Arterial epistaxis

Complications of Posterior Epistaxis

A study of 106 patients requiring posterior packing found a 46 percent rate of complications, many of them major, suggesting the need for caution in treatment.

Anatomical variations of anterior ethmoidal artery and their significance in endoscopic sinus surgery: a systematic review

PURPOSE

Anterior ethmoidal artery (AEA) is at risk of injury in endoscopic sinus surgery due to its location. The aim of this review was to assess the anatomical variations of AEA and their significance.

METHODS

A literature search was performed on PUBMED, SCOPUS AND EMBASE. The following keywords were used: ethmoidal artery; anterior ethmoidal artery; anterior ethmoidal canal; ethmoid sinus; ethmoid roof; skull base. The search was conducted over a period of 6 months between October 2016 and April 2017.

RESULTS

105 articles were retrieved. 76 articles which were either case reports or unrelated topics were excluded. Out of the 29 full text articles retrieved, 16 articles were selected; 3 were cadaveric dissection, 5 combined cadaveric dissection and computed tomography (CT) and the rest were of CT studies. All studies were of level III evidence and a total of 1985 arteries were studied. Its position at the skull base was influenced by the presence of supraorbital ethmoid cell (SOEC) and length of the lateral lamella of cribriform plate (LLCP). Inter population morphological variations contribute to the anatomical variations.

CONCLUSIONS

The average diameter of AEA was 0.80 mm and the intranasal length was 5.82 mm. 79.2% was found between the second and third lamellae, 12.0% in the third lamella, 6% posterior to third lamella and 1.2% in the second lamella. Extra precaution should be taken in the presence of a well-pneumatized SOEC and a long LLCP as AEA tends to run freely below skull base.

Endoscopic Anatomy of the Sphenopalatine and Posterior Nasal Arteries: Implications for the Endoscopic Management of Epistaxis

Background

Refractory posterior epistaxis is a challenge for otolaryngologists. Most algorithms for managing this condition ultimately call for interrupting the arterial blood supply to the nasal mucosa. Traditionally, this was accomplished either by transantral arterial ligation or by arteriographic-guided embolization. More recently, the endonasal endoscopic approach has also been described. Because the primary blood supply to the posterior nasal cavity is derived from the terminal branches of the sphenopalatine and the posterior nasal arteries, we conducted this anatomic study to examine and describe the anatomic relationship of these two arteries as they exit the pterygopalatine fossa and enter the nasal cavity.

Methods

We performed endoscopic dissections of this anatomic region in nine fresh and one formalin-preserved cadaver specimens. A total of 19 sides were examined.

Results

In 3 of 19 specimens (16%), the sphenopalatine artery branched from the sphenopalatine artery within the sphenopalatine canal, allowing the two arteries to exit together. In 8 of the 19 specimens (42%), the sphenopalatine artery exited much more posteriorly, yet from within a shared posteriorly elongated sphenopalatine foramen. In the remaining eight specimens (42%), the sphenopalatine artery exited through a distinct foramen directly posterior to the larger sphenopalatine foramen.

Conclusion

Understanding this anatomic relationship is important in performing endoscopic arterial ligation. If the sphenopalatine artery is not specifically identified and ligated, an important component of the posterior nasal circulation will not be addressed adequately by this surgical approach.

Acute epistaxis

Preview Acute anterior nosebleeds are frightening because bleeding is often so copious and seemingly unstoppable. But, ironically, this type is usually less severe than posterior epistaxis, in which blood may run briskly but unseen down the throat. The choice among the many treatment methods available depends on the source and cause of epistaxis. The authors present a methodical approach to patient evaluation and describe the best therapy for various situations.

Clinical Study of 1,515 Patients Presenting with Epistaxis Over the Last 6 Years

AIM

This study reviews our clinical experience of patients with epistaxis and discusses proper management.

PATIENTS AND METHODS

We retrospectively investigated 1,515 patients with epistaxis treated in our department between 2005 and 2010.

RESULTS

Men over 50 years old predominated. More than half of the patients (n = 828) first visited after consultation hours, and 40% (n = 606) were brought by ambulance. The most common underlying diseases were circulatory diseases (69%, n = 1,047). Antithrombotics were being administered to 23% (n = 345). Kiesselbach's plexus was the most commonly observed bleeding site (51%, n = 769). In 20% (n = 297), no bleeding point was confirmed because hemostasis had been achieved on arrival. Anterior packing was the most common primary treatment, followed by electrocauterization. Hospitalization was required in 2% (n = 30). Re-bleeding occurred within 14 days after primary treatment in 14% (n = 206). Surgical treatment was performed for 5% (n = 11).

CONCLUSIONS

Patients showing repeated pulsatile arterial bleeding require hospitalization for surgical therapy, although outpatient therapy is sufficient in most cases. A risk of re-bleeding should be considered if patients show unclarified bleeding points and circulatory diseases.

Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK

INTRODUCTION

Epistaxis is the one of the most common otorhinolaryngology emergencies. This study examined the age and sex distribution of all patients admitted with epistaxis to National Health Service (NHS) hospitals in Wales, UK, over a period of 18 years and 9 months.

METHODS

The Patient Episode Database for Wales was examined for all patient admissions with a diagnosis of epistaxis between April 1991 and December 2009. The age and sex of these patients was recorded and the proportion of the underlying population affected was calculated by comparing admission rates to the population data derived from the 1991 and 2001 national population censuses for Wales.

RESULTS

A total of 26,725 patients were admitted to NHS hospitals in Wales with epistaxis over the period studied. The proportion of the population admitted with epistaxis increased from the age of 40 onwards. For all ages except patients in the 10-14 years group, a higher proportion of the male population was admitted with epistaxis than the comparable female population. This discrepancy was most pronounced between the ages of 15 and 49 years, with the female-to-male ratio of hospital admissions with epistaxis being 0.55. These ages (15 and 49 years) approximate the average age of menarche and menopause respectively in the UK.

CONCLUSIONS

Women of menstrual age have fewer hospital admissions with epistaxis. This may be due to oestrogens providing protection to the nasal vasculature (as they do to other areas of the vascular tree).

Internal maxillary artery ligation for idiopathic intractable epistaxis

Epistaxis though common, is rarely life threatening. Routinely nose pinching, anterior find posterior nasal packing and endoscopic cauterization of bleeding points is sufficient to control epistaxis in 99% of the cases. It is mandatory to rule out local and systemic causes before labeling a case as idiopathic by using a battery of investigative modalities. Here are two interesting cases of epistaxis which did not respond to conventional therapeutic modalities in which transantral internal maxillary artery ligation was attempted leading to complete cure.

Use of trans-septal mattress suture of Little's area for anterior epistaxis

BACKGROUND

In some cases of epistaxis, anterior packing and/or electrocoagulation are not sufficient and suturing is needed. However, standard suturing techniques are sometimes ineffective. This paper reports the use of a new kind of trans-septal mattress suture, based on regional vascular anatomy, in this clinical context.

METHODS

Four adult patients with haemorrhage in Little's area underwent standard suturing, but bleeding persisted. These patients were successfully treated with trans-septal mattress suturing, using four punctures around the haemorrhage site.

RESULTS

No relapses or complications were observed over a six-month follow-up period.

CONCLUSION

In cases of persistent bleeding from Little's area, suturing should surround the bleeding area. The described suturing method is simple, efficacious and cheap.

Pressure injection demonstrates points of weakness in the posterior nasal arteries

OBJECTIVE

To test the hypothesis that potential sites of weakness within normal nasal arteries, when stressed, contribute to the mechanism of epistaxis, we 'stress-tested' nasal arteries in unfixed cadaveric heads, using pressure injection of feeding arteries.

MATERIALS AND METHODS

Indian ink with latex was injected into maxillary arteries under high pressure (620 mmHg). Stepwise dissection was carried out and areas showing ink leakage were examined. Control heads were injected at standard embalming pressures (375 mmHg).

RESULTS

Ink leakage was found in all heads injected at higher pressure, and was restricted to the nasal mucosa. Histological examination of leakage points demonstrated vessel disruption consistent with dissecting aneurysm formation.

DISCUSSION

Results showed that high pressure injection caused leakage from arteries in the posterior nose; the distribution of leakage points was consistent with many clinical investigations. The lesions produced were comparable with our best histopathological model of epistaxis, i.e. dissecting aneurysm formation. This suggests that pre-existing weaknesses in the arterial configuration may exist.

Surgical treatment of nasal packing refractory epistaxis

Aim

Materials and Methods

Results

Conclusion

Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis

OBJECTIVES

The precise identification of the bleeding point is important to the efficient management of epistaxis. Our hypothesis was that the septum was the commonest bleeding site.

STUDY DESIGN AND SETTING

This was a prospective clinical study of 50 consecutive adult idiopathic posterior epistaxis patients carried out in a busy teaching hospital.

METHODS

The nasal cavity was inspected with endoscopy to identify the site of bleeding before any intervention. The location of bleeding sites was recorded on a proforma.

RESULTS

Of bleeding sites posterior to the piriform fossa, 94 percent were identifiable, with 70 percent arising from the septum.

CONCLUSIONS AND SIGNIFICANCE

This is the largest prospective study of the bleeding site in adult patients with posterior epistaxis and the only one with a well-defined population. The vast majority of posterior bleeding sites can be identified by endoscopy without general anesthesia. The septum should be examined closely in cases of idiopathic bleeding.

A fourth locus for hereditary hemorrhagic telangiectasia maps to chromosome 7

Hereditary hemorrhagic telangiectasia (HHT) is a genetically and clinically heterogeneous multisystem vascular dysplasia. Mutations of the endoglin and ACVRL1 genes are known to cause HHT. However, existence of HHT families in which linkage to these genes has been excluded has suggested that other gene(s) can cause HHT in some families. Recently, a family was reported to be linked to chromosome 5q, the HHT3 locus. Here we report on linkage results on a family with classic features of HHT, albeit a less severe phenotype with regards to epistaxis and telangiectases, in which linkage to HHT1, HHT2, and HHT3 is ruled out. Whole genome linkage analysis and fine mapping results suggested a 7 Mb region on the short arm of chromosome 7 (7p14) between STR markers D7S2252 and D7S510. We obtained a maximum two point LOD score of 3.60 with the STR marker D7S817. This region was further confirmed by haplotype analysis. These findings suggest the presence of another gene causing HHT (HHT4). The features in this family that strongly suggest the presence of a hereditary, multisystem vascular dysplasia would be easily missed during the typical evaluation and management of a patient with an AVM. This family helps emphasize the need to obtain a very detailed, targeted medical and family history for even mild, infrequent but recurring nosebleed, subtle telangiectases. Further studies of the candidate region and the identification of the gene responsible for the vascular anomalies in this family will add to our understanding of vascular morphogenesis and related disorders.

Endoscopic sphenopalatine artery ligation--when, why and how to do it. An on-line video tutorial

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.

An anatomical study of the arteries of the anterior nasal septum

OBJECTIVE

The anterior nasal septum is a clinically important area, yet anatomical descriptions of its arterial pattern are hitherto incomplete. This study aimed to test the hypothesis that the arteries of the anterior nasal septum form a fine random network of vessels.

STUDY DESIGN

The arterial pattern of the nasal septum was traced by microdissection of 12 cadaveric septa (24 sides).

SETTING

Each septum was microdissected with a Watson-Barnet dissecting microscope. Specimens were photographed and the vascular patterns were analyzed.

RESULTS

The anterior septum has a consistent large arterial anastomotic triangle receiving major contributions from sphenopalatine, anterior ethmoidal, and superior labial arteries.

CONCLUSION

Systematic microdissections clearly demonstrate that the arteries of the anterior septum do not form a random network. Instead, they form a consistent arterial anastomotic triangle consisting of large, thin vessels.

SIGNIFICANCE

The study provides background material useful to the understanding of nasal physiology and pathology including epistaxis.

Epistaxis

Epistaxis is a frequent complaint, and may often cause great anxiety in patients and clinicians. Epistaxis results from the interaction of factors that damage the nasal mucosal lining, affect the vessel walls, or alter the coagulability of the blood, and which may be categorized into environmental, local, systemic and medication related. The knowledge of the first aid treatment of epistaxis is very poor, amongst not only the public, but also health professionals. Immediate emergency department management of epistaxis depends on prioritized assessment and treatment, including resuscitation if necessary, together with the application of relatively simple otolaryngological techniques. There is little high quality evidence regarding routine, alternative or adjunctive treatments.

Absence of association between hypertension and epistaxis: a population-based study

The association between epistaxis and hypertension is still disputed. In a cross-sectional study, we evaluated this association in a sample of 1174 individuals older than 18 years, representative of inhabitants of Porto Alegre, RS, Brazil. Epistaxis was defined as any episode of non-traumatic nosebleeding after 18 years of age. Hypertension was defined as the mean of two blood pressure readings > or = 160/95 mmHg or the use of antihypertensive drugs. The prevalence of epistaxis and hypertension were 14.7% (95% confidence interval, CI 12.7-16.7) and 24.1% (95% CI 21.7-26.6), respectively. History of epistaxis in the adulthood (risk ratio = 1.24, 95% CI 0.83-1.85), and in the previous 6 months (risk ratio 0.79, 95% CI 0.40-1.56; p = 0.510) were not associated with hypertension after controlling for gender, age, race, history of allergic rhinitis or nasal abnormalities, alcohol abuse, smoking and years of study. History of epistaxis was positively associated with history of allergic rhinitis and inversely associated with years at school. In conclusion, we demonstrated that hypertension is not associated with history of epistaxis in the adulthood in free-living individuals.

Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery

Posterior epistaxis poses a challenge to the otolaryngologist as the bleeding point itself cannot easily be identified. Haemostasis by conventional means is usually nasal packing and this results in repeated/persistent haemorrhage, morbidity and prolonged bed occupancy. In recent years the increased availability of rigid endoscopes and a better understanding of the anatomy of the nasal cavity have facilitated a direct approach to the sphenopalatine artery. Using a 0 degrees or 30 degrees rigid nasendoscope the sphenopalatine artery-the main blood supply to the nose-can be clearly identified and treated. Over the last 12 months we have employed endoscopic intranasal clipping of the said artery under a general anaesthetic to control persistent posterior nasal bleeding. Twelve patients have undergone 14 procedures within 48 h of failure of their conservative management. In all the epistaxis was controlled no complications were noted. The average follow-up period in our series was nine months. We believe that intranasal endoscopic clipping of the sphenopalatine artery is effective and less traumatic than either any other site of arterial ligation technique or repeated packing. In this series we employed only clipping of the artery and not diathermy/electrocautery to reduce the theoretical risk to adjacent structures

Is epistaxis evidence of end-organ damage in patients with hypertension?

OBJECTIVES/HYPOTHESIS

To study the association between history of mild to severe epistaxis with different stages of hypertension and with other evidence of target organ damage in a sample of patients attending an outpatient hypertension clinic, controlling for potential confounding factors.

STUDY DESIGN

A survey of adult patients with hypertension.

METHODS

A consecutive sample of 323 adults with hypertension was studied. The main outcome measures were history of adult epistaxis, high blood pressure, duration of hypertension, nasal abnormalities, and fundoscopic and electrocardiogram abnormalities.

RESULTS

Ninety-four patients (29.1% of the whole sample) reported at least one episode of nosebleed after 18 years of age. Of these, 59 (62.8%) needed medical assistance to control at least one of the episodes. The history of epistaxis was not associated with blood pressure classified according to the World Health Organization/International Society of Hypertension paradigm or classified as severe or not severe. There was a trend of an association between history of epistaxis and duration of hypertension. The history of severe epistaxis (epistaxis that needed medical assistance) was not associated with blood pressure classified as severe or not severe and with duration of hypertension. More patients with left ventricular hypertrophy had a positive history of adult epistaxis. There was no association between history of epistaxis or history of severe epistaxis and fundoscopic abnormalities. Among the abnormalities detected at rhinoscopy, only the presence of enlarged septal vessels was associated with history of epistaxis. The presence of enlarged septal vessels was strongly and independently associated with history of epistaxis in the logistic regression model. Duration of hypertension and left ventricular hypertrophy showed a trend for an association with the history of epistaxis in the adult life.

CONCLUSIONS

A definite association between blood pressure and history of adult epistaxis in hypertensive patients was not found. The evidence for an association of duration of hypertension and left ventricular hypertrophy with epistaxis suggests that epistaxis might be a consequence of long-lasting hypertension. The association between the presence of enlarged vessels at rhinoscopy with history of epistaxis in hypertensive patients is a novel observation that needs to be addressed in future observations.

Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis

OBJECTIVE

This study examined the advantages and disadvantages of internal maxillary artery (IMA) ligation versus embolization for the treatment of refractory posterior epistaxis.

METHODS

Thirty-nine patients underwent 42 procedures for treatment of posterior epistaxis at the University of Cincinnati Medical Center between 1986 and 1994. Complication rates, failure rates, demographics, and the costs of IMA ligation and embolization were compared. A review of 20 studies published between 1973 and 1995 was done to determine the complication and failure rates of IMA ligation and embolization. Finally, a mail survey was used to determine the availability and use of IMA ligation and embolization by urban and rural otolaryngologists in Ohio.

RESULTS

Complication and failure rates of IMA ligation and embolization were similar at our institution. In the literature review, IMA ligation had a higher complication rate, but fewer failures. Although the major complication rates were not significantly different, those associated with embolization were often more serious than those associated with IMA ligation. At our institution, the cost of IMA embolization was significantly lower than the cost of IMA ligation. Only 11% of Ohio otolaryngologists in nonurban areas have embolization available to treat posterior epistaxis.

CONCLUSION

IMA ligation is more effective than IMA embolization but may be associated with a higher minor complication rate. The major complications that occur with IMA embolization are often more serious. Although IMA embolization was less expensive at our institution, it is unavailable in most nonurban regions in Ohio. Training in the use of IMA ligation for refractory posterior epistaxis should continue in otolaryngology residency training programs despite the increasing availability of embolization at university training centers.

Claudication on mastication following bilateral external carotid artery ligation for posterior epistaxis

This case highlights a potentially disabling complication of intermittent claudication in the region of the masseter muscles on mastication, following bilateral external carotid artery ligation for epistaxis. Although there have been few reports of this complication this may be a reflection of the fact that the operation is rarely performed, and not because the complication is rare. Its potentially disabling nature, and its possible common occurrence after this procedure make awareness of it by surgeons who may carry out this procedure important.

Recurrent epistaxis and nasal septal deviation in young adults

Epistaxis is common in young adults but the aetiology is unknown in many cases. To investigate the possibility that septal deviations are associated with epistaxis, 54 servicemen with recurrent epistaxis were compared with 46 controls. The epistaxis group were significantly more likely to have a history of nasal trauma (P = 0.008) and radiologically-proven nasal fracture (P = 0.002); on clinical examination, they were more likely to have a deviated septum (P < 0.00001), maxillary spur (P = 0.00004) and nasal obstruction (P = 0.011); they were also more likely to have radiological evidence of a deviated septum (P = 0.020). Those patients able to locate their epistaxis to one side tended to do so to the side of their septal deviation. This study supports the hypothesis that septal deviation is associated with epistaxis.

Haemorrhagic nasal nodules

Haemorrhagic nodules have been mentioned previously as a significant cause of epistaxis in adults. We have taken photographs and obtained biopsies to characterize them. They consist of an aneurysmal dilatation of an unusually sited muscular artery with evidence of hypertensive changes in the wall, and thrombus and haemorrhage into the adjacent connective tissue.

Dominant maxillary artery as a cause of failure in maxillary artery ligation for posterior epistaxis

Ligation of the maxillary artery is a logical and effective method for the arrest of severe uncontrollable posterior epistaxis. The failure rates for arrest of haemorrhage are given in the literature as 10-13%. In our centre, over the last 9 years, 23 patients have undergone maxillary artery ligation to control epistaxis without a failure. Bilateral maxillary artery ligation was carried out whenever the maxillary artery of the bleeding side was found to be of small diameter. To investigate whether there is an asymmetry in the size of the maxillary arteries we performed 13 cadaveric dissections. In 6 of the cadavers one maxillary artery was significantly larger than the other. This fact has hitherto not been observed by otolaryngologists or anatomists. Failure to arrest haemorrhage may have resulted from ligation of the non-dominant maxillary artery with consequent opening of cross-anastomoses from the dominant side.

Combined internal maxillary and anterior ethmoidal arterial occlusion: the treatment of choice in intractable epistaxis

Whilst it is generally accepted that the standard management for anterior or benign epistaxis is either cautery or anterior nasal packing, that of posterior or intractable epistaxis remains controversial. Various modalities of treatment, ranging from posterior nasal packing to arterial ligation and embolization, have been advocated but none have been unanimously accepted as the treatment of choice. The purpose of this paper was to determine the efficacy of internal maxillary arterial ligation versus combined internal maxillary arterial ligation and anterior ethmoid arterial coagulation in intractable epistaxis. Over a six year period, from 1985 to 1990, 454 patients were admitted and treated for epistaxis. Forty-seven patients were diagnosed as having intractable epistaxis on the basis that the epistaxis failed to settle on anterior nasal packing. They were moved to the next step in management, which was combined anterior and posterior nasal packing. There were 30 failures, one was found to have choriocarcinoma of the maxilla, and was treated with cytotoxics, and the other 29 were moved to the next step, which was arterial ligation. Fifteen patients had internal maxillary arterial ligation, and 14 combined internal maxillary arterial ligation and anterior ethmoidal arterial coagulation. Large windows were created in both the anterior and posterior walls of the maxillary sinuses and all identifiable branches of the internal maxillary artery were dissected out carefully and two medium size ligating clips were placed over the main trunk, the sphenopalatine and the descending palatine branches. Single clips were placed on all other identifiable branches. Coagulation of the anterior ethmoidal artery was performed with a bipolar cautery.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of posterior epistaxis with the use of the fibreoptic nasolaryngoscope

Posterior epistaxis is usually treated by repeated nasal packing and in failed situations by ligation of feeding arteries with considerable morbidity and mortality. The most logical approach should be location of the bleeding site and arrest of haemorrhage by local treatment. The exact location of the bleeding area can be identified in actively bleeding noses with the fibreoptic naso-laryngoscope and the bleeding arrested by chemical, or thermal cautery and in failed situations by using small nasal packs confined to the bleeding site. This approach to the management of posterior epistaxis is effective and reduces the duration of hospital stay. It significantly reduces the discomfort to the patient. The current practice of indiscriminate blind nasal packing in the hope of arresting nasal haemorrhage by incidental pressure on the bleeding site should be re-evaluated.

Epistaxis: anatomical and clinical correlates

One hundred and seven consecutive patients with acute and chronic epistaxis were examined to identify the site and nature of the source. Aetiological factors in the history, nasal anatomy or pathology were noted, along with the blood pressure and laboratory results. In most presentations an anterior bleeding point was isolated. Cautery usually sufficed in both anterior and posterior sources. No source was hidden behind a septal spur or deflection. Hypertension was associated with bleeding from the middle meatus, but not with the severity of bleeding. Patients on antihypertensive medication were more likely to be admitted. Point sources of bleeding were from prominent vessels or haemorrhagic nodules; the latter are not well recognized and are easily overlooked. Routine blood tests did not reveal unsuspected abnormalities or change management; neither did sinus X-rays. Initial examination of the nose in the acute phase by experienced personnel is suggested, to reduce admissions and avoid nasal packing.

A surgical alternative to internal maxillary artery ligation for posterior epistaxis

Posterior epistaxis is a disease of varying magnitude and is associated with considerable morbidity. Surgical management often consists of transantral ligation of the internal maxillary artery and its branches, with or without ligation of the ethmoidal arteries. Ten patients underwent an alternative surgical procedure in which the nasopharynx and posterior nasal cavity were indirectly examined for bleeding sites with a large laryngeal mirror. Nasal septal reconstruction with mobilization of the anterior cartilaginous septum from the maxillary crest allowed lateral displacement of the septum with excellent visualization of the lateral nasal walls. Hemorrhage was controlled by electrocoagulation of bleeding sites with a disposable, malleable suction electrocautery. No complications occurred in this group of 10 patients and no further epistaxis has been reported during a follow-up of 17 to 35 months.

The nasal: paranasal block technique. Preparation and uses

A new technique for removing nasal: paranasal blocks at autopsy is described. The technique allows the removal of these cavities without disfigurement of the head after the brain has been removed. The importance of the technique in relation to training on endo-nasal micro-surgery, and histopathological study of nasal and paranasal disorders is emphasized.

[Haemorrhage and haemostasis in face, visceral cranium, neck and middle ear region (author's transl)]

Head and neck surgery is accompanied by more or less heavy tendency to bleed. Spontaneous bleeding will occur, because of general and local peculiarities depending on the vascularisation of this region. The general part of the paper deals with normal haemostasis and the diagnosis of haemorrhagic diathesis. This part also shows simple surgical measures in order to stop bleeding. The special section of the paper explains bleeding problems by case history. Here mainly complications are shown exceedingly imporant to the ENT Doctor, because of their more common frequency i.e. nose-bleeding, adenotonsillextomy as well as alarming haemorrhage from great vessels of the neck (arrosion bleeding of the carotid artery, lesion due to accidents and following necksurgery).