Intractable Posterior Epistaxis Research Articles

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.

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 a 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. 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. A 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. 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%) cases 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. 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.

Arterial Blood Supply of the Nose: An Angiographic Study

Objective: To define anatomical variations associated with arterial blood supply of the nose which has clinical implications on the management of different disorders, especially intractable posterior epistaxis. Study Design: Case series. Methods: Selective angiography of external and internal carotid arteries of 100 patients scheduled for routine angiography was done. Results: Different anatomical variations were documented. The ophthalmic artery can arise from the middle meningeal artery in 1% while ethmoidal arteries can be absent in 5%. The maxillary artery courses as 2 loops in the pterygopalatine fossa in 64% of cases where the descending palatine artery originates before the first loop or on its top so that caution is needed in controlling epistaxis. The sphenopalatine artery has different patterns of branching and may have more than 2 branches in 18% of cases. In 19% of cases, there is cross-circulation between both sides through the nasal blood supply. Conclusion: Angiographic study of the nose is a very helpful tool for accurate knowledge of anatomical variations of the arteries with a tremendous effect on our surgical approaches and techniques for the management of different diseases in the nasal region, especially intractable posterior epistaxis.

난치성 후방 비출혈 환자에서 내시경하 접형구개동맥 소작술과 선택적 동맥 색전술의 비교 분석

난치성 후방 비출혈 환자에서 내시경하 접형구개동맥 소작술과 선택적 동맥 색전술의 비교 분석

Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis.

Background:Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery.Objective:This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen.Methods:By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis.Results:Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (−9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor.Conclusion:Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.

Endoscopic Cauterization of Sphenopalatine Artery in Posterior Epistaxis- Our Experience

IntroductionEpistaxis is one of the commonest emergencies in Otorhinolaryngology. The management of intractable posterior epistaxis sometime becomes challenging to ENT surgeons. Over the last decade endoscopic cauterization of sphenopalatine artery has emerged as a viable and minimally invasive alternative.
 Materials and MethodsThirty four patients with intractable posterior epistaxis were treated by endoscopic sphenopalatine artery cauterization between March 2010 & February 2013.
 ResultsThere was no recurrence of epistaxis with an average follow-up of 12 months in 30 out of 34 patients. Only 4 patients had anterior epistaxis in follow up period, which were managed with anterior nasal packing. The success rate of endoscopic sphenopalatine artery cauterization, in this study was 88%.
 ConclusionEndoscopic sphenopalatine artery cauterization is a safe & efficient method of controlling persistent posterior epistaxis with minimal complication.

Intractable Posterior Epistaxis due to a Spontaneous Low-Flow Carotid-Cavernous Sinus Fistula: A Case Report and a Review of the Literature

We report a case of a 90-year-old patient with intractable posterior epistaxis presenting as the only symptom of a nontraumatic low-flow carotid-cavernous sinus fistula. Purpose of this case report is to introduce low-flow carotid-cavernous sinus fistula in the differential diagnosis of intractable posterior epistaxis. We provide a literature review for the sequence of actions for the confrontation of posterior epistaxis. We also emphasize the significance of the radiological diagnostic and therapeutic procedures in the management of posterior epistaxis due to pathology of the cavernous sinus. The gold-standard diagnostic procedure of carotid-cavernous sinus fistula is digital subtraction angiography (DSA). DSA with coils is also the state-of-the-art therapy. By failure of DSA, neurosurgery or stereotactic radiosurgery (SRS) may be used as alternatives. SRS may also be used as enhancement procedure of the DSA. Considering the prognosis of a successfully closed carotid-cavernous sinus fistula, recanalization occurs only in a minority of patients. Close follow-up is advised.

Septal perforation and bilateral partial middle turbinate necrosis after bilateral sphenopalatine artery ligation

To report previously unreported complications of bilateral sphenopalatine artery ligation. We present the case of a 45-year-old man who underwent bilateral sphenopalatine artery ligation to control intractable posterior epistaxis. After four months, he re-presented with nasal obstruction and crusting. Examination under general anaesthesia showed posterior septal perforation and bilateral necrosis of the lower parts of the middle turbinates. The necrotic parts were excised. The patient had no more complaints. Following sphenopalatine artery occlusion, ischaemic necrosis is a potential risk in anatomical areas that receive their only arterial supply from this artery. The staging of bilateral sphenopalatine artery occlusion needs to be studied.

Waldenstrom Macroglobulinemia Presenting as Isolated Persistent Epistaxis: A Very Rare Presentation

Nose bleed is the most common rhinological emergency. There are multiple risk factors for the development of epistaxis and it can affect any age group, but it is the elderly population with their associated morbidity who often require more intensive treatment and subsequent admission. Most cases of epistaxis occur in the Little's area, a location readily accessible and treatable by cautery or anterior nasal packing. However, posterior epistaxis often requires more aggressive measures including posterior nasal packing and endoscopic cauterization. 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 hereby report fourth case of Waldenstrom Macroglobulinemia in English literature, which presented as isolated persistent epistaxis and was treated by therapeutic plasmapheresis.

Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting

Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting

Endoscopic cauterization of the sphenopalatine artery in pediatric intractable posterior epistaxis

Objective To evaluate the rule of endoscopic sphenopalatine artery cauterization in posterior intractable epistaxis in pediatric age group as regard technical difficulty, efficacy, and safety in children. Study design Retrospective study. Patients and methods From March 2008 to February 2011, 7 children (4 male, 3 female) with idiopathic intractable posterior epistaxis, patients’ age ranged from 8 to 14 years (10.7 average). All patients underwent preoperative laboratory investigations to exclude bleeding or coagulation disorders and CT paranasal sinus. All patients underwent endoscopic sphenopalatine artery cauterization (7 procedures for 7 patients, 5 were in the right side and 2 were in the left side). Results postoperative evaluation showed no recurrence for epistaxis during the post operative follow up period. Also, no complications were found. The average follow up period was 17.8 months. Conclusions Endoscopic cauterization of sphenopalatine artery in pediatric age group was effective and safe technique providing that the surgeon has a good experience regarding pediatric endoscopic sinonasal anatomy. Minimal endoscopic technique in this age group is important to avoid unnecessary operative and postoperative complications. Avoid excessive cauterization to lateral nasal wall in this technique is crucial to avoid unexpected nerve injury or tissue necrosis.

Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting

The management of intractable posterior epistaxis is challenging for any physician. Nasal packing, often combined with use of an endonasal balloon system, is painful for the patient, and torturous to maintain for two to three days. If conservative treatment fails, the most commonly used treatment options are currently invasive procedures such as endoscopic coagulation of bleeding arteries, external ligation and, rarely, embolisation. This paper describes a simple, non-invasive technique of treating posterior epistaxis with hot water irrigation. Technical information is presented, and the benefits of the method are discussed.

Endoscopic devascularisation of sphenopalatine bundle in intractable posterior epistaxis: technique, efficacy and safety

To evaluate endoscopic cauterisation of the sphenopalatine neurovascular bundle, as treatment for intractable posterior epistaxis, with regard to efficacy, safety and post-operative sequelae. A prospective study reviewed 42 patients with severe posterior epistaxis who were treated with endoscopic cauterisation of the sphenopalatine neurovascular bundle, over a 17-month period. Hypertension and hepatic disease were present as predisposing factors in 66.7 and 35.7 per cent of patients, respectively. Branching of the sphenopalatine artery at its foramen was present in more than 85 per cent of patients. The success rate was 100 per cent, with no recurrent epistaxis in the follow-up period. Severe nasal dryness was present in only four patients (9.5 per cent); hypoaesthesia was found in the nasal mucosa of eight patients, without any patient complaints. Endoscopic sphenopalatine neurovascular bundle cauterisation is an effective treatment for refractory posterior epistaxis. In this study, neurovascular bundle cauterisation did not cause any neurological deficits or major complications.

直視下に出血部位を確認しながら血管内治療を施行した難治性鼻出血の１例：症例報告

【目的】特発性鼻出血に対し直視下に出血点を確認しながら塞栓術を施行し良好な結果が得られた1例を報告する．【症例】54歳男性．左中鼻甲介後端からの難治性出血が持続したため，血管内治療を施行した．まず直視下にて出血点に鑷子の先端をあて，外頚動脈撮影を行った．出血点が蝶口蓋動脈の外側後鼻枝であることが確認され，蝶口蓋動脈末梢部に離脱式コイルを留置した．出血部位の血流が消失した時点で手技を終了した．術後，症状は軽快し，退院となった．【結論】特発性鼻出血に対し血管内治療を施行する場合，直視下で出血部位を正確に確認した上で塞栓術を行うことは安全で確実であると考えられた．

Endoscopic Ligation of the Sphenopalatine Artery and the Maxillary Artery for the Treatment of Intractable Posterior Epistaxis

Intractable posterior epistaxis sometimes requires intensive treatment, such as surgery or embolization. Maxillary artery ligation has been widely used for the treatment of intractable posterior epistaxis. It is highly effective, but significant complications may occur, including an oroantral fistula and damage to the infraorbital nerve. Embolization is less invasive and can be performed in poor surgical candidates. However, it has more serious complications, such as facial nerve paralysis and hemiplegia. This investigation evaluates the effectiveness and complications of endoscopic ligation of the sphenopalatine or maxillary artery for the treatment of intractable posterior epistaxis. Between April 2003 and March 2007, 46 patients were hospitalized for the treatment of severe posterior epistaxis in our University Hospital. Thirty patients were successfully treated by anterior and/or posterior nasal packing, and five patients were treated by electrocoagulation. Endoscopic ligation was performed under general anesthesia in 11 patients (6 men and 5 women; age range, 50-80 years). Eight patients underwent endoscopic ligation of the sphenopalatine artery, and three patients underwent endoscopic ligation of the maxillary artery through the middle meatus and posterior antral wall opening. There were no complications, and the patients' postoperative courses were uneventful. Recurrent epistaxis occurred in one patient on oral anticoagulants 15 months after ligation of the sphenopalatine artery, and it was successfully treated by anterior nasal packing. Endoscopic ligation of the sphenopalatine or maxillary artery is safer than arterial embolization and is less invasive than transantral ligation of the maxillary artery. This technique appears to be a simple and highly effective surgical treatment for patients with intractable posterior epistaxis.

Efficacy of selective percutaneous embolization for the treatment of intractable posterior epistaxis and juvenile nasopharyngeal angiofibroma (JNA)

Conclusion. Percutaneous embolization reduces the reappearance of epistaxis and the mean length of hospital stay for patients with intractable epistaxis or juvenile nasopharyngeal angiofibroma (JNA). Objectives. To assess whether percutaneous embolization is effective for the treatment of intractable epistaxis and JNA. Patients and methods. Twenty-eight patients with intractable posterior epistaxis treated by embolization (25 males; m = 59.78 years; SD = 14.3) and 28 unembolized patients (24 males; m = 59.21 years; SD = 15.13) were studied retrospectively. Eight patients with JNA (all males; mean = 16.5 years; SD = 2.35; four embolized before surgery and four unembolized) were also analyzed. Results. Embolization was bilateral in 71.4% of subjects, blood transfusion was required in 28.57%, incidence of complications was 53.57%, and seven of the embolized patients with intractable epistaxis suffered from recurrence of the epistaxis. There were no statistically significant differences between the embolized and unembolized groups. The mean hospital stay was longer in unembolized patients (4.46 days; SD = 2.42) than for the embolized patients (3.78 days; SD = 3.9), p=0.394. The most serious complications occurred in patients embolized with idiopathic epistaxis and the mean post-embolization hospital stay was longer in this subgroup (4.14 days; SD = 4.39) than in patients with Rendu-Osler-Weber syndrome (2.40 days; SD = 1.140), p=0.395. Unembolized patients with JNA presented greater hemorrhage (m = 2025 ml; SD = 325) and a longer mean hospital stay (m = 18 days; SD = 3) than the group of embolized patients (m = 360 ml; SD = 185 and m = 9 days; SD = 1, respectively).

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 entirely satisfactory because of morbidity, high failure rates and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior epistaxis 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 and posterior nasal packing.

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.

Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation?

The optimal surgical management for failed conservative measures in epistaxis remains unclear. Given the growing enthusiasm for endoscopic transnasal sphenopalatine artery ligation, it is prudent and timely to evaluate the evidence base for this technique. This study aims to analyse the current evidence for transnasal endoscopic sphenopalatine artery ligation by reviewing the literature and also by comparing the results with other approaches to the management of epistaxis. A detailed literature search identified 11 publications relating to endoscopic sphenopalatine artery ligation. The total number of patients in the pooled series was 127, of which 98% had control of epistaxis following surgery. These results compared favourably to the results of most other techniques used in the modern treatment of epistaxis. Nonetheless, the total number of patients in the 11 case series is small. It is therefore recommended that all units using this technique audit their results to see if the high success rates achieved in the literature are reproducible. If this is the case, then endoscopic sphenopalatine artery ligation may indeed be the surgical answer to intractable posterior epistaxis.

Embolización selectiva terapéutica en epistaxis incoercibles

AbstractEpistaxis is a common otolaryngologic emergency that is controlled frequently with conservative measures. on the other hand, more aggresive treatments are requiered in refractory or severe epistaxis, which may have systemical impact. about intractable posterior epistaxis, selective embolization of external carotid territory is an effective option for managing. three patients with severe epistaxis successfully treated with selective embolization and a review of literature are exposed