[Practical aspects regarding endoscopic treatment for epistaxis]

Endoscopic localization of the sphenopalatine foramen: do measurements matter?

The objective of this study was to evaluate different methods and measurements for localization of the sphenopalatine foramen (SPF) during endoscopic transnasal exposure. The study design consisted of descriptive anatomical study and the setting was in Microsurgical Cadaver Dissection Lab. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the SPF. Multiple measurements were obtained from nasal sill (NS) to SPF, ethmoid crest (EC), and other related landmarks. The results showed that EC was identified in all sides with different degrees of projection. SPF extended below the inferior edge of EC, i.e., lying both in the superior and middle meatus, in 12 sides (75 %), while it was laying only in the superior meatus in 4 sides (25 %). An accessory foramen was identified in 3 sides (18.7 %), all of which were located in middle meatus. The distance from NS to SPF ranged widely from 55 to 76 mm (mean ± SD 64.4 ± 6 mm). The average angle of elevation formed between SPF to NS and nasal floor was 11.4° (range 11-12°). Although many previous studies have reported measurements to SPF, we do not believe these measurements are of practical help due to the wide range of measurements and the lack of standard reference points. The main constant landmark for SPF remains the EC. Since SPF frequently extends below EC, the mucoperiosteal flap should be extended below the inferior edge of this crest to avoid missing the middle meatal part of SPF or any accessory foramina.

Endoscopic cauterization of the sphenopalatine artery in pediatric intractable posterior epistaxis

OBJECTIVE

To evaluate the rule of endoscopic sphenopalatine artery cauterization in posterior intractable epistaxis in pediatric age group as regard technical difficulty, efficacy, and safety in children.

STUDY DESIGN

Retrospective study.

PATIENTS AND METHODS

From March 2008 to February 2011, 7 children (4 male, 3 female) with idiopathic intractable posterior epistaxis, patients' age ranged from 8 to 14 years (10.7 average). All patients underwent preoperative laboratory investigations to exclude bleeding or coagulation disorders and CT paranasal sinus. All patients underwent endoscopic sphenopalatine artery cauterization (7 procedures for 7 patients, 5 were in the right side and 2 were in the left side).

RESULTS

postoperative evaluation showed no recurrence for epistaxis during the post operative follow up period. Also, no complications were found. The average follow up period was 17.8 months.

CONCLUSIONS

Endoscopic cauterization of sphenopalatine artery in pediatric age group was effective and safe technique providing that the surgeon has a good experience regarding pediatric endoscopic sinonasal anatomy. Minimal endoscopic technique in this age group is important to avoid unnecessary operative and postoperative complications. Avoid excessive cauterization to lateral nasal wall in this technique is crucial to avoid unexpected nerve injury or tissue necrosis.

[Sphenopalatinum foramen: an anatomical study]

INTRODUCTION

The position of the sphenopalatine artery is essential for the endoscopic treatment of severe posterior epistaxis. This artery passes through its own foramen, which has a wide range of locations and anatomic relations.

OBJECTIVE

To carry out a descriptive osteological study on the sphenopalatine foramen area. Its anatomy, size, position and relations with turbinates and choanae are described, as well as the existence of accessory foramina.

MATERIAL AND METHODS

Exploration and anatomical study was carried out in 32 human hemi-crania.

RESULTS

The area between middle and superior meatus was considered the most common location of the sphenopalatine foramen in 56.24% of the cases (18 specimens), followed by the superior meatus, with 37.5% (12 hemi-skulls). The foramen was located in middle meatus in just two cases. We found accessory foramina in 50% of the cases, most commonly positioned below the middle meatus. The ethmoidal crest appeared in every skull, producing an anterior osseous projection on the sphenopalatine foramen.

CONCLUSION

There are variations in position, number and anatomic relations that may cause changes in the sphenopalatine artery orifice and its branches into the nasal fossa. The ethmoidal crest, located on the anterior side of the sphenopalatine foramen, can be considered a permanent landmark to find the foramen.

[Ligation of the sphenopalatine artery in posterior epistaxis. Retrospective study of 50 patients]

OBJECTIVES

The aim of this study was to evaluate the efficacy of endoscopic ligation of the sphenopalatine artery in the treatment of severe posterior epistaxis.

METHODS

We have carried out a retrospective study on 50 patients hospitalised with posterior recurrent epistaxis, in whom posterior nasal packing was not effective. All of them underwent surgical treatment, with endoscopic ligation of the sphenopalatine artery to control the epistaxis.

RESULTS

Only seven patients had a new epistaxis after surgery. One of them is being studied for some kind of coagulopathy, another patient was controlled by ligation of the anterior ethmoidal artery and it was necessary to ligate the contralateral sphenopalatine artery in a third patient. The other four patients were controlled with posterior nasal packing and discharged two days after surgery, without any complications.

CONCLUSIONS

We believe that endoscopic ligation of the sphenopalatine artery is a safe technique, with fewer complications than other methods such as posterior packing or embolisation.

[Nasal packing in posterior epistaxis. Comparison of two methods]

OBJECTIVE

To evaluate tolerance and efficiency of two nasal blocking systems for posterior refractory epistaxis.

PATIENTS AND METHODS

A five year comparative and longitudinal prospective study was developed in patients with epistaxis who attended our Emergency Unit and who required posterior nasal packing. Two groups were considered: one group was treated with a bi-chamber pneumatic inflation system (n=105). In other one, posterior occlusion was carried out with gauze, accessing through the mouth and using nasal reinforcement (n=47). The tolerance was measured by means of an analogue scale of pain intensity during the placement and maintenance of the packing, as well as for the need of analgesia. The efficiency was evaluated by episodes of re-bleeding, need for other concomitant measures, blood transfusion and side effects.

RESULTS

In patients with inflatable nasal packing its placement was significantly faster (36+/-19s vs. 228+/-102 s; p<0.001) and less painful (6.7+/-1.7 vs. 8.3+/-1.5; p<0.001), requiring less analgesia until its removal. Patients with pack of gauze showed a lower average incidence of re-bleeding (17% vs. 26 %; p<0.001), fewer cases of blood transfusion (15% vs. 18%; p<0.001) or of other procedures (4% vs. 11 %; p<0.001). The sanitary cost of the latter was also lower (1327+/-202 euro vs. 1648+/-318 euro; p<0.001) and it generated less short and long-term complications

CONCLUSIONS

The classical posterior packing with gauze is less rapid and comfortable to adapt, but it ensures a higher success rate in the control of epistaxis, produces fewer local injuries and reduces sanitary costs in comparison with inflatable balloon packing.

Endoscopic intraoperative control of epistaxis in nasal surgery

OBJECTIVE

Epistaxis represents a dangerous post-operative complication of nasal surgery. The advances of endoscopic procedures have also brought along the possibility of a surgical solution of nasal bleeding. These procedures include endoscopic cautery of the bleeding points, and more difficult techniques of endoscopic ligation of the sphenopalatine artery or the anterior ethmoidal artery. These surgical methods permit avoiding nasal packing, a very annoying procedure for the patient. This study aims to evaluate the advantages of this approach at the end of a nasal surgery to prevent routine nasal packing.

METHOD

133 subjects were operated on by the same surgeon in the Otorhinolaringology Department of University of Foggia (Italy) from March 2006 to March 2007. 17 (12.8%) patients were submitted to septoplasty, 42 (31.5%) to turbinoplasty (in 22 accompanied by septoplasty) and 74 (55.6%) to endoscopic sinus surgery (ESS) for nasal polyposis or nasal tumors.

RESULTS

Only 16 cases (12%) underwent nasal packing, while in the remaining 117 (88%) endoscopic control of bleeding permitted avoiding packing. In 53 (39.8%) patients only an endoscopic cauterization of bleeding points was performed; in 29 (21.8%) cases a sphenopalatine artery ligation was necessary. Only 2 subjects (1.5%) underwent anterior ethmoidal artery ligation. In the remaining 34 (25.5%) patients no procedure was necessary, due to the apparently scarce bleeding in the endoscopic vision at the end of surgery. In this group of non-packed patients, only 8 (6.8%) needed a post-operative tamponade while in the group of packed patients, 2 (12.5%) cases had a re-bleeding and a revisional surgery was necessary.

CONCLUSION

Intra-operative precautional packing is therefore not justified during nasal surgery because of the small percentage of post-operative epistaxis. Intra-operative control of bleeding allowed nasal packing to be avoided in a large percentage of cases.