Randomized controlled trial comparing Nd:YAG laser photocoagulation and bipolar electrocautery in the management of epistaxis

Randomized controlled double-blinded clinical trial of the effect of bevacizumab injection in the management of epistaxis in HHT patients undergoing surgical cauterization

INTRODUCTION

Given its role in the disease pathophysiology, inhibition of VEGF-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). This study evaluates the efficacy of a submucosal injection of bevacizumab, a VEGF-inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery.

METHODS

This randomized, double-blinded placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality-of-life (QOL), including the Epistaxis Severity Score (ESS) and Short Form 12 (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71.

RESULTS

Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated reduced ESS versus baseline at 1 (-1.2, p = 0.01) and 4 (-1.2, p = 0.05) months post-procedure. The bevacizumab group demonstrated reduced ESS versus baseline at 1 (-2.3, p<0.001), 2 (-2.3, p<0.001), 4 (-2.0, p = 0.003), and 6 (-1.3, p = 0.05) months post-procedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months but the difference was not statistically significant.

CONCLUSION

The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared to electrocautery alone. This article is protected by copyright. All rights reserved.

Laser-Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review

BACKGROUND AND OBJECTIVES

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis.

STUDY DESIGN/MATERIALS AND METHODS

A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ² and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates.

RESULTS

Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients.

CONCLUSIONS

HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

A blind area of origins of epistaxis: technical or cognitive?

PURPOSE

To investigate common origins and features of anterior epistaxis.

METHODS

Patients (168) with anterior nose bleed were studied from May to October 2013. Endoscopic examination with angled endoscope and then subsequent management (radiofrequency, selective packing,) was performed.

RESULTS

Under thorough nasal endoscopy, anterior nasal bleeding origin was ranked in turn as follows: the anterior nasal septum (NS 83.3%), the small area of anterior lateral wall of nasal cavity corresponding to the nasal back (NB 7.1%), the anterior end of the inferior turbinate (IT 5.4%), and the nasal part of the nasal cavity roof (NR 4.2%). Arterial lesion and hypertension led to large instant quantity of bleeding; hypertension and negligible bleeding origin prolonged bleeding duration. Bleeding was successfully controlled with nasal endoscopy and radiofrequency or selective packing.

CONCLUSIONS

The arterial bleeding small area of anterior lateral wall of nasal cavity corresponding to the nasal back and the nasal part of the nasal cavity roof accounted for more than 10% of anterior epistaxis and a thorough endoscopic examination should include these area with angled endoscope. Then radiofrequency and selective packing will sharply reduce the bleeding duration.