Optimizing the outcome of transnasal endoscopic sphenopalatine artery ligation in managing refractory posterior epistaxis: A case-control analysis

Posterior epistaxis management: review of the literature and proposed guidelines of the hellenic rhinological-facial plastic surgery society

PURPOSE

Posterior epistaxis is a common emergency in ENT practice varying in severity and treatment. Many management guidelines have been proposed, all of which are a product of retrospective analyses due to the nature of this pathology, as large-scale double-blind studies are impossible-even unethical-to conduct. The purpose of this review is to perform a thorough analysis and comparison of every treatment plan available and establish guidelines for the best possible outcome in accordance to every parameter studied. Given the extensive heterogeneity of information and the multitude of studies on this topic, along with the comparison of various treatment options, we opted for a literature review as our research approach.

METHODS

A review of the literature was performed using PubMed Database and search terms included "posterior epistaxis", "treatment", "management", "guidelines", "algorithm" "nasal packing", "posterior packing", "surgery", "SPA ligation", "embolization", "risk factors" or a combination of the above.

RESULTS

Initial patients' assessment invariably results in most cases in posterior packing. There seems to be a superiority in recent literature of early surgery over nasal packing as a definitive treatment. Embolization is usually used after surgery failure, except for specific occasions.

CONCLUSION

Despite the vast heterogeneity of information, there seems to be a need for re-evaluation of the well-established treatment plans according to more recent studies.

Management of Recurrent and Refractory Posterior Epistaxis by Transnasal Endoscopic Sphenopalatine Artery Cauterization: a Prospective Cohort Study

Transnasal endoscopic sphenopalatine artery occlusion procedures are becoming the standard of care for intractable posterior epistaxis. Improved endoscopic anatomical features of the lateral nasal wall and endoscopic skill with high-resolution cameras result in a higher success rate of endoscopic intervention. To evaluate the safety and effectiveness of endoscopic cauterization of the sphenopalatine artery (ESPAC) in controlling intractable posterior nasal bleeding. This prospective cohort study enrolled patients with refractory posterior epistaxis from August 2016 to December 2019. The trial recruited patients between 18 and 65 years of age with a history of recurrent and refractory posterior epistaxis receiving endoscopic arterial cauterization due to conservative treatment failure. All of the cases involved bipolar cauterization. Recurrent nosebleeds must pause for at least three months for a procedure to be considered successful. In the first 30 days following surgery, complications are recorded. 415 patients with epistaxis received both inpatient and outpatient care. Transnasal ESPAC was necessary for 36 patients (11.5%). The most common comorbidity was hypertension accounting for 9 (23%) cases. Thus, 26 of 36 (72%) cases had a unilateral ESPAC, while 10 (28%) had a bilateral ESPAC. Twenty-two (61%) and ten (28%) patients had single and two branching patterns of the sphenopalatine artery, respectively. Septal correction and middle meatus antrostomy (44%) were the most performed additional procedures. During the three-month follow-up period, 35 patients in this study had epistaxis control; the success rate of ESPAC was 97.2%. There were no significant postoperative complications found. Endoscopic sphenopalatine artery cauterization is successful in controlling 97.2% of posterior epistaxis. It is safe and effective without any significant complications.

Woodruff's plexus-arterial or venous?

PURPOSE

Woodruff's plexus is a vascular network located on the posterior lateral wall of the inferior meatus of the nasal cavity and it is generally considered to be responsible for posterior epistaxis. Despite being initially identified in 1949 as a venous plexus, discrepancies exist within literature regarding this anatomical structure, particularly its arterial or venous nature and its association with posterior epistaxis. This systematic review aims to collate information pertaining to Woodruff's plexus and evaluate our current understanding of this vascular area.

METHODS

The systematic review was performed using published data in PubMed, Google Scholar, Scopus, EBSCO and Web of Science platforms using keywords such as 'Woodruff', 'posterior' and 'plexus'. Articles referring to Woodruff's plexus were collected and analysed by independent reviewers.

RESULTS

The search revealed 154 papers, out of which only 40 were included in the review. Out of this number only two papers were anatomical dissection studies, both of which identify the plexus as venous in nature. Seventeen studies describe the plexus as venous by citing these two papers. The remainder of the articles (23) consider Woodruff's plexus as arterial with variability in the reported arteries that supply it.

CONCLUSION

Woodruff's original description of a venous plexus is supported by modern anatomical studies. There are a multitude of reports that Woodruff's plexus is arterial in nature, despite the absence of existing anatomical studies to support this notion. This misconception has likely arisen due to clinical associations in relation to posterior epistaxis.

Randomized Comparative Study of Microwave Ablation and Electrocautery for Control of Recurrent Epistaxis

OBJECTIVE

To compare the outcomes of adult patients with recurrent epistaxis treated intraoperatively with either bipolar electrocautery or microwave ablation (MWA).

STUDY DESIGN

Prospective randomized control study.

MATERIALS AND METHODS

One hundred ten patients with idiopathic recurrent epistaxis who met the inclusion criteria were randomly assigned into MWA group and bipolar electrocautery group. Primary outcomes were the proportion of patients in each group whose bleeding had stopped within 24 hours after treatment and time to achieve successful hemostasis. Secondary outcomes were the rebleeding rate after 3 days, 1 and 12 weeks, and 6 months and complications.

RESULTS

Successful immediate arrest of epistaxis was achieved in all patients. The times to achieve successful hemostasis were 2.13 ± 1.04 minutes in the MWA group and 6.60 ± 2.68 minutes in the bipolar electrocautery group (P = .000). The rates of recurrent bleeding were similar in patients treated with the different approaches (P = .231). However, secondary crusting was observed endoscopically in 59 patients in the bipolar electrocautery group, while pseudomembrane of the ablation zone was seen in 19 (36.5%) patients in the MWA group. Nevertheless, there were no severe postoperative complications, including septal perforation and orbit and brain complications, in either group at the 6-month follow-up.

CONCLUSION

Bipolar electrocautery and MWA had similar outcomes for the treatment of adult patients with recurrent epistaxis. However, MWA resulted in rapid hemostasis with less local nasal pain and less crust. Thus, MWA could be a favorable treatment option for patients with idiopathic recurrent epistaxis.

The distribution of bleeding sites in idiopathic hidden arterial epistaxis

OBJECTIVE

To determine the frequency distribution of bleeding sites in idiopathic hidden arterial epistaxis.

METHODS

In this retrospective cohort study, 107 patients with hidden arterial epistaxis were endoscopically examined for sites of bleeding.

RESULTS

All sites of hidden arterial epistaxis were identified by endoscopic examination. Bleeding sites were identified at initial surgery in 103 patients and during the second surgery in 4. The bleeding sites included: the olfactory cleft region in 47 patients, the inferior meatus region in 29, the middle meatus region in 11, multiple bleeding sites (olfactory cleft and anterior septum) in 3, the anterior roof of the nasal cavity in 4, the nasal floor in 11 and the nasopharynx in 2. The bleeding points showed a white or red volcano-like bump in 75 patients, isolated prominent telangiectasia in 21 and mucosal ulceration in 11.

CONCLUSION

Common sites of hidden arterial epistaxis include the olfactory cleft, inferior meatus and middle meatus. However, there should be awareness of some uncommon bleeding sites (including the anterior roof of the nasal cavity, the nasal floor and the nasopharynx) and of multiple bleeding sites.

Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta-analysis

OBJECTIVES

Epistaxis, especially posterior epistaxis, is occasionally refractory to treatment. In these cases, sphenopalatine artery surgeries, including cauterization and ligation, are required. Previous reports have demonstrated treatment results for these procedures but failed to provide high-level evidence. The aim of this study was to quantify the rates of failure and perioperative complications of these procedures by using a meta-analysis technique.

METHODS

We systematically searched electronic databases and identified articles regarding epistaxis, sphenopalatine artery ligation, or cauterization. Pooled rebleeding and complication rates were calculated by using a random effects model.

RESULTS

A total of 896 cases of sphenopalatine ligation or cauterization for epistaxis were analyzed. Pooled rebleeding rates for the entire cohort, cauterization group, and ligation group were 13.4% (95% confidence interval [CI] 10.0-17.8, P < 0.001), 7.2% (95% CI 4.6-11.0, P < 0.001), and 15.1% (95% CI 9.8-22.5, P < 0.001), respectively. Pooled perioperative complication rates for the entire cohort, cauterization group, and ligation group were 8.7% (95% CI 4.9-15.1, P < 0.001), 10.2% (95% CI 3.8-24.5, P < 0.001), and 6.4% (95% CI 1.8-20.9, P < 0.001), respectively.

CONCLUSION

Overall, sphenopalatine surgery for refractory epistaxis is an effective method because of its low rates of failure and complications. Cauterization is more effective than ligation, whereas complications are comparable between the two procedures. Laryngoscope, 129:1731-1736, 2019.

Identification of bleeding sites and microwave thermal ablation of posterior epistaxis

BACKGROUND

Microwave ablation (MWA) is a relatively new technique which has been used to achieve hemostasis at surgical field. However, few publications have reported MWA for epistaxis.

OBJECTIVES

Our objectives were to identify the bleeding sites/points in instances of posterior epistaxis and to evaluate the efficacy of MWA for controlling bleeding.

MATERIAL AND METHODS

Patients with posterior epistaxis who met the inclusion criteria were examined and treated endoscopically using MWA. Recurrent bleeding and complications were evaluated at 1 and 3 months after treatment.

RESULTS

Of the 71 patients, the bleeding site/point was identified in 67 patients while 4 patients was unknown. Of the 67 patients with known bleeding sites, the olfactory cleft was in 44 patients, the middle meatus in 5 patients, and the inferior meatus in 18 patients. Only the bleeding point was coagulated in the 67 patients while prophylactic MWA in the 4 patients. No side effects or complications (including recurrent bleeding, crusting, nasal discomfort, and nasal septal perforation) were seen at 3-month follow-up.

CONCLUSIONS

MWA may effectively control posterior epistaxis with a low cost and without complications.