]. ...
Objective:
In addition to rhinoscopy, computed tomography of paranasal sinuses (CT) may be performed on patients with primary unknown cause of severe epistaxis (SE) or recurrent epistaxis (RE) to further assess the potential cause of bleeding. The aim of this study was to evaluate CT findings during the work-up of intractable epistaxis patients.
Methods:
6937 patients were treated in our emergency department with acute epistaxis between 2009-2018. 304/6937 patients underwent CT and rhinoscopy due to intractable SE or RE. 33 patients presented with head trauma prior to epistaxis and were excluded from the final analysis. In 271 cases the primary causes of SE (n = 252) or RE (n = 19) remained unknown. Two observers retrospectively evaluated CT scans for potential sources of epistaxis. Disagreement was settled by consensus. CT and rhinoscopy findings were compared.
Results:
In 247/271 (91.1%) SE patients no related pathology was found on CT. A possible cause for epistaxis was found in all RE patients, but only in 5/252 (1.9%) patients with SE. Most tumours (10/11) and inflammatory conditions (9/10) were found in patients with RE. In three SE cases, a tumour was suspected on CT, from which two suspicions were refuted during rhinoscopy. CT revealed 10 cases of inflammatory conditions of the sinus and anatomical variant as potential cause of bleeding.
Conclusion:
For patients with unknown causes of epistaxis, supplementary CT imaging may be a useful diagnostic add-on to rhinoscopy in the event of RE, tumour suspicion or inflammation of the paranasal sinuses. However, in most cases of first-time SE, CT does not necessarily add to the diagnosis. In these cases, the marginal benefit of CT needs to be weighed carefully against its risks.
... 11,17 Selective embolisation of the branches of the SPA and/or facial artery also has high efficacy rates, ranging from 80% to 90%. 21 Therefore, treatment of severe epistaxis is not standardised and varies greatly between the institutions. In a study performed by Sylvester et al. 22 on 1813 patients, treatment with surgery trended downward, whereas the embolisation rates remained constant. ...
... Long published case series describe minor transient complication rates of between 25% and 59%, major transient between 0% and 1%, and persistent <2%. 21,24 In our series 2 patients (18% of those embolised) had minor transient complications, and one patient had a permanent complication. ...
Objective
The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolisation were compared.
Material and method
Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively.
Results
Eleven patients (17%) underwent embolisation, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolisation was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolisation. One patient suffered a hemispheric stroke after embolisation. No post-surgical complications were observed.
Conclusions
Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient.
... Endovascular treatment is also established as a safe and effective option in the management of epistaxis. 6,7 However, complication rates as high as 25% to 39% 6,7 have been reported and include local inflammation, bleeding, necrosis of skin, neurologic complications, and even aneurysmal rupture. This risk profile may make such treatment modalities less suitable for surface lesions such as facial artery aneurysm. ...
... Endovascular treatment is also established as a safe and effective option in the management of epistaxis. 6,7 However, complication rates as high as 25% to 39% 6,7 have been reported and include local inflammation, bleeding, necrosis of skin, neurologic complications, and even aneurysmal rupture. This risk profile may make such treatment modalities less suitable for surface lesions such as facial artery aneurysm. ...
... 5 Published etiologies of epistaxis requiring endovascular intervention include idiopathic, traumatic, post-operative, aneurysms, arterio-venous malformations, fistulae, hereditary haemorrhagic telangiectasia (HHT) and neoplastic causes. [6][7][8][9] MethOds And MAteRiAls Study population After obtaining institutional review board approval, a retrospective review was undertaken of cases of epistaxis that underwent endovascular management from September 2010 to January 2016. All patients are routinely followed up for 12 months. ...
... days post-embolization. 9,12,14 Pre-embolization ligation 17.8% of cases failed surgical ligation and we prefer patients not to have SPA ligation prior to embolization as the target tissue arterioles may not be accessed directly by PVA if ligation antedates the procedure. Only three endovascular series include ligation failures which comprised 8.0-11.4% of subjects. ...
Objective:
Embolization is a treatment option for intractable epistaxis, however concerns regarding tissue necrosis, stroke and blindness persist in the literature.
Methods:
A retrospective review of patients from September 2010 - January 2016 treated with embolization for epistaxis was performed. No patient was excluded. Followup was 12 months and no patient was lost.
Results:
62 embolizations on 59 patients occurred. 21 cases were taking anticoagulants, P2Y12 inhibiting agents or had a systemic coagulopathy. Embolized territories typically involved bilateral distal internal maxillary arteries with unilateral or bilateral facial arteries with polyvinyl alcohol particles. 60 cases had procedural general anesthesia. There were no major complications. 6 died of unrelated causes. Of the surviving 53 patients, excluding the 3 patients with hereditary hemorrhagic telangiectasia, 5 had recurrent epistaxis post embolization. Four were taking P2Y12 inhibiting and/or anticoagulants, none of which required surgery, prolonged packing or repeat embolization. This group had a propensity to recur compared to cases taking aspirin only or no antiplatelet/anticoagulant (77.8% vs 97.1%, p=0.04). The fifth underwent repeat embolization after previously only having ipsilateral distal internal maxillary and facial arteries treated.
Conclusion:
Embolization for epistaxis is safe and effective. Of those who had recurrent epistaxis post embolization, most were taking P2Y12 inhibition and/or anticoagulation. We prefer bilateral distal internal maxillary artery and unilateral facial artery embolization under general anesthesia for optimal safety and efficacy. Advances in knowledge: Embolization with this technique seems to facilitate superior outcomes without complications despite the large proportion of patients taking anticoagulating or P2Y12 inhibiting agents.
... to 25%. [1,2] Cranial nerve palsies, stroke and blindness are among those reported [3,4]. ...
... Embolization of head and neck tumours facilitates surgery by reducing intra-operative bleeding thus allowing better visualization. However, reflux or passage of embolic materials through the ECA-ICA anastomoses has been responsible for devastating complications [1][2][3][4]. ...
Background
Embozene® is a new neuroembolizing microsphere used to reduce intraoperative bleeding for head and neck tumours. We report a case of iatrogenic ophthalmic artery occlusion after Embozene® embolization of the external carotid artery (ECA).
Case presentation
A 22-year-old African gentleman presented with left nasal obstruction and epistaxis for 2 years and was diagnosed with nasopharyngeal carcinoma. He subsequently underwent embolization of the maxillary branch of the left ECA using Embozene® Microspheres - 250 μm in size before endoscopic tumour excision to reduce intra-operative bleeding. He complained of sudden painless profound visual loss in the left eye (LE) two hours after embolization. Visual acuity in LE was no light perception. Fundus examination showed pale retina with no cherry red spot. Arterial narrowing and segmentation were seen in all quadrants. A diagnosis of left ophthalmic artery occlusion was made. Despite immediate management including ocular massage and lowering of intraocular pressure, the visual loss remained. Retrospective review of digital subtraction angiogram showed an anastomosis between the left ophthalmic artery and anterior deep temporal artery as a potential route for microspheres migration.
Conclusion
Pre-operative angio-architecture understanding and diligent selection of embolic material are helpful in preventing this adverse event. The use of newer agents for embolotherapy may cause migration of embolic material from the external to the internal carotid system leading to ophthalmic artery occlusion and blindness.
... Endovascular particle embolization for head and neck tumors and epistaxis management 1 is a safe, efficacious and well established procedure. [2][3][4][5][6][7][8] Two categories of particles are commonly used: polyvinyl alcohol (PVA) (old generation, irregular shape) and hydrogel microsphere (new generation, spherical) particles. We report here ischemic complications that unexpectedly occurred at the level of cranial nerves, skin and mucosa during head and neck embolization procedures using microsphere particles and we review some of the particle characteristics that could explain these complications. ...
... Early reports of clinical complications 14,15 and death 16 in head and neck applications were thought to be related to impurity in particle size 12 (with smaller size particles infiltrated in PVA preparations). Manufacturers have since improved the sieving process and the uniformity of now commercially available products was demonstrated by Derdeyn et al. 12 The safety profile of this embolization agent since its industrial refinement is reflected in the literature [4][5][6]17 and translated to daily routine in neuro-interventional practice. Morbid complications (stroke, loss of vision, cranial nerve paresis, necrosis of the parotid gland and soft tissue necrosis including nasal ala, buccal mucosa, hard palate and facial skin) 18 are the most feared complications but they remain rare occurrences as reviewed by Sadri et al. 19 They are thought to occur secondary to particle embolization to the internal carotid artery territories via internal/external carotid arterial anastomoses. ...
Endovascular particle embolization is a common procedure with a relatively safe profile. We report here four cases in which cranial nerves, skin and mucosal ischemic complications occurred with the use of hydrogel microspheres (250–500 µm in size). Given the compressibility and higher penetration potential of microsphere particles compared with polyvinyl alcohol particles of similar size, we suggest oversizing hydrogel microsphere particles for head and neck embolizations.
... As complicações da embolização arterial são classificadas em maiores ou menores, ocorrendo em 17% a 25% dos casos 9,12 . As complicações menores são dor ou parestesia facial, cefaléia e edema facial, que geralmente se resolvem na primeira semana. ...
... Em nosso estudo o paciente apresentou uma lesão extensa de asa nasal com fistulização para sulco gengivolabial e fístula oronasal em palato duro. Tseng et al. 12 e Elden et al. 9 publicaram as maiores casuísticas de complicações decorrentes da embolização arterial. Segundo estes autores, a incidência de lesões cutâneas foi menor que 1%, sendo que em nenhum caso houve lesão cutânea mucosa extensa semelhante àquela apresentada neste relato. ...
Epistaxe é uma afecção muito comum, sendo geralmente autolimitada ou tratada com medidas mais conservadoras como compressão local, compressas frias, controle da pressão arterial, cauterização sob anestesia local (química ou termo-elétrica) ou tamponamento nasal anterior. Contudo, podem se apresentar como quadros graves e de difícil tratamento, sendo necessárias medidas mais agressivas como tamponamento nasal antero-posterior, ligadura arterial cirúrgica ou embolização. Apresentamos o caso de um paciente de 49 anos de idade que cursou com epistaxe de difícil controle e evoluiu com uma grave complicação relacionada ao tratamento realizado em outro serviço.
... Las complicaciones neurológicas mayores incluyen ACV, pérdida visual y paresia del nervio facial, pudiendo resultar de la ruptura de una placa durante la angiografía o por reflujo de las partículas a la carótida interna u anastomosis entre ambos sistemas carotídeos. (4,5) La tasa de complicaciones reportada por la bibliografía es de 25-59% para las menores transito- rias, 0-1% para las mayores transitorias y menor al 2% de persistentes. En nuestra serie las complicaciones atribuibles a la angioembolización son de 22%, comparables con las reportadas en la literatura general. ...
Resumen Introducción: Las complicaciones del tratamiento endovascular son infrecuentes. Las lesiones isqué-micas a los tejidos de la cabeza y el cuello se han reportado de forma esporádica, siendo complica-ciones raras gracias al aporte redundante de la am-plia red anastomótica en esta región. Objetivos: Realizar una análisis estadístico de los pacientes que se sometieron a tratamiento endo-vascular por epistaxis, identificando las complica-ciones, y realizar una revisión comparada con la literatura disponible evaluando la efectividad del tratamiento. Material y método: Se realizó una búsqueda en las historias clínicas de todos los pacientes a los que se les realizó tratamiento endovascular por epistaxis desde junio de 2008 hasta septiembre de 2017 en el Hospital Italiano de Buenos Aires. Los criterios que se tomaron en cuenta para incluirlos fueron pacien-tes tratados con terapia endovascular por epistaxis posterior, con o sin tratamiento médico (taponaje) y/o quirúrgico previo entre junio de 2008 y septiem-bre de 2017. Se excluyó a pacientes con diagnóstico de enferme-dad de Rendu Osler Weber (HHT). Resultados: Del total de los pacientes que fueron sometidos a tratamiento endovascular solo 5 (22%) sufrieron complicaciones, de carácter leve y transi-torio. Todos los pacientes resolvieron la complica-ción del tratamiento endovascular con tratamiento y control médico en un plazo menor a los 30 días. Conclusiones: La embolización transarterial es un tratamiento efectivo y seguro para la epistaxis in-(1) Médicos residentes. tratable cuando es refractaria al tratamiento conser-vador o existen impedimentos para el tratamiento quirúrgico bajo anestesia general. Abstract Introduction: Complications of endovascular treatment are infrequent. Ischemic injuries to the tissues of the head and neck have been reported sporadically, being rare complications thanks to the redundant contribution of the extensive anastomo-tic network in this region.
... 22,23 It is imperative that the practitioner has a thorough fund of knowledge in head and neck anatomy, the relationship of relevant structures, and hemodynamics to reduce risks of these complications; in experienced hands, interventions in the supply of the external carotid artery carry a major complication rate of less than 2%. 24,25 ...
Objectives The aim of the study is to evaluate the effect of preoperative vascular embolization (PVE) on juvenile nasopharyngeal angiofibroma (JNA) surgical outcomes using a national pediatric hospitalization database.
Methods The health care cost and utilization project Kids' Inpatient Database was queried for all cases of operative management of JNA between the years of 1997 and 2016. Cases were stratified based on whether the patient received PVE. A multiple linear regression was used to predict the effect of PVE on hospital length of stay (LOS) and total cost while controlling for patient demographic factors and comorbidities. The odds ratio (OR) of receiving a perioperative blood transfusion was computed using a binary logistic regression for PVE patients.
Results A total of 473 patients who underwent JNA surgical resection in this time period were identified. The use of PVE has increased from 0% in 1997 to 66% of all cases by 2016. PVE was found to decrease LOS by 1 day (p = 0.036) and decrease the odds of needing a perioperative blood transfusion (OR = 0.511, p = 0.041). Patients receiving PVE were charged an additional $35,600 (p < 0.001), but recent data in 2016 indicate that hospital costs for PVE are decreasing.
Conclusion PVE of JNA is becoming increasingly prevalent. Embolization results in decreased hospital LOS and lower odds of needing blood transfusions. While embolization increases the cost of management, this trend should be re-evaluated as this procedure is becoming more widespread.
... The embolization procedure varies according to the centre in the vessels embolized and the embolic material used. Regarding the vessels embolized, authors report embolizing any combination of the ipsilateral IMAX, bilateral IMAX, ipsilateral or bilateral Facial Artery (FA) [5]. Several authors have noticed an inverse linear relationship between the number of vessels embolized and the incidence of recurrent bleeding, but have also noticed a linear relationship between the number of vessels embolized and the incidence of minor complications [3]. ...
... Minor complications included those that were transient, including facial pain, headaches, mental confusion, paresthesia, jaw pain, groin pain, numbness, and facial edema. 8,9 Statistical Analysis For the comparison of categorical variables, v 2 tests were performed. For the comparison of continuous variables, Student's t tests were performed. ...
Background
Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and selective embolization both provide excellent treatment success rate in the management of intractable epistaxis. Few long-term studies comparing these approaches have been previously published. Recommendations often present these techniques as alternatives, but there is no clear consensus.
Objective
The purpose of this study was to evaluate and compare the clinical efficacy of sphenopalatine artery ligation versus embolization to control intractable epistaxis.
Methods
We performed a retrospective study including all patients referred to our tertiary medical center for severe epistaxis and treated by surgical ligation and/or embolization. The patients were classified into 2 groups: those who underwent TESPAL only and those who underwent endovascular embolization only. We evaluate and compare long-term clinical outcomes after surgical ligation or embolization for the control of intractable epistaxis in terms of effectiveness (recurrence rate) and safety (complication rate).
Results
Forty-one procedures of supraselective embolization and 39 procedures of surgical ligation for intractable epistaxis are reported and analyzed. No significant difference was observed between the groups in terms of demographic factors, comorbidities, or average length of hospital stay. The 1-year success rate was similar (75%) in both groups. Complications (minor and/or major) occurred in 34% cases in the embolization group and in 18% in the surgical group ( P = .09, ns). Bilateral embolization including facial artery was the only treatment method associated with a significant risk of complications ( P = .015).
Conclusion
TESPAL seems to provide a similar control rate with a decrease in the number of complications compared to selective embolization in the context of intractable epistaxis. Further studies are required.
... Angiographic embolization is becoming more common and the result is about 90 percent successful rate. 8,9 However, there are 4percent rate of severe complications like stroke and blindness with embolization. 10 In this case study, we were unable to detect any obvious causes that may lead this patient to have an anterior nasal airway spontaneous intractable epistaxis episodes besides his prior engagement in vaping habit. ...
p>Epistaxis although is a common presentation that seldom require surgical intervention, it is still consider as an emergency. We report a case of 26 years old gentleman with atraumatic intractable anterior epistaxis after recent history of vaping. Purpose of this case report is to highlight the flow of management of anterior epistaxis. We provide a literature review for the sequence of actions for the management of anterior epistaxis and also a discussion on association between vaping habit and epistaxis.
J MEDICINE January 2017; 18 (1) : 44-46</p
Trotz hoher Erfolgsrate und niedriger Komplikationsrate der arteriographischen Embolisation bei der Nasenblutung kommt diese Behandlungsmethode in vielen Institutionen nicht als Standard-Maßnahme im klinischen Kontext zum Einsatz und wird nur als alternativ im Falle eines Scheiterns der chirurgischen arteriellen Clippung in der Blutstillung eingesetzt. In der vorliegenden retrospektiven Arbeit wurden am Kopf- und Schädelbasiszentrum des Klinikums Fulda die Effizienz und die Sicherheit der perkutanen Embolisation der A. sphenopalatina mit Polyvinylalkohol-Partikeln (150-250 µm) in der Behandlung, der mit konservativen Maßnahmen refraktären Epistaxis untersucht. Methode: Retrospektive Analyse von 99 Patienten, die von Januar 2001 bis Dezember 2018 bei refraktärer, idiopathisch klassifizierter Epistaxis durch eine arteriographische endovaskuläre Embolisation behandelt wurden. Ergebnisse: Es wurden innerhalb des Berichtszeitraums insgesamt 100 Embolisationen bei Epistaxis durchgeführt. Nach Ausschluss von 2 Prozeduren mit bekannten Blutungsursachen wurden 98 Embolisationen bei 95 Patienten mit idiopathischer Epistaxis ausgewertet. Trotz technisch erfolgreicher Intervention in 95% der Fälle, war die Blutung in 81,6% der Fälle zu stillen. Leichte Komplikationen traten in 5% der Fälle auf. Schwere Komplikationen dagegen wurden in keinem einzigen Fall erfasst. Schlussfolgerung: Das Ergebnis dieser Untersuchung bestätigt die Rolle der angiografischen Embolisation der A. sphenopalatina sowohl als einer erfolgreichen, als auch als einer sicheren Methode in der Behandlung der konservativ refraktären Epistaxis. Aufgrund der geringen Invasivität, hohen Erfolgsrate und niedrigen Komplikationsrate sollte die transkutane Embolisation als Standard-Therapie nach dem Scheitern der konservativen Maßnahmen zur Blutstillung einer Epistaxis zum Einsatz kommen. Die chirurgische Blutstillung durch die arterielle Clippung sollte nur im Falle eines Misserfolgs der Embolisation als Verfahren der zweiten Wahl bei der Blutstillung eingesetzt werden.
The protocols for managing intractable idiopathic epistaxis have evolved with advances in endoscopic techniques. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) has been the treatment of choice for idiopathic intractable epistaxis. If TESPAL fails, transantral ligation of internal maxillary artery (IMA) used to be the dictum along with radiological interventions. Here we discuss about the role of endoscopic IMA ligation in cases of failed TESPALs. Retrospective study at a tertiary hospital was performed. 28 cases of intractable idiopathic epistaxis underwent TESPAL in our institution of which 2 cases had rebleed. We also had two referred cases of failed TESPALS. Of this 4 patients, three patients underwent endoscopic IMA ligation and one patient underwent selective embolisation. All the patients who underwent endoscopic IMA ligation for failed TESPAL had no further episodes of epistaxis. One patient who underwent selective embolization also had no further episodes of bleed but had transient facial pain and trismus. When TESPAL fails, endoscopic IMA ligation can be considered as an alternative procedure before resorting to embolization.
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.
Objectives
Trans‐nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost‐saving strategy. Our main aim was to perform cost‐effectiveness analyses on TESPAL compared to embolisation to treat patients with epistaxis.
Design
We performed a retrospective, monocentric, comparative analyses on patients referred to our center and treated with embolisation or TESPAL.
Setting
This economic evaluation was carried out from a payer's perspective (i.e., French National Health Insurance) within a time horizon of 12 months.
Participants
Thirty‐seven TESPAL procedures and thirty‐nine embolisation procedures to treat intractable epistaxis were used in the analyses.
Main outcome measures
The primary outcome is presented as the cost per 1% of non‐recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1‐year follow‐up. Cost estimates were performed from the payer's perspective.
Results
Hospitalisation costs were higher for embolisation compared to TESPAL (5,972 vs. 3,769 euros). On average, hospitalization costs decreased by 41% when a patient was treated by TESPAL compared to an embolisation strategy (p= 0.06). The presence of comorbidities increased hospitalization costs by 79% (p=0.04). TESPAL enabled 1,867€ to be gained in intractable epistaxis.
Conclusions
The outcomes from our decision model confirm that TESPAL is more cost‐effective for patients with intractable epistaxis.
This article is protected by copyright. All rights reserved.
Radionecrosis is a feared complication after high‐dose radiation therapy (RT) of head and neck squamous cell cancer (HNSCC).
The aim of our retrospective study on 37 HNSCC patients was to evaluate the performance of different (18F)fluoro‐deoxy‐D‐glucose (FDG) positron emission tomography (PET) / computed tomography (CT) parameters for distinguishing radionecrosis and tumor persistence/recurrence.
Histopathological work‐up revealed osteoradionecrosis in 21/37 (57%) patients, chondroradionecrosis in 8/37 (21.5%) patients and tumor persistence/recurrence in 8/37 patients (21.5%).
Presence of a permeative growth pattern may identify tumor recurrence/persistence and rule out radionecrosis in HNSCC patients after RT (accuracy: 100%).
With similar high accuracy (accuracy: 99%), the combination of a low SUVmax, location of the hottest voxel inside bone/cartilage and the presence of a pathological fracture independently predicts radionecrosis.
This article is protected by copyright. All rights reserved.
Though most authors agree that TESPAL (transnasal endoscopic sphenopalatine artery ligation) should be considered in case of epistaxis resistant to nasal packing, there is no consensus on the indication for a unilateral/bilateral procedure.
In this retrospective study of 83 patients with spontaneous intractable unilateral spontaneous epistaxis, we compared the outcomes of unilateral (n=36) vs bilateral (n=47) TESPAL.
The main outcome was failure, defined as bleeding recurrence requiring another therapeutic procedure under general anaesthesia.
The success rate was higher with bilateral TESPAL (91.5%) than with unilateral TESPAL (75%), without any major complication (p=0.041).
This retrospective study supports the rationale for bilateral rather than unilateral TESPAL, and paves the way for further prospective studies.
This article is protected by copyright. All rights reserved.
Juvenile nasopharyngeal angiofibroma (JNA) is a hypervascular tumor and uncontrolled hemorrhage makes its removal very difficult. Although preoperative intravascular embolization of a feeding artery is recommended, serious complications such as iatrogenic thrombosis in the brain and insufficient decrease in blood flow to the tumor are concerns. Recently, coblation plasma technology has been reported to be useful for tumor removal with minimum hemorrhage under a clear surgical field. Here we report successful removal of advanced JNA without preoperative embolization, using intraoperative ligation of the maxillary artery and coblation plasma technology. The left nasal cavity of a 23-years-old man was closed by a JNA tumor at Radkowski stage IIC, which was 65mm in size and extended from the nasal cavity to the infratemporal fossa. MRA imaging showed the maxillary artery running along the posterior wall of the maxillary sinus. Therefore, the maxillary artery was first clipped using an endoscopic modified medial maxillectomy (EMMM) approach and endoscopic endonasal en bloc resection of the tumor was then completed using coblation technology with no need for blood transfusion. This case illustrates that preoperative embolization is dispensable in JNA surgery even at Stage IIC if the maxillary artery can be ligated during surgery and a coblation device can be utilized.
Extracranial embolization procedures which are therapeutic endovascular occlusions of vessels outside the cranial cavity are discussed in this chapter. This chapter covers transarterial embolization procedures for head and neck tumors, arteriovenous fistulas and bleeding, percutaneous sclerotherapy and embolization procedures, and spinal embolization for arteriovenous fistulas and malformations.
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.
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.
Résumé
Objectif
Les auteurs exposent les recommandations de la Société française d’oto-rhino-laryngologie et de chirurgie de la face et du cou (SFORL) concernant la prise en charge des épistaxis en deuxième intention, c’est-à-dire après échec du tamponnement antérieur et/ou du tamponnement antéro-postérieur.
Méthodes
Un groupe de travail multidisciplinaire a été chargé d’effectuer une revue de la littérature scientifique sur la thématique étudiée. À partir de ces textes et de l’expérience de chacun, des recommandations ont été rédigées, puis relues par un groupe de lecture indépendant du groupe de travail. Une réunion de synthèse a permis d’aboutir au texte final. Les recommandations proposées ont été classées en grade A, B, C ou accord professionnel selon un niveau de preuve scientifique décroissant.
Résultats
Il est recommandé que l’embolisation artérielle soit effectuée par un neuroradiologue expérimenté disposant d’un plateau technique dédié et du matériel adapté afin de limiter le risque de complications. Il est recommandé d’effectuer une angio-TDM du crâne et des TSA avant embolisation dans le cas d’une épistaxis post-traumatique avec suspicion de lésion de l’artère carotide interne. En cas d’épistaxis persistante malgré l’hémostase endoscopique sphéno-palatine, il est recommandé d’effectuer l’hémostase de l’artère ethmoïdale antérieure par voie canthale interne, avec éventuellement une progression assistée par l’endoscope. Il est recommandé en cas d’épistaxis résistante aux procédures chirurgicales et neuroradiologiques habituelles d’effectuer une exploration chirurgicale des fosses nasales et de l’ethmoïde, avec une coagulation élective en cas de saignement en provenance d’une branche artérielle secondaire, voire une ethmoïdectomie en cas de saignement non systématisé. Un arbre décisionnel a été élaboré pour orienter la stratégie thérapeutique de prise en charge d’une épistaxis en deuxième intention.
Objectives:
The authors present the guidelines of the French Oto-Rhino-Laryngology - Head and Neck Surgery Society (Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou: SFORL) on second-line treatment of epistaxis in adults, after failure of anterior and/or anterior-posterior nasal packing.
Methods:
A multidisciplinary work group was entrusted with a review of the scientific literature on the above topic. Guidelines were drawn up, based on the articles retrieved and the group members' individual experience. They were then read over by an editorial group independent of the work group. The final version was established in a coordination meeting. The guidelines were graded as A, B, C or expert opinion, by decreasing level of evidence.
Results:
Arterial embolization should be performed by an experienced interventional neuroradiologist with adequate technical facilities, to reduce the risk of complications. Cerebral and supra-aortic vessel CT angiography should be performed in case of post-traumatic epistaxis with suspected internal carotid injury. In case of persistent bleeding despite endoscopic hemostasis of the sphenopalatine artery, anterior ethmoidal artery hemostasis should be performed via a medial canthal incision, with endoscopic assistance as needed. In case of persistent epistaxis despite the usual surgical and neuroradiological procedures, surgical exploration of the sinonasal cavities should be performed, with elective coagulation in case of bleeding from secondary branches, and/or ethmoidectomy in case of diffuse bleeding. A decision-tree was drawn up for the management of second-line treatment of epistaxis.
Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be controlled by local or systemic measures. Detailed knowledge of the head and neck vascular anatomy, advances in catheterization techniques, and the availability of new embolic materials have improved the safety, efficacy, and predictability of these procedures. To improve patient safety, the oral and maxillofacial surgeon must be familiar with these techniques.
This section provides a comprehensive procedural report for Endovascular Management of Epistaxis procedure with up-to-date explanatory notes, synopsis of the indications and contraindications, and potential complications in an organized and practical format.
Epistaxis is common. At least 60% of us will have episodes of nose bleeding at some time [2]. These occur with peak incidences in children (<10 years) and older adults (>50 years). Only 6% of episodes require medical treatment, and these are usually in the older age group. Bleeding can arise from veins, arteries or arterialised veins (e.g. associated with a vascular malformation or an arteriovenous shunt). Most episodes are idiopathic, though epistaxis in adults is frequently associated with systemic hypertension and other medical comorbidities.
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
The vast majority of epistaxis episodes are self-limiting events.
■ When anterior epistaxis takes origin from Kiesselbach’s plexus, cauterization with the aid of a headlight or loupes under local anesthesia can be easily performed.
■ In anterior epistaxis from the anterior ethmoid artery (AEA) and posterior epistaxis from the posterior ethmoidal artery (PEA) or the sphenopalatine artery (SPA), nasal packing should be used only as a temporary measure in order to appropriately plan the next therapeutic step.
■ An endoscopic approach under general anesthesia is always warranted as first-line surgical treatment. Arterial embolization and open-field ligation should be reserved only for cases of failure of appropriate endoscopic attempts or for patients with contraindications to an endoscopic approach.
■ In posterior epistaxis, SPA should be addressed first and, only in case of inadequate bleeding control, the AEA and PEA should be subsequently coagulated.
■ In anterior epistaxis, the first surgical step should be AEA coagulation, followed by SPA and PEA cauterization only in where there is insufficient control of epistaxis.
■ In hereditary hemorrhagic teleangiectasia (HHT) syndrome (Rendu-Osler-Weber syndrome), aggressive nasal packing should be always avoided in order to minimize mucosal trauma.
■ In HHT, endoscopic photocoagulation with different types of laser under local or general anesthesia is a costeffective therapeutic tool that is associated with minimal morbidity.
L’épistaxis, écoulement sanglant provenant des fosses nasales, est une pathologie fréquente et bénigne dans l’extrême majorité des cas et qui ne nécessite pas de prise en charge médicale. Cependant, elle peut devenir une véritable urgence médico-chirurgicale de par son abondance, sa répétition ou la fragilité du terrain (patients coronariens par exemple). Les épistaxis peuvent être essentielles ou symptomatiques d’une affection sous-jacente. Il faut devant une épistaxis, résoudre quatre problèmes : la reconnaître, notamment ne pas méconnaître une épistaxis déglutie ou une hémorragie d’origine veineuse qui n’est pas du ressort de la radiologie interventionnelle ; en préciser l’abondance et le retentissement, notamment comme facteur de décompensation d’une autre pathologie ; en rechercher l’étiologie et en particulier ne jamais méconnaître une tumeur (adolescent masculin) ; assurer l’hémostase. Les épistaxis sont non seulement de nature et d’étiologies différentes, mais elles doivent être abordées selon le contexte clinique. L’embolisation artérielle est le traitement de choix des épistaxis graves et réfractaires et de certaines hémorragies de la sphère ORL. Réalisée par des opérateurs entraînés, c’est une méthode efficace et présente peu de risque de complications ; son utilisation dans les centres référents est croissante dans le temps (Brinjikji et al., 2013). Toutefois, elle reste une méthode moins employée que la chirurgie, notamment aux États-Unis où sur un échantillon de 69 410 patients traités sur les dix dernières années pour une épistaxis réfractaire, 92,6 % ont bénéficié d’une ligature chirurgicale, 6,4 % d’une embolisation et 1 % d’un traitement combiné (Brinjikji et al., 2013). Parfois les épistaxis sont cataclysmiques et nécessitent une prise en charge en extrême urgence. Dans tous les cas, la collaboration étroite avec le service de chirurgie ORL, la présence d’un anesthésiste réanimateur, et au minimum une sédation sont autant de facteurs d’amélioration de la prise en charge et donc des résultats de l’embolisation. Tous les patients et/ou leur entourage auront bénéficié d’une information « loyale, claire et appropriée ».
Epistaxis is defined as flow of blood from the nasal fossae and is a common and benign disorder in the great majority of cases which does not require medical care. It may however become a genuine medical or surgical emergency because of the amount, repeated episodes or patient's medical vulnerability (such as coronary artery disease patients). Epistaxis may be either primary or a symptom of an underlying disease. Four levels of problems need to be answered faced with epistaxis: recognizing it, and in particular not missing "epistaxis" due to swallowed blood or venous hemorrhage, which falls outside of the scope of interventional radiology; establishing the amount and its repercussions, particularly as a decompensating factor in another disease; investigating its cause and in particular never missing a tumor (male adolescents); obtaining hemostasis. Epistaxis varies not only in type and cause but must be considered in its clinical context. Arterial embolization is a treatment of choice for severe refractory epistaxis and some hemorrhages. When carried out by trained operators, it is an effective method with few risks of complications and is increasingly being used in reference centers (Brinjikji et al.). It remains, however, a method which is less widely used than surgery, particularly in the United States where in a series of 69,410 patients treated over the last 10 years for refractory epistaxis, 92.6% underwent surgical ligation, 6.4% embolization and 1% combined treatments (Brinjikji et al.). Epistaxis is occasionally catastrophic and requires extremely urgent management. In each case, close collaboration with the surgeon, the presence of an intensive care anesthetist and at least sedation are all factors which improve management and therefore the results of embolization. All patients and/or their friends/close family should have given "reliable, clear and appropriate" information.
Extracranial embolization procedures are therapeutic endovascular occlusions of vessels outside the cranial cavity. This chapter covers head and neck transarterial embolization procedures, percutaneous procedures, and spinal embolization.
Epistaxis usually responds to conservative therapy such as nasal packing or electrocauterization. But sometimes more invasive techniques such as selective embolization is justified. We report our experience of 10 patients with selective endovascular embolization for refractory 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.
Patients undergoing neurosurgery or neurointerventional
procedures require constant ohservation and assessment by
nurses with specialised skills in neuroscience nursing. While
many patients require intensive care admission there are
certain groups of patients that may be safely managed within
a neurosurgical step-down unit.
Our institution is unique within NSW having for many years
maintained a specialised neurosurgical intensive care unit
with its own staff of neurosurgical ICU nurses. Over the
years, the complexity of patients admitted to that unit
continued to increase along with the demand for the service.
After a proposal for a neurosurgical step-down unit was
accepted by the health service executive we began planning
for that unit. This involved nursing, medical, and allied health
staff from both the neurosurgical intensive care unit and
ward. This paper will outline the development process and
describe the step-down unit model of care including the types
of patients admitted, their length of stay, the pros and cons of
the model and plans for the future.
Among the major complications of transsphenoidal surgery, less attention has been given to severe postoperative epistaxis, which can lead to devastating consequences. In this study, we reviewed 551 consecutive patients treated over a 4year period by the senior author to evaluate the incidence, risk factors, etiology and management of immediate and delayed post-transsphenoidal epistaxis. Eighteen patients (3.3%) developed significant postoperative epistaxis - six immediately and 12 delayed (mean postoperative day 10.8). Fourteen patients harbored macroadenomas (78%) and 11 of 18 (61.1%) had complex nasal/sphenoid anatomy. In the immediate epistaxis group, 33% had acute postoperative hypertension. In the delayed group, one had an anterior ethmoidal pseudoaneurysm, and one had restarted anticoagulation on postoperative day 3. We treated the immediate epistaxis group with bedside nasal packing followed by operative re-exploration if conservative measures were unsuccessful. The delayed group underwent bedside nasal hemostasis; if unsuccessful, angiographic embolization was performed. After definitive treatment, no patients had recurrent 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-cmPope 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 3.62.2 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.
(13) (PDF) Chitosan Nasal Packing For Recalcitrant Epistaxis. Available from: https://www.researchgate.net/publication/264636078_Chitosan_Nasal_Packing_For_Recalcitrant_Epistaxis [accessed Apr 13 2020].
Raccomandazioni cliniche sulla gestione delle epistassi. Documento finale dei lavori della Consensus Conference tenutasi a Rimini il 14 maggio 2009 nell'ambito del 96°
Introduction Intractable hemorrhage of the nasal or oropharyngeal cavities can be life threatening, and endovascular embolization is one of the few effective treatments for severe recurrent bleeds. Traditionally, embolic particles have been used for transarterial embolization.
Objective To investigate the safety and efficacy of a less commonly performed treatment—namely, feeding artery occlusion with liquid embolic agents.
Methods We retrospectively reviewed our neurointerventional database for patients who had undergone transarterial embolization for intractable nasal and oropharyngeal hemorrhage with Onyx, N-butyl-2 cyanoacrylate (n-BCA) glue, or both, at our institution over a 5-year period from 2008 to 2013.
Results Forty-six patients who underwent a total of 51 procedures met the inclusion criteria. Causes of hemorrhage included neoplasm n=35 (68.6%), trauma n=12 (23.5%), and idiopathic n=4 (7.9%). The bleeding was oropharyngeal in 66.7%, nasal in 29.4%, and 3.9% originated from both sites. Embolic agents used were n-BCA in 26 cases (51.0%), Onyx in 22 cases (43.1%), and both agents in three cases (5.9%). Mean total procedural time was 93.1 min (range 34–323 min), and mean fluoroscopy time was 39.1 min (10– 121 min). Mean follow-up time was 7.4 months (0.25–36 months). Five of the 46 patients (10.9%) required re-embolization and one (2.0%) rebled during the same hospital stay. One periprocedural cardiovascular adverse event occurred that was unrelated to the embolic agent used, but no other complications were seen.
Conclusions Transarterial embolization with n-BCA or Onyx is a safe and effective treatment for patients with intractable nasal and oropharyngeal hemorrhage. Further prospective studies are warranted to confirm these findings.
Whilst it is generally accepted that the standard management for anterior or benign epistaxis is either cautery or anterior nasal packing, that of posterior or intractable epistaxis remains controversial. Various modalities of treatment, ranging from posterior nasal packing to arterial ligation and embolization, have been advocated but none have been unanimously accepted as the treatment of choice.
The purpose of this paper was to determine the efficacy of internal maxillary arterial ligation versus combined internal maxillary arterial ligation and anterior ethmoid arterial coagulation in intractable epistaxis.
Over a six year period, from 1985 to 1990,454 patients were admitted and treated for epistaxis. Forty-seven patients were diagnosed as having intractable epistaxis on the basis that the epistaxis failed to settle on anterior nasal packing. They were moved to the next step in management, which was combined anterior and posterior nasal packing. There were 30 failures, one was found to have choriocarcinoma of the maxilla, and was treated wtih cytotoxics, and the other 29 were moved to the next step, which was arterial ligation. Fifteen patients had internal maxillary arterial ligation, and 14 combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation.
Large windows were created in both the anterior and posterior walls of the maxillary sinuses and all identifiable branches of the internal maxillary artery were dissected out carefully and two medium size ligating clips were placed over the main trunk, the sphenopalatine and the descending palatine branches. Single clips were placed on all other identifiable branches. Coagulation of the anterior ethmoidal artery was performed with a bipolar cautery. There were three (20 per cent) failures in the internal maxillary arterial ligation group and none in the combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation group. Furthermore, the three failures were successfully treated with anterior ethmoidal arterial coagulation. The conclusion is that combined internal maxillary and anterior ethmoidal arterial occlusion is the treatment of choice in intractable epistaxis.
The contents of this book are: Arterial Anatomy: Introduction. - The Internal Maxillary System. - The Pharyngo-occipital System. - The Upper Cervical Vertebral Column: The Cervical Arteries. - The Musculocutaneous Elements of the Head and Mouth. - Thyrolaryngeal Arteries. - The Transosseous Peripheral Nervous System Arterial Supply. - Dangerous Vessels. - Collateral Circulation. - The Pharyngoocipital Collateral Pattern. - The Internal Maxillary Collateral Pattern. - The Linguofacial Collateral Pattern. - Multiple Constraints and Chronology of the Collateral Response. - Angiographic Protocols. - Angiographic Protocol of the Parasellar Region. - Angiographic Protocol of the Posterior Base of the Skull. - Angiographic Protocol of the Carotid Region. - Angiographic Protocol of the Nasomaxillaary Region. - Angiographic Protocol of the Maxillomandibular Region. - Angiographic Protocol of the Temporofacial and Scalp Region. - Angiographic Protocol of the Thyrolaryngeal Region. - References. - Subject Index.
• Epistaxis that originates from the posterior aspect of the nasal cavity is most often due to hemorrhage from one of the branches of the internal maxillary artery. There are multiple methods of treatment of this problem that vary in effectiveness, complexity, and stress on the patient. Most cases are controlled with either packing or surgical arterial ligation, but occasionally patients either cannot tolerate this therapy or continue to hemorrhage. We describe ten patients who were referred to the Neuroradiology Section of the Massachusetts General Hospital from the Massachusetts Eye and Ear Infirmary for angiography and embolization of the internal maxillary artery for epistaxis.
(Arch Otolarygol 105:333-337, 1979)
Epistaxis which is not controlled by anterior and posterior nasal packing is usually treated by ligation or embolization of the arterial supply to the nose. Transantral ligation of the maxillary artery, or embolization of its branches, have recently been considered the treatments of choice. Ligation of the external carotid artery has the advantage of being a short procedure which can be readily performed under local anesthesia, and does not require particular surgical expertise or the use of specialized equipment. This procedure, in combination with ligation of the ipsilateral anterior ethmoidal artery, controlled the bleeding in 14 of 15 patients over a nine-year period. There were no deaths and no significant complications. Although ligation and embolization of the maxillary artery are of proven efficacy, ligation of the external carotid artery is similarly effective and its simplicity may still make it the procedure of choice in some situations.
Thirty patients with intractable idiopathic epistaxis were treated with endovascular therapy. Embolization of the internal maxillary artery controlled the epistaxis in 87% of the patients, and the success rate was increased to 97% after supplemental embolization of the facial artery. The only complication observed was transient postembolization hemiparesis, which occurred in one of the 30 patients. Intractable idiopathic epistaxis is defined as epistaxis of unknown cause that is refractory to nasal packing. Such epistaxis is commonly treated with surgical intervention, including ligation of the terminal segments of the internal maxillary artery and the ethmoid arteries. An alternative approach is performance of endovascular therapy. In our opinion, embolization is a safe and effective procedure when it is carried out by appropriately trained personnel. In most patients, its performance requires use of only neuroleptanalgesia; surgery can be avoided, and the duration of hospitalization is significantly shortened. We recommend that embolization be adopted as the primary modality for the treatment of idiopathic intractable epistaxis.
A 15-year-old boy underwent neuroradiologic embolization of the left internal maxillary artery with polyvinyl alcohol to stop traumatic epistaxis after failure of surgical clipping and nasal packing. Selective catheterization of the external carotid artery before embolization showed a faint choroidal blush. Although the procedure provided hemostasis, embolization to the central retinal artery and ciliary arteries resulted in loss of vision. The route of the emboli to the eye was via the anastomotic network of the lacrimal artery supplied by the external carotid artery system. Neuroradiologic embolization of the external carotid artery is an effective mode of therapy for dural-cavernous fistulas when fed by the external carotid artery system. Because the blood flow to the brain and eye is predominantly supplied by the internal carotid artery, embolization of the external carotid artery is considered relatively safe. The authors document the importance of recognition of the choroidal blush during selective external carotid artery angiography as a sign of collateral blood flow to the eye. Physicians and patients need to be aware of the risk of blindness as a complication of external carotid artery embolization when this sign is present.
The method of choice for uncontrollable epistaxis that is refractory to anterior and posterior nasal packing is controversial. In a retrospective study, the therapeutic results in 42 patients with uncontrollable epistaxis were reviewed, with special consideration of 11 cases in which the patients received angiography and embolization of branches of the internal maxillary artery. Out of this collective, only one patient received surgery, ie, transantral internal maxillary artery ligation. The results of primary embolization demonstrated the effectiveness and illustrated the potential role of embolizing procedures in uncontrollable epistaxis.
Two cases of intractable epistaxis are reported in which angiographic demonstration of the bleeding site was followed by successful therapeutic embolization with Gelfoam particles. The particles were inserted through the catheter as near the bleeding site as possible, and cessation of bleeding was immediate.
Risk of carotid artery embolization is usually attributed to inadvertent occlusion of the internal carotid system. This report highlights some recently noted complications associated with occlusion of external carotid branches. A case of bilateral facial paralysis following embolization of the internal maxillary arteries for severe epistaxis is presented. The clinician must recognize that facial paralysis is a real and sometimes inevitable sequela to the ever-increasing practice of arterial embolization in the head and neck.
On the basis of long-term study on embolization for severe epistaxis, the authors show the different indications and results of this relatively new method; and 54 cases are presented including Rendu-Osler diseases, primary and traumatic epistaxis, or those due to vascular malformation and benign or malignant tumors. Embolization can prove a very effective method in most cases.
After posterior nasal packing, the two most common therapies for intractable epistaxis are transantral ligation of the internal maxillary artery and percutaneous embolization of the distal internal maxillary artery. However, optimal management of intractable posterior epistaxis remains controversial. We retrospectively reviewed the charts of 21 patients treated for intractable epistaxis and obtained data on presentation, risk factors, treatment, success rates, complications, and cost. Twelve patients received percutaneous embolization, five underwent transantral ligation, and four required both. The success rates for transantral ligation and percutaneous embolization were 89% and 94%, respectively. No mortality or serious morbidity occurred with either technique. A cost comparison revealed that transantral ligation was moderately less expensive than percutaneous embolization ($5941 vs. $6783). Although some authors advocate transantral ligation or percutaneous embolization as the procedure of choice for intractable epistaxis, a direct comparison of efficacy and cost reveals that they are comparable procedures with specific strengths and weaknesses. We present our experience and a review of the literature, highlighting the indications and advantages of each technique. We conclude that the choice of treatment modality should be based on the benefits of each procedure as it pertains to the specific needs of the individual patient.
Epistaxis occurs often in children, but these patients are seldom hospitalized. Two cases of intractable epistaxis, which were definitively treated with internal maxillary artery embolization, are presented with an algorithm for management of similar cases.
To determine the effectiveness of therapeutic embolization in the treatment of intractable epistaxis.
Cohort.
Tertiary care hospital.
Consecutive referred sample of 57 patients with intractable epistaxis.
Percutaneous transfemoral catheterization and angiography of the internal maxillary arteries. Embolization of the most distal branches with 0.1- to 0.9- cm3 medium-sized polyvinyl alcohol particles on the suspected side of bleeding.
Outcome was successful if no further interventional treatment was required for epistaxis.
Anatomical abnormalities precluded embolization in three patients. Three of the remaining 54 patients required supplementry embolization. Including these three patients, 52 (96%) of 54 patients had successful control epistaxis. The major neurologic complication rate was 6% (three of 54 patients), with no permanent deficits.
Therapeutic embolization is an effective and safe technique and should be considered as the primary treatment modality in severe epistaxis.
Ninety-seven patients were referred to the Toronto Hospital (Western Division) between January 1984 and January 1992 for selective angiographic embolization (108 embolizations, including repeat procedures) to control intractable or recurrent severe epistaxis. Eighty-one patients (comprising 94 embolizations) were referred on an emergent basis because of failure of conventional conservative therapy, consisting of anterior and posterior packing. The remaining 16 patients (14 embolizations) were referred electively for recurrent epistaxis. A retrospective review of these cases was performed, with long-term telephone follow-up achieved in over 95% of cases. Embolization safely controlled active hemorrhage in 88% of the emergent cases. The success rate increased to 90% when two cases in which the source of epistaxis was found to be from the internal carotid artery were excluded (because these vessels could not be safely embolized). Of the patients whose epistaxis was initially controlled by embolization, 82% had no further nosebleeds (follow-up time ranged from 2 to 82 months; average, 26.8 months). More than half of the long-term failures were seen in patients with Osler-Weber-Rendu disease. Overall, the mortality rate was 0% and the long-term morbidity rate was 2% (one cerebral vascular accident and one case of skin slough in the territory of the superficial temporal artery.
Epistaxis is a common condition as well as a frequent otolaryngologic emergency, with up to 60% of people experiencing one episode in their lifetime and 6% seeking medical attention. Treatment is controversial, with many options being available. We retrospectively reviewed the hospital course and management of 65 patients who experienced epistaxis from January 1, 1986, to October 31, 1991, to compare medical and surgical treatment methods. Fifty-one patients were managed medically. Of these, 36 patients required one treatment (group 1), 10 required multiple treatments (group 2), and seven required multiple admissions (group 3). The mean lengths of hospitalization were 3.27, 4.90, and 5.57 days respectively. Fourteen patients were managed surgically. The preoperative stay of nine patients who underwent unsuccessful medical management at our institution (group 4) was 3.9 days, with an average postoperative stay of 7.3 days. The difference in length of stay was statistically significant between surgical and medical groups and the postoperative stay of group 4 was different from the length of stay of group 1 patients. The remaining five patients were initially treated elsewhere (group 5). Seventeen (33.3%) medical and only 1 (7%) surgical patients underwent unsuccessful initial therapy. Complication rates were not statistically different for each group. Transfusion requirements were evaluated as a possible predictive factor. Eighteen patients (35.3%) in the medically managed group required transfusions, compared with 11 patients (78.6%) treated surgically (p < 0.01). The medical group received an average of 0.91 units, compared to the surgical group that received 2.93 units preoperatively (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
• Thirty-one patients with posterior epistaxis refractory to nasal packing alone or in combination with surgical ligation (n=8) underwent diagnostic angiography and therapeutic embolization of the internal maxillary artery. Embolization resulted in the cure of epistaxis in 22 cases (71.0%). Of the nine failures (29.0%), seven underwent successful surgical clipping of the ethmoid arteries, and two were treated conservatively and died of their primary hematologic disease within 33 days. Late rebleeding occurred in two patients: one underwent reembolization and the other was treated surgically. No severe or permanent complications occurred. The results indicate that embolization is a feasible alternative to surgical intervention for patients with posterior epistaxis, and we recommend it as the treatment of choice in cases with high surgical risk or failure of prior arterial ligation.
(Arch Otolaryngol Head Neck Surg. 1993;119:837-841)
Intractable epistaxis developed in a 13-year-old girl after she fell down a flight of stairs sustaining facial fractures and fracture of the skull base. Epistaxis was found to emanate from a right ascending pharyngeal artery, which the authors promptly and successfully embolized using polyvinyl alcohol particles and microfibrillar collagen.