Young's procedure in the treatment of epistaxis

Treatment of severe refractory epistaxis in hereditary hemorrhagic telangiectasia using a two-flap nasal closure method

BACKGROUND

Nasal closure has been shown to effectively manage severe epistaxis refractory to other treatments in patients with hereditary hemorrhagic telangiectasia (HHT). The nasal closure procedure may be underutilized because of its surgical complexity and flap breakdown.

METHODS

This work is a retrospective review of 13 HHT patients treated for severe epistaxis with nasal closure between 2005 and 2013. Operating room (OR) time, need for revision surgery, preprocedure, and postprocedure epistaxis severity score (ESS), complete blood count values, and Glasgow Benefit Inventory (GBI) questionnaire results were collected for each patient. The technique is described. We characterize a typical nasal closure patient and compare outcomes based on our experience with the traditional 3-flap closure and a simplified 2-flap nasal closure procedure.

RESULTS

The average candidate for nasal closure in this series had an ESS of 7.88, hemoglobin (Hgb) of 8.3 g/dL, and received multiple transfusions, iron therapy, and cautery/coagulation procedures. Average ESS subsequent to nasal closure using the 2-flap method is 0.92 and mean GBI score is 56.3. Comparison of 5 patients who underwent the traditional 3-flap nasal closure procedure and 8 patients receiving the 2-flap nasal closure showed no significant difference in postoperative ESS or GBI metrics. Mean operating room times of the traditional and simplified methods were 3.12 hours and 1.44 hours (p = 0.0001). Mean time to first revision for 8 nasal closure patients was 21.5 months.

CONCLUSION

In short-term follow-up, the 2-flap procedure showed comparable effectiveness with significantly reduced complexity and operative time compared to the traditional nasal closure method.

First experiences with an individual nasal olive in patients with hereditary haemorrhagic telangiectasia (HHT)

Hereditary haemorrhagic teleangiectasia (HHT) is most notably characterized by vulnerable vascular formations of the nasal superficial mucosa. Epistaxis is one of the most common symptoms of the afflicted patients, with an incidence of more than 90 %. A variable series of treatments have been described, ranging from nasal ointments to the complete surgical occlusion of the nose. The objective of this pilot study is the presentation of first experiences in treating patients suffering from HHT and chronically recurrent epistaxis with an individual nasal olive made from silicone. Eleven patients (six men, five women) aging from 44 to 80 years with known HHT were treated at the ENT department of Homburg/Saar between October 2008 and July 2012 because of nasal bleeding by Nd:YAG laser or argon plasma coagulation. After the surgical treatment, an imprint of the nasal aditus was taken to manufacture an individual custom-made silicone nasal olive. Patients were wearing the nasal olive for 3-8 h a day. Check-ups were made every 6 months. Epistaxis severity score (ESS) was used pre- and post-nasal olive application. The observation period was 12-48 months. The utilization of the silicone nasal olive led to a distinct reduction of epistaxis events. Apart from the nasal olive, our patients needed no further treatment of the nose during the observation period except for a nasal ointment. Insertion and removal of the nasal olive were handled by the patients themselves. The local manipulation in handling the nasal olive caused no epistaxis itself. A significant improvement of the ESS and satisfaction was reported in all patients. Use of an individually manufactured silicone nasal olive is a promising extension to the established treatments of epistaxis in HHT patients. Tolerance towards this treatment by the patients was high due to the low personal burden and encumbrance. The extended use of the presented method in HHT patients may be beneficial. However, a more prolonged observation period is necessary in the future to judge the long-term efficiency of individual nasal olives.

The Young's Procedure for Severe Epistaxis from Hereditary Hemorrhagic Telangiectasia

Background

Surgical treatment of epistaxis in hereditary hemorrhagic telangiectasia (HHT) has historically been managed with the laser procedure or the septodermoplasty procedure. For transfusion-dependent patients with severe epistaxis we have been performing the Young's procedure or surgical closure of the nostrils. The objective of this study was to report treatment of severe epistaxis related to HHT with the Young's procedure and assess patient outcome.

Methods

Patients with severe iron or blood transfusion–dependent epistaxis who underwent a Young's procedure in three otolaryngology HHT centers were reviewed. Patients were evaluated for postoperative epistaxis and subjective outcome.

Results

Forty-three patients underwent a Young's procedure for severe epistaxis and were observed for a mean of 34 months. The procedure was well tolerated by all patients and 30 of 36 patients (83%) experienced complete cessation of bleeding after the Young's procedure. Patients had a mean increase in hemoglobin of 4.68 g/dL after the procedure. The average Glasgow Benefit Inventory score after surgery was 43.56. No patients requested a reversal of the procedure.

Conclusion

The Young's procedure is a safe and efficacious procedure with complete cessation of epistaxis in most patients with severe epistaxis and HHT.

The Use of Silastic Nasal Splints in the Treatment of Chronic Epistaxis and Nasal Septal Ulceration

Some cases of epistaxis are chronic and resistant to treatment. We describe a novel method of treating persistent epistaxis with Silastic splints. This procedure is simple to perform and reverse, and it is much better tolerated than is total obstruction of the nostrils (Young's procedure). In addition, the presence of the splints reduces the likelihood of digital trauma, which can prevent healing. We describe the case of a 43-year-old man with a 5-year history of persistent epistaxis who was successfully treated with this procedure.

A treatment algorithm for the management of epistaxis in hereditary hemorrhagic telangiectasia

We examined the management options used for epistaxis of varying severity in patients with hereditary hemorrhagic telangiectasia (HHT) to develop a treatment algorithm. Fifty patients with HHT were studied from 1991 to 1997 to consider various treatment options and their relative efficacy. There were 28 females and 22 men; their ages ranged from 15 to 85. Follow-up ranged from 6 months to 6 years. A wide variety of treatments had been used (including various forms of cautery, septal surgery, topical and systemic hormones, antifibrinolytic therapy, arterial ligation, laser therapy, and closure of the nostrils). Treatments used during the follow-up period were argon laser therapy (40), systemic estrogen or progesterone (17), septodermoplasty (12), or closure of the nostrils (14). Patients were divided into those with mild to moderate disease (requiring one or no blood transfusions during the course of their illness) and those with severe disease (requiring more than one blood transfusion). Using this broad categorization, those with mild to moderate disease did well with sequential argon laser therapy with or without the adjunct of septodermoplasty or hormone therapy. Those with severe disease did not find argon laser therapy beneficial but found their epistaxis completely stopped with closure of the nasal cavities. Based on these findings, a simple treatment algorithm defines the optimum treatment options for epistaxis in this difficult-to-treat group of patients.

Closure of the nasal cavities in the treatment of refractory hereditary haemorrhagic telangiectasia

From a cohort of 35 patients with hereditary haemorrhagic telangiectasia (HHT), 12 patients have undergone closure of the one or both nasal cavities during the last three years for refractory epistaxis. All had failed other forms of treatment including hormone therapy, laser coagulation and septodermoplasty. All patients were available for follow-up at six months or longer. In all patients where complete closure was achieved (11 out of 12) bleeding ceased completely from the operated side.

Hereditary haemorrhagic telangiectasia: Young's procedure in the management of epistaxis

Two cases of hereditary haemorrhagic telangiectasia are presented. Epistaxis was intractable in both patients. Young's procedure proved successful in controlling nose bleeds. One of the patients has been followed-up for 14 years. Methods of treatment are discussed with a review of the literature.