Nasotracheal intubation under curve-tipped suction catheter guidance reduces epistaxis

BACKGROUND

Nasotracheal intubation (NTI) has greater potential for trauma of nasopharyngeal mucosa than orotracheal intubation. The present study investigated the success rate of NTI and frequency of nasal bleeding using a curve-tipped suction catheter (CTSC) to guide nasotracheal tube advancement.

METHODS

Subjects comprised 131 adult patients who under-went NTI. Subjects were randomly divided into two groups: a) NTI under CTSC guidance (G[+] group). The CTSC (14 Fr) was first inserted through the tracheal tube, with the tip of the CTSC emerging from the distal end of the tube. The curved tip was directed ventrally. Both tracheal tube and CTSC were advanced together through the nasopharynx; b) NTI without CTSC guidance (G[-] group). The tracheal tube was advanced into the nasal cavity and passed into the pharynx without CTSC guidance. The time required to pass the endotracheal tube through the nasal cavity (nasal passage time), success rate of nasal passage with nasotracheal tube, and the incidence and severity of nasal bleeding were compared.

RESULTS

Success rate for nasal passage was 100% in the G(+) group (62/62) and 82.6% in the G(-) group (57/69; P = 0.0006). Frequency of nasal bleeding was significantly lower in the G(+) group (21/62, 33.9%) than in the G(-) group (37/69, 53.6%; P = 0.023). Severity of nasal bleeding was also significantly lower in the G(+) group than in the G(-) group (P = 0.030).

CONCLUSIONS

Nasotracheal intubation under CTSC guidance increases the success rate of airway instrumentation, and also reduces the incidence and severity of epistaxis.

Nasal packs with X-ray indicators

Nasal packing is routinely performed by many surgeons following nasal surgery and is also frequently used for the treatment of epistaxis. The use of nasal packing, however, is sometimes associated with serious complications such as aspiration, bowel perforation, obstructive apnea, and hypoxia. This author has also once had the experience of losing a nasal pack during a procedure performed on a mentally impaired patient. If a nasal pack could be easily tracked by x-ray, treatment would be faster and easier. We now use x-ray indicators quilted into our nasal packs, which enable us to find the packs quickly and easily with plain x-ray film.

Endonasal transsphenoidal surgery: the patient's perspective—survey results from 259 patients

BACKGROUND

Patient impressions remain an important yet often overlooked aspect of surgical success. Herein we present postoperative questionnaire results in patients after a standard direct endonasal approach, an extended suprasellar endonasal approach, and a reoperative transsphenoidal surgery for tumor removal with the operating microscope.

METHODS

From July 1998 through April 2005, of 452 patients undergoing endonasal surgery, 346 were sent questionnaires, and of these, 259 (75%) completed them. Nasal packing was placed for 24 hours in the first 95 patients but not in the last 357.

RESULT

Overall, 73% of patients reported a better experience than expected and 8% worse than expected. A worse than expected overall experience was noted in 15% of patients with nasal packing compared with 5% of patients without packing (P = .001). Of patients with preoperative headache, 49% resolved, 34% somewhat resolved, and 5% worsened. The frequency of rhinological complaints declined from 2 weeks to 3 months postsurgery (P < .001); by 3 months or more postsurgery, 67% to 87% of patients had no rhinological complaints and 1% to 2% had severe complaints. Of 30 patients with prior sublabial surgery, the endonasal procedure afforded easier recovery (87%), less pain (80%), better nasal airflow (79%), and a shorter hospital stay (median 3 vs 5 days) (P < .001). Of 28 patients with complications, the severity of rhinological complaints was similar to those without complications except this subgroup reported greater loss of sense of smell 3 months after surgery (P < .001).

CONCLUSIONS

Rhinological recovery is typically rapid and relatively complete after direct endonasal transsphenoidal surgery using both standard and extended suprasellar approaches. Compared with the sublabial route, the endonasal approach is associated with less pain, better nasal airflow, and a shorter hospital stay.

Advice given to patients with epistaxis by A&E doctors

This study was devised to determine the proportion of patients with epistaxis seen in accident and emergency (A&E) departments and discharged with verbal/written advice, and to examine if this information affects re-attendance rates. A questionnaire was given to all A&E doctors probing their current practice regarding advice given to patients with epistaxis on discharge. The information was complemented with a case note audit of patients with epistaxis seen and discharged by A&E doctors over a 2 month period, which assessed the content and format of advice given and the number of re-attendances. The standard used stated that all patients discharged from A&E should be given both verbal and written advice regarding the prevention and management of further bleeds. The A&E doctors were then invited to a presentation on the management of epistaxis and the appropriate advice to give patients on discharge. Written advice leaflets on the prevention and management of further bleeds were placed in the A&E department and were accessible to doctors and patients. Case notes were re-audited over the following 2 month period. Verbal and written advice increased from 19% to 61% and 2% to 54% respectively. The number of re-attenders who had previously only seen A&E doctors was reduced from 11 (17%) in the first half to 5 (8%) in the second half of the cycle, representing a 9% reduction. We conclude that the provision of adequate verbal and written advice to patients with epistaxis may have an important role in the prevention of further bleeds and subsequent re-attendance to A&E departments.

Rezidivierende Epistaxis bei hereditärer hämorrhagischer Teleangiektasie

BACKGROUND AND OBJECTIVE

Hereditary hemorrhagic telangiectasia (HHT) is an inherited autosomal dominant vascular disease, which can cause multiple symptoms, the cardinal one being chronic recurrent nosebleeds. The aim of this study was to determine, whether these chronic recurrent episodes are felt by the patients to be merely isolated episodes or affect their quality of life (QoL). Also assessed was the extent to which QoL is more impaired in patients with HHT than in those with other chronic diseases.

PATIENTS AND METHODS

This prospective cross-sectional study was based on a German questionnaire, "Profile of Quality of Life of Chronically Ill Patients"(PLC) together with a newly formulated questionnaire dealing with HHT-specific symptoms. Comparisons were made with German normative reference data, as well as with data from randomly selected patients with various chronic diseases.

RESULTS

90% of patients with HHT considered their recurrent nosebleeds to be the most disturbing symptom, interfering with hobbies and leisure time in 63% of them. Those with HHT had worse results in 5 of 6 PLC scales than those with other chronic diseases such as cardiomyopathy or rheumatic disease. 73% of the patients stated that they would appreciate new ways of treating these nosebleeds.

CONCLUSION

There is a great need for optimizing the treatment of chronic recurrent nosebleeds. Lasting reduction of such bleeds by new therapeutic methods seems unlikely to happen in the near future. For this reason multimodal treatment options, including psychological and relaxation techniques, should be considered. Such an approach may reduce the stress on patients (and subsequent nosebleeds) and result in a direct improvement of their quality of life.

[A clinical analysis of intractable spontaneous epistaxis with 289 cases reviewed]

OBJECTIVE

To explore the clinical characteristics and the prevention strategy of intractable spontaneous epistaxis.

METHOD

Two hundred and eighty-nine patients with intractable spontaneous epistaxis were retrospectively analyzed.

RESULT

Intractable spontaneous epistaxis was characterized by the onset season, age, sex, and the associated disease. Nasal septums were the most common sites of bleeding. Recurrent epistaxis was mainly associated with the failure of locating the bleeding sites.

CONCLUSION

Control of elevated blood pressure is essential for the prevention of intractable spontaneous epistaxis. Once epistaxis occurs, the importance of the first treatment for the haemostasis should be emphasized. For the uncontrollable epistaxis, multiple interventions are necessary.

Simple new method of protecting the septum during oxygen delivery via a nasal canula

Epistaxsis and crustation are common problems associated with long-term use of oxygen through nasal prongs in patients suffering from chronic obstructive pulmonary disease. The nasal prong can cause direct trauma to the septal mucosa. We describe a simple solution to this problem with use of the disposable ear tip used in tympanometry.

[Haemostatic ointment efficacy in the treatment and prevention of epistaxis: a multi-centric study in 100 patients]

OBJECTIVE

To evaluate the protective effects of an haemostatic ointment, at rhinosinusal mucosa level, on the development of bleeding in patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days.

PATIENTS AND METHODS

100 patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days. Patients underwent 15 days of treatment with an haemostatic ointment 2 times/day.

RESULTS

The haemostatic ointment significantly reduced the percentage of patients affected by epistaxis and the number and severity of bleeding episodes (p < 0.001). 51% of patients experienced nasal obstruction during treatment, which persisted at the end of therapy only in 11% of them (p < 0.001). Nasal burning, nasal itching and rinorrhea involved less than 40% of patients in the first days of treatment and no more than 10% at the end of therapy (p < 0.001).

CONCLUSIONS

The use of the haemostatic ointment in the treatment and in the prevention of not severe epistaxis acquire, in our opinion, a strong rationale.

Conchopexy suture to prevent middle turbinate lateralisation and septal haematoma after endoscopic sinus surgery

Endoscopic ethmoidectomy is now one of the commonest surgical procedures performed by ear, nose and throat surgeons. Access to the ethmoid air cells is via the middle meatus following medialisation of the middle turbinate and uncinectomy. The most satisfactory postoperative results are achieved by maintaining patency of the middle meatus. This allows delivery of topical medication and sinus aeration. Spontaneous lateralisation of the middle turbinate during the healing period, with or without synechiae, can compromise the surgical benefit. This paper describes a conchopexy suture placed at completion of ethmoidectomy. A carefully placed yet simple suture technique will maintain a widely patent middle meatus during the phase of post-operative healing. A slight modification allows quilting of mucoperichondrial flaps after septal surgery.

An evaluation of effect of pterygopalatine fossa injection with local anesthetic and adrenalin in the control of nasal bleeding during endoscopic sinus surgery

BACKGROUND

The aim of this study was to determine the effect of pterygopalatine fossa infiltration with lidocaine and adrenalin on bleeding in the surgical field during endoscopic sinus surgery.

METHODS

A prospective blind randomized controlled trial was performed. Fifty-five patients were randomized to receive a unilateral transoral infiltration of the pterygopalatine fossa with 2 mL of 2% lidocaine and 1:80,000 adrenalin. The operating surgeon was blinded as to which side had been infiltrated at the start of surgery. The surgical field was graded on a previously validated surgical field grading scale every 15 minutes with the side being operated on alternated every 30 minutes. The pulse, mean arterial blood pressure, and end-tidal CO2 concentration were monitored with each surgical field observation.

RESULTS

At each individual time point from 30 minutes to 3.5 hours there was a significant difference in surgical grade between injected and noninjected sides in favor of the injected side (p = 0.01). The difference between surgical grades averaged across all time points was slight but significant. The injected side had an overall mean of 2.59 (SE, 0.22) compared with 2.99 (SE, 0.23) for the noninjected side. Heart rate also was found to correlate independently to surgical grade.

CONCLUSION

Injection of the pterygopalatine fossa resulted in an improved surgical field during endoscopic sinus surgery.

Natural history and control of epistaxis in a group of German patients with Rendu-Osler-Weber disease

INTRODUCTION

Epistaxis is the most common symptom of a complex, genetically determined vasculopathy, which is known under the notion hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber-syndrome). This study was initiated to gain more knowledge about the natural history of epistaxis in a German HHT-population.

PATIENTS AND METHODS

Data of 49 HHT patients were ascertained by interviewing these patients with a standardized disease specific questionnaire. Patients' files were retrospectively reviewed for data concerning age, gender, past medical history, laboratory parameters, number of hospital admissions for epistaxis, conservative and operative types of therapy, treatment results and follow-up.

MAIN RESULT

Epistaxis was the first and most prominent symptom in 93% of the patients and could be triggered most frequently by stress. Half of the patients had experienced first episodes of epistaxis in childhood, but usually epistaxis did not become troublesome before the age of 35 years. The effects of hormonal changes or therapies with systemic hormones were inconclusive with regard to impact on epistaxis. Patients with septal perforations had to be admitted for inpatient epistaxis treatment more frequently than patients with an intact nasal septum. An overall reduction of frequency and intensity of epistaxis could be achieved in 89% of the patients through the daily use of nasal lubricants and a minimum of two treatment sessions with the Nd:YAG laser. However in none of the cases the treatment results were permanent. More than 50% of the patients, who had been screened for visceral arteriovenous malformations, were positive for pathologic vascular lesions.

PRINCIPAL CONCLUSION

The natural history of epistaxis in German HHT patients is similar to previously described entities from other parts of the world. First clinical signs of HHT may be present at an earlier age than previously thought.

A simple technique to reduce epistaxis and nasopharyngeal trauma during nasotracheal intubation in a child with factor IX deficiency having dental restoration

Epistaxis and airway trauma are often associated with nasotracheal intubation. We describe a patient with Factor IX deficiency who required nasotracheal intubation. An inexpensive, nonproprietary, rapid technique was used to reduce the trauma of intubation.

Nasal endoscopy and control of epistaxis

PURPOSE OF REVIEW

This review is designed to update the reader on the current state of nasal endoscopy in the control of epistaxis. Recent articles are reviewed and demonstrate recent developments and results.

RECENT FINDINGS

The use of endoscopy for control of anterior and posterior epistaxis is beneficial, with less morbidity then external procedures or Caldwell Luc approaches. Postoperative endoscopic sinus surgery epistaxis is easily treated with endoscopic visualization. Epistaxis secondary to tumors can be controlled via an endoscopic approach. Patients with Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) can have more selective laser control of telangiectasia using endoscopic technique. Endoscopic septodermoplasty is straight-forward and avoids external incisions. Following a protocol for control of hemorrhage from an injured carotid artery during endoscopic sinus surgery, patients can survive with good function.

SUMMARY

Endoscopic visualization and techniques are the state of the art for surgical control of epistaxis. Alternatives are embolization or external/Caldwell-Luc approaches.

The use of a nasal obturator in hereditary haemorrhagic telangiectasia: an alternative to Young's procedure

Epistaxis associated with hereditary haemorrhagic telangiectasia (HHT) is a challenging condition. Septodermoplasty, electrocautery and laser treatment often provide short-term relief only. The surgical closure of the nostrils ('Young's procedure') represents a longer term solution but has the disadvantage of causing permanent complete nasal obstruction. A Silastic obturator has the advantage of being a non-surgical intervention and allows temporary relief of the nasal obstruction. We present the cases of three patientswith HHT who used the obturator with good clinical effect, suggesting that this is a realistic non-surgical alternative to Young's procedure for patients with HHT.

Packing in endonasal surgery

Nasal packing is used to control bleeding in epistaxis and after endonasal surgery, for internal stabilization, and to prevent synechiae or restenosis, particularly after surgery. Generally accepted standards regarding the materials that should be used for packing, how long the packing should be left in place, or the indications for nasal packing are lacking. In view of the present lack of standardization and the many different packing materials used, we review the currently available materials and outline their respective properties, indications, and risks.

Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage

We evaluated whether a thermosoftening treatment with warm saline of a nasotracheal preformed tube can improve navigability through the nasal passageways and reduce epistaxis and nasal damage. A total of 150 patients were randomly allocated to three groups: Group I (untreated tube group, n = 50), Group II (35 degrees C treated tube group, n = 50), and Group III (45 degrees C treated tube group, n = 50). In Groups II and III, the tubes were softened at 35 +/- 2 degrees C and 45 +/- 2 degrees C with warm saline, respectively. In Group I the tube was prepared at room temperature (25 +/- 2 degrees C). The incidence of epistaxis and nasal damage in Groups II and III was significantly less than that of Group I (P: < 0.05). Despite the more frequent incidence of smooth passage in Group III, no statistical difference was found among the groups. Logistic regression analysis also confirmed that epistaxis was more likely to be reduced when the tube had been thermosoftened (odds ratio = 1.46, 95% confidence interval = 1.02, 2.11). We conclude that simple thermosoftening treatment of the nasotracheal tube with warm saline helps to reduce epistaxis and nasal damage.

IMPLICATIONS

Thermosoftening treatment of a nasotracheal tube with warm saline before intubation can effectively reduce epistaxis and nasal damage. This technique is safe, easy, and suitable for all types of tubes and does not require additional implements.

Epistaxis management: what's new and what's noteworthy

In many ways, the treatment of epistaxis is not new. Nasal packing was used in the 4th century BC. Our modern-day management of epistaxis is a little more sophisticated, with the advent of new products, rigid endoscopes, improved surgical techniques, and arterial embolization. Research plays a critical role in shaping our epistaxis practice management. Epistaxis is recognized as one of the most common ear, nose, and throat (ENT) problems; it affects persons of all ages. Proper first aid steps can be effective. Only 10% of individuals with nasal bleeding seek medical attention. Health care providers in all primary care settings encounter patients experiencing epistaxis and need to be knowledgeable in emergency epistaxis management. The evaluation will be key to successful identification of the site of bleeding and to identify possible underlying cause(s) that will guide treatment options.

Transarterial coil embolization of the internal and external carotid and maxillary arteries for prevention of hemorrhage from guttural pouch mycosis in horses

OBJECTIVES

To develop a transarterial coil embolization technique for occlusion of the internal carotid artery (ICA), external carotid artery (ECA), and maxillary arteries (MA) in normal horses and to evaluate this technique for prevention of hemorrhage in horses affected with guttural pouch mycosis.

ANIMALS

Ten adult, normal horses and 4 horses with guttural pouch mycosis.

METHODS

All horses had transarterial coil embolization of the rostral and caudal ICA, caudal MA, and rostral ECA. In 1 affected horse, an aberrant actively bleeding branch of the ECA was also occluded. Normal horses had a premortem angiogram, and were killed either at 1 or 2 weeks or 1, 2, or 3 months after the procedure. Specimens from the ICA, ECA and MA were evaluated by light microscopy.

RESULTS

No surgical complications were observed, except 1 horse that developed laryngeal hemiplegia and 1 pilot horse that had embolization of the cerebral arterial circle. In normal horses, premortem angiography confirmed complete occlusion of all vessels, and coils were positioned as intended. All normal horses had partially maturing to mature, continuous thrombi occluding at the coils. In affected horses, no further episodes of epistaxis were observed. By day 60, all mycotic plaques had resolved without further treatment. Ophthalmic complications were not observed.

CONCLUSION

Transarterial embolization provided a safe, rapid, and effective method for ICA, ECA, and MA occlusion in normal and affected horses. In affected horses, the technique was possible despite active bleeding, allowing adequate identification and occlusion of all sources of hemorrhage.

Microcatheter embolization of intractable idiopathic epistaxis

PURPOSE

To assess the efficacy and safety of microcatheter embolization in the treatment of intractable idiopathic epistaxis.

METHODS

Thirty-seven patients underwent microcatheter embolization in 1991-1998. We evaluated retrospectively the technical and clinical outcome, the number of complications, the duration of embolization in each case, and the number of blood transfusions needed. All embolizations were done with biplane digital subtraction angiography (DSA) equipment. The procedure was carried out under local anesthesia using transfemoral catheterization, except in one case where the translumbar route was used. Tracker 18 or 10 microcatheters were advanced as far as possible to the distal branches of the sphenopalatine artery. Polyvinyl alcohol (PVA) particles were used for embolization in most cases, while platinum coils or a combination of these two materials were occasionally used. The primary outcome was always assessed immediately by angiography. Follow-up data were obtained from patient records, by interviewing patients on the telephone or by postal questionnaires when necessary. The mean follow-up time was 21 months.

RESULTS

The embolization was technically successful in all 37 cases. A curative outcome was achieved in 33 cases (89%). The mean duration of the procedure was 110 min. Four patients (8%) had mild transient complications, but no severe or persistent complications were encountered. Twenty-three patients needed a blood transfusion. Slight rebleeding occurred in three patients during the follow-up; all responded to conservative treatment. One patient suffered two episodes of rebleeding within 2 months after primary embolization. Re-embolizations successfully stopped the bleeding.

CONCLUSION

Embolization is the primary invasive modality for treating intractable idiopathic epistaxis. It proved both safe and effective over a relatively long follow-up.

Percutaneous embolization to control intractable epistaxis in nasopharyngeal carcinoma

BACKGROUND

Epistaxis in patients with nasopharyngeal carcinoma (NPC) who have received radiotherapy can be difficult to control by conventional methods. The use of angiography and embolization to control problematic epistaxis has been well documented in other situations, but its use in severe or recurrent epistaxis following irradiation for NPC has not been described.

METHODS

We retrospectively reviewed case notes of all patients with NPC initially seen with epistaxis over a 4-year period. Those patients with refractory epistaxis which could not be controlled by conventional methods and required angiography and embolization were assessed.

RESULTS

Eight patients who underwent angiography were identified. Five patients showed hypervascularization and three patients had pseudoaneurysms or an aneurysm of the internal carotid artery seen on the angiogram. All these patients were successfully embolized. There were no significant complications after the procedure.

CONCLUSION

We conclude that embolization is a safe and effective method of controlling refractory epistaxis in patients irradiated for NPC.

Occlusion of the internal carotid artery by means of microcoils for preventing epistaxis caused by guttural pouch mycosis in horses

Occlusion of the internal carotid artery by insertion of intravascular platinum microcoils for guttural pouch mycosis was experimentally evaluated in 9 healthy adult Thoroughbred horses. The internal carotid artery was ligated to its origin, and an arteriotomy was made distal to the ligature, which was then occluded by insertion of the microcoil approximately 13 cm distal to its origin. Cessation of blood flow was determined visually and by angiography at the arteriotomy site. Six horses were evaluated for complication clinically and by endoscopy after surgery. One horse was necropsied after 30 days of surgery for histological evaluation of artery thrombus formation. In the other 3 horses, the blood flow of the right internal carotid artery was monitored, before and after microcoil occlusion of the left internal carotid artery. One or 2 microcoils stopped blood flow within a few minutes. No other abnormal findings were observed clinically. Thrombus was observed in the occluded segment of 1 horse 30 days after insertion; but no abnormalities were detected. The blood flow in the right internal carotid artery increased by approximately 28-58% after occlusion of the left internal carotid artery. This microcoil vascular occlusion technique causes an effective thrombosis, and based on experimental studies and clinical application in 2 horses with epistaxis due to guttural pouch mycosis, this technique would appear to be safe and efficacious.

Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation

BACKGROUND

Many complications were reported to be related with nasotracheal intubation. Various chemical or mechanical techniques have been proposed to decrease hemorrhage and trauma associated with nasotracheal intubation but the results remain controversial. We conducted a prospective, randomized, single-blind study to elucidate the effect of an endotracheal tube softened with warm water before use on the incidence and severity of epistaxis following nasotracheal intubation.

METHODS

Sixty-two healthy, (ASA class I or II) patients scheduled for elective surgery were randomly assigned into two groups. Patients in the treatment group were intubated with a softened endotracheal tube made possible by heating it in warm water while those in the control group were intubated with unsoftened (intact) tube. Epistaxis was evaluated immediately after intubation and its severity was graded as none, mild, moderate and severe. The use of Magill forceps and postoperative nasal morbidity were also recorded.

RESULTS

The total incidence of epistaxis in the "unsoftened" group was significantly higher than that of "softened" group (76.7% vs. 43.8%, P = 0.0002). The severity of nasal hemorrhage was also significantly lightened in the "softened" group. No technical difficulty was encountered in intubation with a softened endotracheal tube by prewarming. The morbidity referable to nasal intubation, however, did not differ in both groups.

CONCLUSIONS

In conclusion, our study shows that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during the act of nasotracheal intubation. It is an effective way and worth a try.

Treatment of hereditary haemorrhagic telangiectasia by the pulsed dye laser

Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome, Osler's disease) is an inherited abnormality of the vasculature characterized by abnormal subepithelial vessels. Treatment has included repeated intranasal cautery, intra-arterial embolization and arterial ligation. Historically, the operation of septodermoplasty and the use of systemic/topical oestrogens have been the most effective and lasting treatments, but over time the telangiectasias recur. There is increasing interest in the use of a variety of lasers for intranasal photocoagulation. A report of nine patients suffering from hereditary haemorrhagic telangiectasia who have undergone laser treatment with the Chromos pulsed dye laser is presented. This laser produces light energy at a wavelength of 585 nm and causes localized thermal damage to the blood vessel wall. Initially, no patient saw an improvement in their symptoms, but following an average of approximately three courses of treatment, all have reported a measurable reduction in the number of epistaxes suffered. Although no treatment completely resolves the epistaxis associated with this condition, we have found the pulsed dye laser to be effective at treating telangiectasias within the anterior nasal cavity.

Epistaxis in anticoagulated patients: educating an at-risk population

Epistaxis is a common problem amongst anti-coagulated patients. Application of first-aid principles can control the majority of bleeds. In our sample of 60 patients attending the anticoagulant clinic, 40% were unable to think of a single measure that would be helpful in controlling a nose bleed. 6 weeks after being given first-aid advice the proportion of patients able to recall at least three first-aid principles had improved from 8% to 50%. First-aid education in this respect was well received and there was a good recall rate. Provision of advice verbally backed up by a printed sheet gave best rates of recall.

[Prevalence of hemorrhages due to vitamin K deficiency in The Netherlands, 1992-1994]

OBJECTIVE

To determine the prevalence of vitamin K deficiency bleeding in the Netherlands, in order to evaluate the efficacy of recommendations on vitamin K prophylaxis.

DESIGN

Descriptive.

SETTING

University Hospital Nijmegen, the Netherlands.

METHODS

Active surveillance of vitamin K deficiency bleeding (VKDB) by the Dutch Paediatric Surveillance Unit from October 1, 1992 to December 31, 1994.

RESULTS

Of the 19 reported cases 5 could be validated as late vitamin K deficiency bleeding: 2 idiopathic cases, and 3 secondary cases due to liver disorders. One case had intracranial bleeding and died. None of the cases had received exactly the recommended prophylaxis. The incidence of late VKDB was calculated to be 1.1/100,000 live births. Before vitamin K prophylaxis was recommended the incidence was estimated to be 7/100,000.

CONCLUSION

The present Dutch recommendations for prevention of vitamin K deficiency bleeding-1 mg vitamin K at birth and thereafter for breastfed infants daily 25 micrograms from 2 to 13 weeks-appear effective.

Evaluation of Surgicel Nu-knit, Merocel and Vasolene gauze nasal packs: a randomized trial

A randomised, prospective trial to evaluate Surgicel Nu-knit with Vasolene ribbon gauze and Merocel packs, respectively. Sixty patients (36 males and 24 females) undergoing bilateral nasal surgery, each having the same procedure performed on both sides, were recruited. The mean age was 49 years (range: 16-70 years). At operation, Surgicel Nu-knit was placed in one nostril, the other nostril was randomised to Vasolene gauze or Merocel. Twenty-four hours post-operatively, patients were asked to assess the discomfort experienced in either side of the nose while the packs were in position and on removal. The length of time and estimated amount of bleeding following removal of packs were also assessed. Surgicel Nu-knit caused significantly less discomfort both while in position and on removal than Vasolene gauze (p < 0.01, respectively). Compared to Merocel sponges, Surgicel Nu-knit caused significantly less discomfort on removal (p < 0.01). Bleeding following removal was also significantly less compared to the other packs. One patient in the Surgicel group required a general anaesthetic to remove a retained pack fragment. At 6-week follow-up, no nasal complications were noted in all of the groups.

Early complications of packing after nasal surgery with three different materials

OBJECTIVE

To investigate and compare the early complications of nasal packing with three different packing materials after surgical trimming of nasal turbinates.

DESIGN

From a group of patients admitted to two Ear, Nose and Throat Departments for surgical trimming of inferior turbinates, those who consented were included in this study. Randomised patient packs were used and randomisation was carried out by a third party not directly involved in the study. Patients' nostrils were packed with calcium sodium alginate (Kaltostat), glove finger packs or trousered paraffin gauze.

SETTING

Two District General Hospitals (DGH) in the United Kingdom (UK) during the period from February 1989 to June 1990.

SUBJECTS

92 patients between the age of 16 years and 60 years who consented out of a population who were admitted to two DGHs for surgical trimming of inferior turbinates.

MAIN OUTCOME MEASURES

The state of the nostrils in each patient was assessed by the authors (authors 1 and 3 in Hospital 1 and author 2 in Hospital 2) at the time of discharge and at a postoperative outpatient visit at 3 weeks after discharge.

RESULTS

5% of nostrils packed with calcium sodium alginate (Kaltostat), 27% of nostrils packed with glove finger packs and 20% of nostrils packed with paraffin trouser packs were found to have clots on discharge from the hospital. At the post-discharge followup, when each complication was considered separately, there were more complications in the group who had their nostrils packed for 48 hours (14.2%) than in those who had packs in for 24 hours (7.3%). Significantly less complications were seen at 3 weeks with paraffin gauze packs (6.6%) than in the other two packing material (13.9%).

CONCLUSIONS

Our findings suggest that, of the pack types studied 1) nostrils packed with calcium sodium alginate (Kaltostat) leave less clots in the nostrils 2) leaving packing in for 48 hours produces significantly more complications in the early post-operative period especially with calcium sodium alginate.

A comparison of packing materials used in nasal surgery

A prospective study was performed to compare Telfa, paraffin gauze, Merocel and BIPP used postoperatively following septal or turbinate surgery. Packs were assessed in terms of patient comfort, control of bleeding and ease of removal. There was little to choose between the packs while they were in situ and there was no significant difference in ease of removal. On removal the Telfa and paraffin gauze were associated with less discomfort and less bleeding than BIPP or Merocel (p < 0.05).

Epistaxis and nasotracheal intubation--prevention with vasoconstrictor spray

Eighty patients having anaesthesia for oral surgery requiring nasal intubation were randomly allocated to be intubated with either a plain Magill red rubber or cuffed polyethylene endotracheal tube and in a double blind manner, to receive xylometazoline 0.1% vasoconstrictor nasal spray. The extent of any epistaxis occurring was assessed by an independent observer. With the Magill tube there was bleeding in one out of twenty patients in both the vasoconstrictor group and non vasoconstrictor group at intubation and no bleeding in either of the two groups at extubation. With the polyethylene tube sixteen out of twenty patients had bleeding in the non vasoconstrictor group. This improved to seven out of twenty with the administration of vasoconstrictor drops at intubation (chi square 10.2; p < 0.01) in the polyethylene tube group. At extubation ten out of twenty patients had bleeding in the non vasoconstrictor group improving to two out of twenty with the administration of the vasoconstrictor (chi square 9.6; p,0.01). The use of the vasoconstrictor xylometazoline helped to reduce epistaxis that occurred during nasal intubation and further study into the type of endotracheal tube is recommended.

[Angiofibroma of the nasal fossae: apropos of 12 cases observed in Mali]

Over a period of 2 years, 12 cases of angiofibroma of the nasal fossae were observed in an otorhinolaryngology department in Bamako. The classical female sex bias attributed to this disorder which involved patients under 40 years of age in 10 cases was not found. Also in contrast with usual observations, the lesion was located in the septum in only one third of cases. In all cases management was performed on an outpatient basis and diagnosis was confirmed by histology. All patients underwent excision of polyps by the endonasal route under local anesthesia. In 2 patients with septal angiomas, electrical cautery did not suffice to control bleeding and had to be associated with abrasion from the submucosal to the sub-perichondral area. This African series shows that simple and rapid management of angiofibromas of the nasal fossae prevents complications which could be particularly severe in tropical regions.

The therapeutic value of medical photography

Medical photography is shown to have therapeutic value in illustrating to a patient a previously hidden clinical lesion. The sight of the extent and nature of a hole in her nasal septum which the patient had caused by picking her nose allowed her to stop this habit where previous medication and psychotherapy had failed.

Early management of multiply injured patients with maxillofacial injuries transferred to hospital by helicopter

It has been suggested that early intensive medical treatment will improve the outcome for trauma patients with severe injuries. A Helicopter Emergency Medical Service (HEMS) based in an urban area was inaugurated by The Royal London Hospital. Specially trained medical and paramedical personnel flew with the helicopter to accident scenes. On return to the hospital, multi-disciplinary teams, including maxillofacial, were called to manage the patients. Operations from its own helipad commenced from the end of August 1990. A retrospective study of 192 patients transferred by HEMS to the Royal London Hospital during 16 months was undertaken. 18% (34) patients had facial injuries recognised at primary and secondary surveys according to Advanced Trauma Life Support (ATLS) protocols. The problems of early management are described and routine techniques for the control of haemorrhage from the maxillofacial area were developed.