Interventional Neuroradiology Applications in Otolaryngology, Head and Neck Surgery

Influence of meteorological variables on the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate (Lorca, Spain)

BACKGROUND AND OBJECTIVES

Epistaxis is a common emergency for otorhinolaryngologists. Although the aetiological factors have been widely studied, they remain subject to debate. The role of meteorological variables has been discussed in recent years, but results have been inconsistent. Given a lack of prior data, the aim of our study was to identify the meteorological variables that influence the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate in Spain.

METHODS

Case-control study.

CASES

patients who attended the accident and emergency department of a secondary level hospital for epistaxis over a 9-year period (2011-2019). Controls were established by simple random sampling among emergency rooms visits in general (patients who attended the same centre over the same period of time). Sociodemographic, clinical and meteorological variables were all taken into account.

RESULTS

2749 patients in the epistaxis group and 2764 in the control group. There were significant differences in the epistaxis group, with a higher proportion of male (62.85%) and older patients. Univariate and multivariate analysis revealed that the daily minimum temperature and maximum wind speed were factors significantly associated with the onset of epistaxis. In addition, logistic regression analysis showed that decreases in minimum temperature and increases in maximum wind speed were associated with an increase in epistaxis (p < 0.01). No association was found between hospital admission and the weather conditions.

CONCLUSION

Our findings suggest that low minimum temperatures and high wind speeds are associated with the number of visits to hospital accident and emergency departments for epistaxis, but not with hospital admission.

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany

BACKGROUND

Reports of a decrease in hospital admissions during the coronavirus disease 2019 (COVID-19) lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.

AIM

To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.

METHODS

A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period. This was done on a weekly basis before, during, and after the lockdown. An Interrupted Time Series was used as the analysis method.

RESULTS

In our analysis, we included 26183 patients. The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients (P < 0.05). This effect was most pronounced in the age group of 0-39 years, where the decrease was highly significant (P < 0.001). However, there was no change observed in patients aged 80 years and older (not significant). With the end of the lockdown period, the overall number of patients, especially in the youngest age group, increased abruptly and significantly (P < 0.01).

CONCLUSION

During the lockdown period, there was a decrease in hospital admissions for younger patients with epistaxis, possibly due to the fear of COVID-19 exposure. We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Risk Factors for Severe Clinical Course in Epistaxis Patients

Purpose: Epistaxis is a common medical emergency that may require admission to the emergency department (ED) and treatment by an otolaryngologist. Currently, there are no widely accepted indications for hospitalization, and the decision is based on personal experience. Methods: A retrospective study of 1171 medical records of patients with epistaxis treated at our tertiary medical center ED from 2013 to 2018 with no age limit. The presence of recurrent epistaxis, a posterior source of bleeding, the need for hospitalization, the need for blood transfusion, or surgical intervention defined severe clinical course. Results: The 1171 admissions included 230 recurrent admissions for a total of 941 patients (60% males) who were treated by an otolaryngologist. The average age was 57.6 in the adult population (>15) and 6.6 in the pediatric population (≤15). Of all patients, 39% had hypertension; 39% took antiplatelet/anticoagulation therapy; 63% came during winter-a significant risk factor; 34 (2.9%) had reduced hemoglobin levels of >1gr%, but only 7 received a blood transfusion; 131 (11%) were hospitalized, and 21 (1.8%) required surgical control of the bleeding. Age (OR 1.02; CI 1.01-1.023), male sex (OR 2.07; CI 1.59-2.69), hypertension (OR 1.76; CI 1.27-2.45), and antiplatelet/anticoagulation therapy (OR 2.53; CI 1.93-3.33, OR 1.65; CI 1.11-2.44, respectively), were significantly correlated with severe clinical course. Conclusion: Epistaxis is significantly more common and severe in older male patients with hypertension or antiplatelet/anticoagulation therapy. However, few need a blood transfusion or surgical intervention. In borderline cases with no definitive indication for hospitalization, we suggest adopting these factors as indications for hospitalization due to their marked influence on the clinical course. Routine coagulation tests are indicated in patients treated with warfarin or combined antiplatelet + anticoagulation therapy.

Combining superselective catheterization and electrochemotherapy: A new technological approach to the treatment of high-flow head and neck vascular malformations

Introduction

The study aims to demonstrate a combination of superselective catheterization and electrochemotherapy as a feasible and effective new technological approach in treating high-flow vascular malformations of the head and neck region.

Patients and methods

In the patient with high-flow arteriovenous malformation of the lower lip, superselective catheterization was performed under general anesthesia. The microcatheter was used to administer 750 IU BLM intra-arterially into the feeding vessel. The whole malformation surface was then covered with 15 applications of electric pulses using the plate electrode.

Results

Excellent response, without functional or aesthetic deficits, was obtained in 10 weeks. During this period, debridement and necrectomy were performed regularly on follow-up visits. The pain was managed with oral paracetamol and sodium metamizole.

Conclusion

Combining electrochemotherapy using bleomycin with superselective catheterization and arteriography is a feasible treatment option for high-flow vascular malformations in the head and neck region and could play a significant role in managing these challenging lesions.

Management of a Highly Vascular Low-grade Myofibroblastic Sarcoma of the Mandible

An 11-year-old male patient presented with a large, highly vascular, destructive mandibular mass. An intraoral biopsy showed pleomorphic spindle cells arranged in intersecting fascicles, with scattered atypia. A diagnosis of low-grade myofibroblastic sarcoma was made. The lesion was treated with preoperative arterial embolization followed by surgical resection and reconstruction with a fibular osteomyocutaneous free flap. To our knowledge, no reports of highly vascular mandibular low-grade myofibroblastic sarcoma are available in the literature.

Two rare cases of sinonasal vascular malformation in the pediatric population

Vascular malformations presenting in the nasal cavity and paranasal sinuses are rare. Differentiating benign vascular malformations of the sinonasal cavity from other pathologic entities can be challenging and the role of preoperative angiography and embolization is not well defined. We present two unique cases of large pediatric sinonasal vascular malformations and describe their presentation, diagnosis and subsequent management. Both patients underwent embolization of the ipsilateral arterial supply followed by successful and complete endonasal surgical excision. This report provides description of management of the very rare occurrence of sinonasal vascular malformation in two adolescents.

Interventional Management of Head and Neck Tumors

Advancements in medical imaging and device technology allow minimal invasive procedures for the diagnosis and treatment of various disorders. For the management of tumors in head and neck region, these image-guided interventions play essential role in the often used multidisciplinary approach. Tissue sampling under ultrasound or computed tomography guidance is generally the first step to reach a pathological diagnosis. For head and neck tumors with high vascularity, embolization using particulate matter, liquid embolic agents, or coils is used to achieve successful tumor resection with minimal blood loss. Hemorrhage related to head and neck tumors can be evaluated and managed with endovascular techniques with minimal morbidity and mortality. Intra-arterial chemotherapy, radiofrequency ablation, and cryotherapy are new techniques for the management of advanced head and neck cancer which may serve as an alternative to achieve locoregional control and survival when curative resection may not be feasible.

Topical Tranexamic Acid for the Treatment of Acute Epistaxis: A Systematic Review and Meta-analysis

Objective: To compare topical tranexamic acid (TXA) with control groups for the treatment of acute epistaxis assessing bleeding cessation, discharge within 2 hours, rebleeding rates, complication rates, and patient satisfaction. Data Sources: PubMed, CINAHL, LILACS, Scopus, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched from inception to November 2018. Study Selection and Data Extraction: All randomized controlled trials comparing topical TXA with control groups for the treatment of acute epistaxis in humans were included. There were no age, language, or date restrictions. Data were double extracted into a predefined worksheet, and quality analysis was performed using the Cochrane Risk of Bias tool. Data Synthesis: Three studies (n = 408 patients) were identified. Topical TXA was not associated with a statistically significant difference in cessation of bleeding within 30 minutes. However, more patients were discharged within 2 hours of arrival, there were fewer episodes of rebleeding within both the first 24 hours and at 1 week, and there was higher patient satisfaction in the TXA group. There was no difference identified in complication rates. Relevance to Patient Care and Clinical Practice: This review compares topical TXA with control groups for epistaxis and discusses the risks and benefits of adding this therapy to usual care. Conclusions: Topical TXA appears to be a reasonable option for the treatment of acute epistaxis, with reduced rebleeding rates, shorter discharge times, and minimal risk of complications. Topical TXA may be considered as part of the treatment of acute epistaxis.

Development of two surgical approaches to the pituitary gland in the Horse

BACKGROUND

Current treatment of equine pituitary pars intermedia dysfunction (PPID) requires daily oral medication. Minimally invasive surgical palliation of this condition is appealing as a single treatment to alleviate the clinical signs of disease, dramatically improving the welfare of the horse.

OBJECTIVE

To develop a surgical approach to the equine pituitary gland, for subsequent treatment of PPID.

STUDY DESIGN

A cadaver study to develop methodology and a terminal procedure under anaesthesia in the most promising techniques.

ANIMALS AND METHODS

Four surgical approaches to the pituitary gland were investigated in cadaver animals. A ventral trans-basispheniodal osteotomy and a minimally invasive intravenous approach via the ventral cavernous sinus progressed to live horse trials.

RESULTS

Technical complications prevented the myeloscopic and trans-sphenopalatine sinus techniques from being successful. The ventral basisphenoidal osteotomy was repeatable and has potential if an intra-operative imaging guidance system could be employed. The minimally invasive approach was repeatable, atraumatic and relatively inexpensive.

CONCLUSIONS

A minimally invasive surgical approach to the equine pituitary gland is possible and allows for needle placement within the target tissue. More work is necessary to determine what that treatment might be, but repeatable access to the gland has been obtained, which is a promising step.

Facial Palsy Following Embolization of a Juvenile Nasopharyngeal Angiofibroma

Objectives:

To describe a case of the rare complication of facial palsy following preoperative embolization of a juvenile nasopharyngeal angiofibroma (JNA). To illustrate the vascular supply to the facial nerve and as a result, highlight the etiology of the facial nerve palsy.

Methods:

The angiography and magnetic resonance (MR) imaging of a case of facial palsy following preoperative embolization of a JNA is reviewed.

Results:

A 13-year-old male developed left-sided facial palsy following preoperative embolization of a left-sided JNA. Evaluation of MR imaging studies and retrospective review of the angiographic data suggested errant embolization of particles into the petrosquamosal branch of the middle meningeal artery (MMA), a branch of the internal maxillary artery (IMA), through collateral vasculature. The petrosquamosal branch of the MMA is the predominant blood supply to the facial nerve in the facial canal. The facial palsy resolved since complete infarction of the nerve was likely prevented by collateral blood supply from the stylomastoid artery.

Conclusions:

Facial palsy is a potential complication of embolization of the IMA, a branch of the external carotid artery (ECA). This is secondary to ischemia of the facial nerve due to embolization of its vascular supply. Clinicians should be aware of this potential complication and counsel patients accordingly prior to embolization for JNA.

Surgical and interventional radiological management of adult epistaxis: systematic review

BACKGROUND

There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery.

METHOD

A systematic review of the literature was performed using a standardised published methodology and custom database search strategy.

RESULTS

Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73-100 per cent and 75-92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1-1.5 per cent). No articles directly compared the two techniques.

CONCLUSION

Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis

Objective

To determine the demographics and seasonal and geographic variation of epistaxis in the United States.

Study Design

Retrospective cohort analysis based on data from Medicare claims.

Setting

Emergency department visits.

Subjects and Methods

We used a 5% sample of Medicare data from January 2012 to December 2012. Our cohort included patients with an incident diagnosis of epistaxis during a visit to the emergency department, excluding those with a diagnosis in the prior 12 months. Demographics included age, sex, race, and ethnicity. We compared the rate of emergency department visits for epistaxis by geographic division and individual states.

Results

In the 5% sample of Medicare data, 4120 emergency department visits for incident epistaxis were identified in 2012. Our results showed an increase in the emergency department visits for epistaxis with age. Compared with patients <65 years old, patients who were 66 to 76, 76 to 85, and >85 years old were 1.36 (95% confidence interval [95% CI], 1.23-1.50), 2.37 (95% CI, 2.14-2.62), and 3.24 (95% CI, 2.91-3.62) more likely to present with epistaxis, respectively. Men were 1.24 (95% CI, 1.17-1.32) times more likely to present with epistaxis than women. Blacks were 1.23 (95% CI, 1.10-1.36) times more likely to present with epistaxis when compared with non-Hispanic whites. Epistaxis emergency department visits were 40% lower in the summer months versus winter. The seasonal variation was more pronounced in the northern versus southern United States.

Conclusion

Emergency department visits for epistaxis increase with age and appear to be seasonal, with a more pronounced variation in the northern versus southern United States.

Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies

CONCLUSIONS

Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings.

OBJECTIVE

To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings.

MATERIALS AND METHODS

From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram).

RESULTS

Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).

Postirradiated carotid blowout syndrome in patients with nasopharyngeal carcinoma: a case-control study

BACKGROUND

Carotid blowout syndrome is one of the most devastating complications of nasopharyngeal carcinoma (NPC) therapy.

METHODS

A retrospective review was conducted from January 2004 to April 2013. Thirty-one patients with carotid blowout syndrome were enrolled and a case control study was conducted to analyze the risk factors.

RESULTS

When a comparison was made between the carotid blowout syndrome and matched non-bleeding group, there was a significantly higher local recurrence rate and prevalence of skull base osteoradionecrosis (ORN) in the carotid blowout syndrome group compared to those of the control group (both p < .001). The hazard ratio of carotid blowout syndrome was 3.599 between patients with or without reirradiation (95% confidence interval, 1.465-8.839; p = .005, adjusted for nasopharyngectomy and chemotherapy) using a Cox proportional hazard model.

CONCLUSION

Reirradiation and skull base ORN are strong predisposing factors for carotid blowout syndrome, and therefore they should be mentioned in the informed consent form before treatment.

Arteriovenous fistula presenting as a failed hearing test

Congenital arteriovenous fistulas (AVFs) result from inadequate differentiation of the vascular system during fetal development. This case report describes an AVF of the neck, which possibly manifested as noise interference during a newborn hearing-screening test by otoacoustic emissions (OAEs). This report is in compliance with the institutional review board regulations of the University of Puerto Rico School of Medicine.