The Surgical Management of Massive Epistaxis

Peri-operative complications of sphenopalatine artery ligation: a 10-year series from two secondary care centres

Background

There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed.

Methods

A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0–2657 days).

Results

Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0–8 times).

Conclusion

Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience

PURPOSE

Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15 years in a single academic center.

METHODS

A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL).

RESULTS

The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients.

CONCLUSIONS

This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

BACKGROUND

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

OBJECTIVES

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Life-threatening bleeding in a facial fracture

Life-threatening bleeding in facial fractures is considered rare, and most reports do not recommend a precise treatment guideline. Although various methods have been suggested, they are unpredictable in efficacy and may lead to irreversible shock. To avoid irreversible shock, early detection and correct, effective treatment are mandatory. The authors report a patient who presented with a complex midface fracture after falling on June 23, 1999. Life-threatening oronasal bleeding developed 1 hour after arriving at the emergency room. Initial nasal packing failed to stop the nasal bleeding. After resuscitation, the patient's vital signs were stable but bleeding persisted. Angiography showed diffuse extravasation of contrast medium over the territory of the right internal maxillary artery. Embolization was performed successfully to stop the bleeding. The authors review the literature regarding the incidence, diagnosis, and treatment of life-threatening facial fracture. In the literature, the lack of a precise definition leads to various results by various treatments. The authors have formulated a succinct treatment guideline. They favor angiographic embolization as the first choice of treatment when tight nasal and/or oral packing fails.

Life-threatening bleeding following maxillofacial trauma

Life-threatening bleeding associated with facial trauma is considered rare, and most references on this subject do not recommend a precise treatment plan. The purpose of the present study is to review the origin of bleeding and various treatment methods, and to formulate a plan of management for these patients, emphasizing the role of the maxillofacial surgeon in the immediate intervention to control the bleeding. 222 patients with midface fractures were treated between 1985 to 1990. 10 of them had severe and life-threatening bleeding on admission. Bleeding was controlled by nasal packing (9 patients) combined with temporary fracture reduction (7 patients).

Severe late-onset epistaxis following Le Fort I osteotomy: angiographic localization and embolization

Epistaxis following maxillofacial trauma or maxillofacial surgery is uncommon. It usually occurs within 24 hours of the injury and can usually be controlled by packing. Rarely internal maxillary artery ligation is necessary and embolization has been used in some cases of severe trauma. We present a case of severe late-onset epistaxis following Le Fort I osteotomy. The diagnostic approach and treatment are discussed.

Effect of atherosclerosis and hypertension on arterial epistaxis

Eye fundus examination in twenty cases of hypertensive nose bleeding was carried out to evaluate the effect of hypertension and atherosclerosis on epistaxis. Arteriolar attenuation, atherosclerosis and venous congestion were detected in most of the cases. None showed haemorrhages or exudates. Hypertension and atherosclerosis seem to maintain and increase the severity of epistaxis, once it has been initiated by other factors.

Arterial ligation in epistaxis

Unremitting severe nose bleeds may require arterial ligation. One or more of the four vascular systems supplying the nose may need such surgical interference. Dye injection of 14 cadavers was performed to demonstrate the vascular supply of the nose and the effects of various arterial ligations. Depending upon the site of haemorrhage within the nose, up to three vascular systems may need occlusion. These are the ipsilateral and contralateral external carotid arterial systems and the ipsilateral ethmoidal arteries.

The use of angiography in a case of recurrent epistaxis after multiple arterial ligation

A patient with severe recurrent epistaxis which persisted despite multiple arterial ligation is described. The place of this procedure in the management of epistaxis is discussed. In the present case the bleeding was due to an underlying haemangioma which could only be demonstrated by angiography. It is suggested that this investigation should be carried out in patients who fail to respond to concentional treatment for recurrent epistaxis.