Persistent Epistaxis Research Articles

Sphenopalatine artery ligation: technical note

Epistaxis is a common problem. Most patients presenting to hospital will stop bleeding with simple first-aid measures or with nasal packing. Those who do not stop will usually require surgical management. For persistent posterior epistaxis, the sphenopalatine artery may be ligated as the artery leaves the sphenopalatine foramen to enter the nasal mucosa of the lateral wall of the nose. This may be performed endoscopically. We describe the anatomy of the area and the surgical technique. We also present a brief review of the literature on this technique.

Endovascular Treatment of Persistent Epistaxis due to Pseudoaneurysm Formation of the Ophthalmic Artery Secondary to Nasogastric Tube

We present the case of a 60-year-old man with persistent epistaxis for 20 days that had started 2 weeks after removal of a nasogastric tube placed for an abdominal operation. There was no pathologic finding at selective facial and internal maxillary artery injections. An injury to the ethmoidal branches of the ophthalmic arteries or other arterial origins of bleeding was suspected. The internal carotid artery angiography revealed a pseudoaneurysm of an anterior ethmoidal branch of the left ophthalmic artery. The pseudoaneurysm was occluded with NBCA-histoacryl (25%) injection.

Endovascular Treatment of Persistent Epistaxis due to Pseudoaneurysm Formation of the Ophthalmic Artery Secondary to Nasogastric Tube

The effects of nitric acid (NO) on vessel response to injury include the inhibition of platelet adhesion, platelet aggregation, leukocyte adhesion and smooth muscle cell proliferation. Releasing NO from a stent might reduce the clinical problem of restenosis. The present study was designed to examine whether an NO-eluting covered stent can prevent neointimal formation in a porcine carotid overstretch injury model. The interior of a self-expanding polytetrafluoroethylene (ePTFE)-covered aSpire stent was coated with silicone, which contained 23.6 microg or 54.5 microg sodium nitroprusside (SNP, NO-releasing compound). The stent was implanted into carotid artery. Six pigs were implanted with stents, one high-dose SNP and one uncoated control, following balloon overstretch injury of the carotid artery with a balloon-to-artery ratio of 1.3:1. No local or systemic toxicity was evidenced in the six pigs after carotid artery implantation with either low- or high-dose stents within a week. At day 28, the mean intimal thickness was 0.12 +/- 0.05 mm for NO-eluting stents and 0.43 +/- 0.09 mm for uncoated stents (p = 0.008). The mean neointimal area was reduced from 2.40 +/- 0.39 mm2 for control stents to 0.49 +/- 0.16 mm2 for NO-eluting stents (p < 0.0001), which resulted in a 24% reduction of angiographic vessel narrowing. The NO-eluting ePTFE-covered stent is feasible and effectively reduces in-stent neointimal hyperplasia at 28 days in a porcine carotid overstretch model.

Surgical anatomy of the distal maxillary artery

Problem: Arterial ligation of the sphenopalatine artery is a key option in the management of persistent posterior epistaxis. Coexisting with established transantral techniques are newer endoscopic transnasal methods. Knowledge of the arterial configuration allows understanding of the rationale of current treatments and assists in the interpretation of treatment failures. Methods: One hundred twenty-eight cadaveric tissue blocks containing the pterygopalatine fossae were used. One hundred eighteen blocks were dissected using a Watson-Barnet 25× dissecting microscope. Ten blocks were cleared by the Spalteholz technique after injection with latex-Indian Ink. Arterial configurations were analyzed and photographic records were made. Results: Analysis of the arteries in the pterygopalatine fossa showed 3 common configurations: a single looped form (18%) and 2 double-looped forms (51% and 31%). Terminal bifurcation of the sphenopalatine artery arose before the sphenopalatine foramen in 74.6%. In contrast to previous smaller studies, we found remarkable symmetry in the size of the maxillary arteries and a low incidence of “early” pharyngeal arteries. Conclusion: This is the most comprehensive anatomical study of the distal maxillary artery. The arterial configuration can be easily classified into 3 common forms. Some forms are more liable to lead to confusion at the time of ligation particularly if the osteotomy is inadequate. Significance: Understanding of the arterial anatomy and its variants will reduce the risk of technical failures and improve both the rationale and the reliability of ligation procedures in the treatment of epistaxis. Support: None reported.

Treatment of intractable epistaxis using arterial embolization.

Arterial embolization has become the procedure of choice for managing intractable epistaxis in certain centres in North America and Europe, with arterial ligation reserved for those patients in which it fails. In Ireland, the role of this relatively new technique is poorly defined. The aim of this retrospective study was to investigate the outcome of all patients who underwent arterial embolization for intractable epistaxis in Dublin since it was introduced in 1998. Embolization resulted in complete and immediate resolution of epistaxis in 10 out of 12 patients (82%). Two patients required carotid ligation because of persistent epistaxis. One other patient had a further minor epistaxis 2 days following embolization, which was treated successfully with cautery. No major complications occurred in any of the patients. This study suggests that arterial embolization is an effective and safe method of managing patients with intractable epistaxis.

Endoscopic ligation of the sphenopalatine artery for persistent epistaxis

The aim of this study was to provide a description, with a video sequence, of endoscopic dissection of the spheno palatine artery for persistent epistaxis. The outcome of this procedure in 10 consecutive patients was analysed. All patients undergoing this procedure had continued to suffer from epistaxes despite endoscopic cautery, insertion of Merocel® nasal packs and the use of posterior balloons. Under general anaesthesia neurosurgical patties soaked in 1 : 1000 adrenaline are placed into the middle meatus, inferior to the horizontal ground lamella of the middle turbinate. A small mucoperiosteal flap is elevated off the posterior maxilla and palatine bone until the sphenopalatine foramen is reached. The artery, with a sleeve of fibrous tissue continuous with the submucosa, is seen as it passes medially. The artery may be diathermied or a metal clip applied. All patients have since been contacted by phone. Ten patients aged between 17 and 79 (average 53.5) years have undergone ligation of 11 sphenopalatine arteries over a 26-month period. Inpatient stay averaged 3.4 days before surgery. The procedure took an average of 59 min (range 40–78 min) per artery. A 1 cm2 neurosurgical patty was placed over the flap in the middle meatus until the day following surgery. No patients suffered complications of surgery. Pa tients have been followed up an average 9 months (range 20–22). No patients have had further epistaxes requiring medical attention. Endoscopic ligation of the sphenopalatine artery is an effective treatment for persistent epistaxis and the procedure is associated with low morbidity.

#631 Persistent epistaxis as the presenting symptom of a bile acid synthetic disorder causing profound malabsorption of vitamin K

#631 Persistent epistaxis as the presenting symptom of a bile acid synthetic disorder causing profound malabsorption of vitamin K

Endoscopic ligation or diathermy of the sphenopalatine artery in persistent epistaxis.

Conventional methods of arterial ligation in persistent epistaxis often involve significant surgical morbidity, as well as failure due to arterial anastomosis. We have performed endoscopic intranasal end ligation or diathermy of 11 sphenopalatine arteries in 10 patients with no complications and with no further episodes of epistaxis, with an average follow-up period of nine months.

Endovascular embolization treatment for intractable epistaxis

Intractable epistaxis has been treated with surgical intervention for many years, including ligation of the internal maxillary artery. As an alternative approach, endovascular therapy has gained increased acceptance. The purpose of our study was to evaluate the efficacy and safety of endovascular treatment of untractable epistaxis. Embolotherapy was performed in 26 patients. The indication for embolization was persistent epistaxis even after anterior and posterior nasal packing. In all but two patients, who required general anesthesia, the procedure was performed in local anesthesia. Endovascular embolization of the internal maxillary artery was performed by using microcatheters, which were introduced intraarterially. Particulate embolic agents were used in all but one patient, who was treated by means of minicoils. The embolization of the territory of the internal maxillary artery was possible in all cases, the technical success rate was 96%, the clinical success rate was 100%. No complications were encountered. Because of an acute recurrent bleeding in one case, a second embolization was performed. No delayed hemorrhages were noted. Endovascular embolotherapy seems to be an excellent, safe, and less invasive alternative to surgery in patients with intractable epistaxis.

原発性鼻結核例

We encountered a 32-year-old Philippino man with primary nasal tuberculosis. He developed increasing nasal obstruction and persistent epistaxis. His general health was quite good and chest X-ray showed no abnormality in the lung field. A CT-scan showed no granulation or inflammation in bilateral paranasal sinuses.Granulomatous changes in the mucosa of the right inferior turbinate were the only finding. Biopsy of the inferior turbinate showed caseating granuloma. Finally, we diagnosed his illness as primary nasal tuberculosis because tubercle bacillus was identified using the polymerase chain reaction methods, which found to be useful in precisely diagnosing nasal tuberculosis.The differential diagnosis of nasal granulomatous disease usually includes Wegener's granulomatosis, midline malignant reticulosis, sarcoidisis and tuberculosis. However, tuberculosis of the nose has become so infrequent that it is a virtually forgotten disease. We point out the necessity of including tuberculosis in this differential diagnosis.

Wegener's granulomatosis

<h3>SELECTED CASES</h3><h3>Patient 1</h3> A previously healthy 20-year-old man experienced the subacute onset of an influenzalike illness characterized by diffuse arthralgias, malaise, fever, nonproductive cough, nasal congestion, epistaxis, and frontal headaches. His symptoms were unresponsive to decongestants and multiple courses of oral antibiotics. During the next several weeks he developed pain and swelling over the bridge of his nose and migratory pain and swelling of multiple joints. Because of persistent epistaxis he consulted an otolaryngologist, who noted diffusely inflamed nasal mucosa and performed a biopsy, which showed acute and chronic inflammation. The patient was referred to the National Institutes of Health 4 months after his symptoms began. Laboratory evaluation showed a white blood cell count of 10.8×10⁹/L, hemoglobin of 126 g/L, erythrocyte sedimentation rate of 71 mm/h, creatinine of 80 μmol/L (0.90 mg/dL), and a normal urinalysis. Radiographic studies revealed pansinusitis and a nodule in the upper lobe

Wegener's Granulomatosis

<h3>SELECTED CASES</h3><h3>Patient 1</h3> A previously healthy 20-year-old man experienced the subacute onset of an influenzalike illness characterized by diffuse arthralgias, malaise, fever, nonproductive cough, nasal congestion, epistaxis, and frontal headaches. His symptoms were unresponsive to decongestants and multiple courses of oral antibiotics. During the next several weeks he developed pain and swelling over the bridge of his nose and migratory pain and swelling of multiple joints. Because of persistent epistaxis he consulted an otolaryngologist, who noted diffusely inflamed nasal mucosa and performed a biopsy, which showed acute and chronic inflammation. The patient was referred to the National Institutes of Health 4 months after his symptoms began. Laboratory evaluation showed a white blood cell count of 10.8×10⁹/L, hemoglobin of 126 g/L, erythrocyte sedimentation rate of 71 mm/h, creatinine of 80 μmol/L (0.90 mg/dL), and a normal urinalysis. Radiographic studies revealed pansinusitis and a nodule in the upper lobe

Epistaxis, von Willebrand's type bleeding diathesis and Wilms' tumour: a case report

We report a case of persistent epistaxis in a seven-month-old child with Wilms' tumour who had an associated von Willebrand's type bleeding diathesis. Correction of the bleeding diathesis to control the epistaxis required treatment of the tumour with chemotherapy.

Safety and anticoagulation effect of a low-dose combination of warfarin and aspirin in clinically stable coronary artery disease

The hypothesis that the combination of low-dose aspirin and warfarin therapy is more effective than aspirin alone in secondary prophylaxis after myocardial infarction is to be examined in the Coumadin Aspirin Reinfarction Study. This pilot study addressed the safety and anticoagulation effect of a fixed, low-dose combination in 114 patients (aged 64 ± 8 years, 85% men) with stable coronary artery disease receiving 3 mg of warfarin plus 80 mg of aspirin daily for 8 weeks. The international normalized ratio (INR) was measured within 72 hours of initial therapy, and weekly. Of the 110 patients with evaluable INRs, 87 patients (79%) maintained the 3 + 80 mg combination, 19 (17%) had the dose reduced to 1 mg warfarin + 80 mg aspirin, and 4 (4%) discontinued therapy because of a confirmed INR of ≥4.5. At steady state, patients had INRs of 1.48 ± 0.41 (3 + 80 mg group) and 1.21 ± 0.23 (1 + 80 mg group), and inter- and intra-patient variability (estimated by the mean of the between- and within-patient SDs at steady state) was 0.49 ± 0.08 and 0.13 ± 0.14, respectively. There was no apparent effect of age on INR distribution. Microscopic hematuria was the most frequent (20%) adverse clinical event, but was unrelated to the INR. Three patients required discontinuation of therapy because of bleeding events (persistent hematuria and epistaxis). A fixed low-dose combination of warfarin and aspirin results in a predictable and stable increase in the INR in a large proportion of patients with coronary artery disease. Provided that early INR testing is undertaken in order to identify patients with significant sensitivity to low-dose warfarin and to establish steady-state dosing, the Coumadin Aspirin Reinfarction Pilot Study suggests that this treatment modality may be safe for long-term administration as secondary prophylaxis.

Quest for the aberrant vessel

In most cases of posterior epistaxis, the terminal branches of the internal maxillary artery (IMA)--principally the sphenopalatine artery--are believed to be the source of hemorrhage. However, we recently treated three patients in which unexpected or aberrant vascular anatomy resulted in persistent posterior epistaxis.

Internal maxillary artery variability in the pterygopalatine fossa

The third segment or pterygopalatine branch of the internal maxillary artery has variable branching in the pterygopalatine fossa. This variability in branching can lead to failure in controlling persistent nasal epistaxis by transantral ligation. Although the surgical approach has been previously studied, a systematic classification of this branching has not been previously reported. Through the performance of serial cadaver dissections in the PPF, we have demonstrated the anatomic course and variations of this third segment and offer a relatively simple classification system.

Arteriovenous malformation of the maxilla

The highly vascular nature of the head and neck area provides a particularly enhanced challenge to the head and neck surgeon when a vascular lesion is encountered. Vascular malformations in this area are classified according to the microanatomical architecture and clinical appearance of the lesion. Although bleeding is a common presentation with vascular malformations, other local and systemic problems may be associated with this problem. An unusual case of an arteriovenous malformation of the ethmoid and maxillary sinuses which caused persistent and recurrent epistaxis is presented. A review of the current literature concerning vascular lesions of the head and neck area is included. Adequate treatment of this lesion presently includes angiographically controlled vascular embolization followed by complete surgical excision.

Epistaxis

Successful control of unusually persistent epistaxis is most easily accomplished through an organized stepwise progression of treatment options. This begins with a careful physical examination of the nose to look for a specific bleeding site. Most failures in treatment result from initial inattention to this methodical examination, resulting in improperly placed packing materials. With careful preparation prior to nasal manipulation, most nosebleeds should be readily controllable.

Embolization for traumatic epistaxis: Adjuvant therapy in severe maxillofacial fracture

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

Nasopharyngeal Masses in Adults

Nasopharyngeal masses in adults present a perplexing problem because of the concern for malignancy. A retrospective review of the records, radiographs and biopsy histology of 57 patients presenting in one year with nasopharyngeal masses at the Massachusetts Eye and Ear Infirmary suggests that persistent pain, epistaxis, trismus, or cervical mass are uncommon in patients with benign histology and should alert the clinician to the probability of malignancy. A high index of suspicion on the part of the clinician is essential for the successful recognition of early lesions. The roles of conventional radiography, polytomography, and computed tomography scans are discussed. Patients with malignant lesions are contrasted with those having benign lesions.