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Sundarajan K, Mani S, Arumugam K. Management of Recurrent and Refractory Posterior Epistaxis by Transnasal Endoscopic Sphenopalatine Artery Cauterization: a Prospective Cohort Study. Indian J Otolaryngol Head Neck Surg 2023; 75:2792-2797. [PMID: 37974743 PMCID: PMC10645779 DOI: 10.1007/s12070-023-03793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/10/2023] [Indexed: 11/19/2023] Open
Abstract
Transnasal endoscopic sphenopalatine artery occlusion procedures are becoming the standard of care for intractable posterior epistaxis. Improved endoscopic anatomical features of the lateral nasal wall and endoscopic skill with high-resolution cameras result in a higher success rate of endoscopic intervention. To evaluate the safety and effectiveness of endoscopic cauterization of the sphenopalatine artery (ESPAC) in controlling intractable posterior nasal bleeding. This prospective cohort study enrolled patients with refractory posterior epistaxis from August 2016 to December 2019. The trial recruited patients between 18 and 65 years of age with a history of recurrent and refractory posterior epistaxis receiving endoscopic arterial cauterization due to conservative treatment failure. All of the cases involved bipolar cauterization. Recurrent nosebleeds must pause for at least three months for a procedure to be considered successful. In the first 30 days following surgery, complications are recorded. 415 patients with epistaxis received both inpatient and outpatient care. Transnasal ESPAC was necessary for 36 patients (11.5%). The most common comorbidity was hypertension accounting for 9 (23%) cases. Thus, 26 of 36 (72%) cases had a unilateral ESPAC, while 10 (28%) had a bilateral ESPAC. Twenty-two (61%) and ten (28%) patients had single and two branching patterns of the sphenopalatine artery, respectively. Septal correction and middle meatus antrostomy (44%) were the most performed additional procedures. During the three-month follow-up period, 35 patients in this study had epistaxis control; the success rate of ESPAC was 97.2%. There were no significant postoperative complications found. Endoscopic sphenopalatine artery cauterization is successful in controlling 97.2% of posterior epistaxis. It is safe and effective without any significant complications.
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Affiliation(s)
- Karthik Sundarajan
- Upgraded Institute of Otorhinolaryngology, Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai, Tamil Nadu 600003 India
| | - Suresh Mani
- Department of Head and Neck Surgery, CMC, Vellore, India
| | - Karthiga Arumugam
- Upgraded Institute of Otorhinolaryngology, Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai, Tamil Nadu 600003 India
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Alkhalifah KM, Alhumaidan NI, Alotaibi TA, Almnjwami RFM, Alzelfawi LA, Almughamsi RH, Alqahtani RK, Aldossari MH, Fageeh YA. A Systematic Review and Meta-Analysis of the Awareness of and Attitudes Toward Epistaxis. Cureus 2023; 15:e46590. [PMID: 37933345 PMCID: PMC10625789 DOI: 10.7759/cureus.46590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/08/2023] Open
Abstract
Epistaxis, commonly known as nasal bleeding, ranks among the most prevalent emergencies encountered in otorhinolaryngology. The etiology of epistaxis is multifaceted, arising from both local and systemic factors. In Saudi Arabia, a country with a relatively high prevalence of epistaxis, understanding the level of awareness and attitudes toward first aid management of epistaxis is of paramount importance. This systematic review aims to bridge this knowledge gap by evaluating the awareness of and attitudes toward epistaxis first aid in Saudi Arabia. This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A comprehensive electronic search was executed across PubMed, Google Scholar, and Web of Science databases, encompassing studies published between January 2015 and July 2023. The study included exclusively cross-sectional studies, assessing awareness and attitude toward epistaxis first aid in Saudi Arabia across all populations and studies in English. The 17 selected studies were all published after October 2017, with three published in the year of this systematic review (2023). Sample sizes exhibited substantial variability, ranging from 57 to 2,441 individuals. Despite widespread awareness of epistaxis, the general population often disregards it as a minor health issue. This discrepancy highlights the importance of addressing epistaxis seriously, given the potential for severe bleeding as a medical emergency. The review of 17 studies revealed significant variations in epistaxis awareness levels, influenced by factors such as age, gender, and varying sample sizes. Notably, higher awareness levels were observed in studies involving the general Saudi population and those employing self-administered questionnaires. The average awareness and knowledge of epistaxis and its management among Saudi residents were moderate, with an estimated awareness level of 63%. A large-scale epidemiological survey, considering sociodemographic factors, is recommended to provide a more comprehensive understanding of epistaxis awareness.
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Affiliation(s)
- Khalid M Alkhalifah
- Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, SAU
| | - Norah I Alhumaidan
- College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, SAU
| | | | | | - Lama A Alzelfawi
- College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, SAU
| | | | - Renad K Alqahtani
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | - Yahya A Fageeh
- Otolaryngology - Head and Neck Surgery, College of Medicine, Taif University, Taif, SAU
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Ramachandran SN, Retnathankom A, Rege I, Reddy KT. Endovascular management of a sphenopalatine artery pseudoaneurysm: a rare cause of delayed intractable epistaxis following endoscopic transsphenoidal pituitary surgery. BMJ Case Rep 2023; 16:e253998. [PMID: 37130637 PMCID: PMC10163417 DOI: 10.1136/bcr-2022-253998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Vascular injuries during pituitary surgery are feared as they can lead to serious disability and can be life threatening. We are describing a case of severe intractable epistaxis following endoscopic transnasal transsphenoidal surgery for pituitary tumour due to a sphenopalatine artery pseudoaneurysm which was successfully managed using endovascular embolisation techniques. Very few cases of sphenopalatine artery pseudoaneurysm following endoscopic nasal surgery have been described. A middle aged male patient with a pituitary macroadenoma underwent endoscopic transsphenoidal pituitary surgery and returned to us after 3 days of discharge with severe epistaxis. Digital subtraction angiography showed contrast leakage and left sphenopalatine artery pseudoaneurysm. Glue embolisation of the distal sphenopalatine branches and pseudoaneurysm was done. Good occlusion of pseudoaneurysm was seen. Such a diagnosis for epistaxis following endoscopic transnasal surgery should be borne in mind, so prompt treatment can be planned to avoid life threatening complications.
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Affiliation(s)
| | | | - Ishant Rege
- Department of Neurosurgery, Amrita Institute of Medical Sciences, Cochin, India
| | - Krishna Tej Reddy
- Department of Neurosurgery, Amrita Institute of Medical Sciences, Cochin, India
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Nosulya EV, Miroshnichenko SA, Luchsheva YV, Aleksanyan TA, Ogorodnikov DS. [Epidemiology and modern methods of treatment of non-traumatic nosebleeds]. Vestn Otorinolaringol 2023; 88:63-68. [PMID: 37970772 DOI: 10.17116/otorino20238805163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies. OBJECTIVE To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds. MATERIAL AND METHODS The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds. RESULTS The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%. CONCLUSION The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.
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Affiliation(s)
- E V Nosulya
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - S A Miroshnichenko
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - Yu V Luchsheva
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - T A Aleksanyan
- Sverzhevsky Research Institute of Clinical Otorhinolaryngology Moscow Department of Healthcare, Moscow, Russia
| | - D S Ogorodnikov
- Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
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Muacevic A, Adler JR, Vazquez Martinez MA, Cáceres-Perkins W, Vazquez-Fuster J, Anzalota-Del Toro M, Perez-Del Valle C. From the Nares to the Bone Marrow: A Role for Transarterial Embolization in an Aberrant Life-Threatening Cause of Epistaxis. Cureus 2022; 14:e31278. [PMID: 36505113 PMCID: PMC9732710 DOI: 10.7759/cureus.31278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/10/2022] Open
Abstract
Identifying underlying bleeding diathesis that is amenable to medical therapy must be determined to provide timely treatment and minimize morbidity. Nasal bleeding is viewed as an annoyance by most who suffer from its episodes. However, it can at times be a baleful ailment that can compromise a patient's airway, breathing, and circulation, which can result in death. A 75-year-old Hispanic man presented with life-threatening epistaxis and was ultimately diagnosed with multiple myeloma (MM). The patient suffered profuse bleeding and hemodynamic compromise, requiring endoscopic nasal packing, red cell transfusions, platelet transfusions, and right external carotid artery angiogram with maxillary arteries embolization prior to chemotherapy. Embolization of maxillary arteries helped to stabilize the patient to diagnose MM and start definitive management with chemotherapy. On data review, we could not find another case with severe epistaxis secondary to MM, which was controlled with endovascular embolization. This case highlights the difficulties in managing a rare condition and the importance of a multidisciplinary approach in patients who present with life-threatening epistaxis secondary to plasma cell dyscrasia.
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Trau G, Venkatasamy A, Djennaoui I, Renaud M, Fath L, Ciftci S. An image-guided (CT) assessment of a new asymmetric balloon for the treatment of epistaxis. Eur Arch Otorhinolaryngol 2021; 278:4823-4830. [PMID: 33755780 DOI: 10.1007/s00405-021-06758-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The main objective was to perform an image-guided (CT) assessment of the efficacy of the CAVI-T™ balloon to compress the sphenopalatine artery (SPA) on cadaver heads, for the management of epistaxis. The secondary objectives were to analyse the deployment and stability of this balloon according to the volume injected into the nasal cavity, to optimise its use. METHODS A descriptive anatomical study was performed. The catheterization of the SPA was performed on four fresh-frozen heads with a SPA approach through the maxillary sinus, leaving the nasal cavity unscathed. Computed Tomography images were acquired without and with the balloon, inflated by injections of progressive volumes of diluted iodine, for optimal contrast with the surrounding tissues. We evaluated the positioning of the balloon according to two predetermined markers on the device. RESULTS Out of 68 image-guided acquisitions, the CAVI-T™ balloon compressed the SPA in 88% of cases. The other nasal cavity structures were compressed in 86% to 100% of the cases, depending on the positioning of the CAVI-T™ balloon, therefore allowing a complete obstruction of the nasal cavity. The device remained stable upon inflation and did not obstruct the nasopharynx. CONCLUSION The CAVI-T™ balloon provided effective compression of the SPA and the different structures of the nasal cavity.
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Affiliation(s)
- Guillaume Trau
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre UF 6701, Service Oto-Rhino-Laryngologie et chirurgie cervico-faciale, 1 avenue Molière, 67200, Strasbourg, France.
| | - Aina Venkatasamy
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Streinth Lab (Stress Response and Innovative Therapies), Inserm UMR_S 1113 IRFAC, Interface Recherche Fondamental et Appliquée à la Cancérologie, Strasbourg, France
| | - Idir Djennaoui
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre UF 6701, Service Oto-Rhino-Laryngologie et chirurgie cervico-faciale, 1 avenue Molière, 67200, Strasbourg, France.,ICube-Laboratoire des Sciences de l'ingénieur, de l'informatique et de l'imagerie (ICube) UMR 7357, Strasbourg, Illkirch, France
| | - Marion Renaud
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre UF 6701, Service Oto-Rhino-Laryngologie et chirurgie cervico-faciale, 1 avenue Molière, 67200, Strasbourg, France
| | - Léa Fath
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre UF 6701, Service Oto-Rhino-Laryngologie et chirurgie cervico-faciale, 1 avenue Molière, 67200, Strasbourg, France.,Institut National de la Santé et de la Recherche Médicale, INSERM, UMR-S 1121, "Biomatériaux et Bioingénierie", Strasbourg, France
| | - Saït Ciftci
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre UF 6701, Service Oto-Rhino-Laryngologie et chirurgie cervico-faciale, 1 avenue Molière, 67200, Strasbourg, France.,Institut National de la Santé et de la Recherche Médicale, INSERM, UMR-S 1121, "Biomatériaux et Bioingénierie", Strasbourg, France
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Galili J, Holm Nissen M, Ovesen T. Outcome of treatment for severe epistaxis: nasal packing and endoscopic sphenopalatine artery ligation. RHINOLOGY ONLINE 2021. [DOI: 10.4193/rhinol/20.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Severe epistaxis is a frequent emergency condition encountered by otolaryngologists and is often treated with nasal packing. In the event of failure surgical treatment is considered. We aimed to evaluate the efficacy of Nasal Packing (NP) and Endoscopic Sphenopalatine Artery Ligation (ESPAL) as treatment of severe epistaxis in terms of failures and recurrences including risk factors. Methodology: Retrospective descriptive study of patients with epistaxis treated with NP, admitted to an ENT department from 2011-2017. If initial treatment with NP failed, patients were considered for ESPAL. Results: An analysis of 511 patients was performed. All patients were treated with NP at the time of admission, and 14% of pa- tients were treated with ESPAL due to failure of NP. The majority of patients was only admitted once. Twelve percent were readmit- ted within 30 days, 7% were readmitted >30 days later. Treatment failure after ESPAL was 7.9%. No significant difference in the risk of readmission was found between patients treated with NP alone and patients treated with ESPAL. Conclusion: The majority of epistaxis patients were effectively treated with NP alone. We found good effect of ESPAL although no significant differences in risk of readmission NP vs. ESPAL were identified.
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Ruys L. Successful management of severe epistaxis in a dog with leishmaniasis using nasal balloon catheters and carotid artery ligation. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2020-001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Laura Ruys
- AniCura Diergeneeskundig Verwijscentrum DordrechtDordrechtThe Netherlands
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Bathula SSR, Patrick T, Srikantha L. Epistaxis management on COVID-19-positive patients: Our early case experience and treatment. Clin Case Rep 2020; 8:2195-2198. [PMID: 32837722 PMCID: PMC7404437 DOI: 10.1002/ccr3.3137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/02/2020] [Accepted: 06/07/2020] [Indexed: 11/22/2022] Open
Abstract
Epistaxis management on COVID‐19 patients is concerning for otolaryngologists due to the highly virulence and increased concentration within respiratory droplets and nasal secretions. Authors suggest initial management with oxymetazoline nasal drops and local pressure before considering nasal packing with absorbable material to prevent COVID‐19 transmission to surrounding healthcare workers.
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Affiliation(s)
- Samba Siva R Bathula
- Department of Otolaryngology - Head and Neck Surgery Detroit Medical Center Detroit MI USA
| | - Tyler Patrick
- Department of Otolaryngology - Head and Neck Surgery Detroit Medical Center Detroit MI USA
| | - Luxman Srikantha
- Department of Otolaryngology - Head and Neck Surgery Detroit Medical Center Detroit MI USA
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Management of epistaxis in patients on novel oral anticoagulation therapy. The Journal of Laryngology & Otology 2020; 134:316-322. [PMID: 32281535 DOI: 10.1017/s0022215120000754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy. OBJECTIVE This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management. METHOD A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019. RESULTS Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined. CONCLUSION Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.
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Abstract
OBJECTIVE The aim of the study was to assess different radiologic bony landmarks for endoscopic localization of the sphenopalatine foramen (SPF). METHODS Paranasal computed tomography (CT) scans of adults without sinonasal pathology were included. On axial cuts, the anteroposterior distances from the SPF to maxillary line, anterior head of the middle turbinate, basal lamella of the middle turbinate, choanal arch, and posterior fontanel of the maxillary sinus ostium were measured. While on coronal cuts, the vertical distances from the SPF to the nasal floor was measured. The registered measurements were then studied and statistically analyzed. RESULTS In 70 patients (140 sides, 840 measurements), the mean distances from the SPF to nasal floor, choanal arch, maxillary line, anterior head of the middle turbinate, basal lamella, and posterior fontanel were 25.6 ± 2.4, 8.5 ± 1.38, 36.4 ± 2.6, 34.6 ± 4.26, 8.1 ± 1.27, and 13.7 ± 1.7 mm, respectively, without significant differences between right and left sides. Females showed significantly shorter mean distances between SPF and the nasal floor (P = 0.0011), choanal arch (P = 0.0459), and posterior fontanel (P < 0.0001) than males. While no significant differences were detected between both sexes as regard distances from SPF to maxillary line (P = 0.5579), anterior head of middle turbinate (P = 0.8581), and basal lamella (P = 0.0638). CONCLUSION Preoperative CT can provide multiple easily detected, reliable, and simple bony landmarks that can help SPF endoscopic localization. Thus the authors recommend adding these measurements to the preoperative CT checklist for patients scheduled for sphenopalatine artery ligation and/or excision of vascular lesions.
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Ahmadi N, Huang J, North HJ, Lord D, Cheng AT. Avoiding blindness in managing epistaxis for a child with Duane's Retraction Syndrome. Int J Pediatr Otorhinolaryngol 2019; 126:109615. [PMID: 31416016 DOI: 10.1016/j.ijporl.2019.109615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/28/2019] [Accepted: 07/28/2019] [Indexed: 11/25/2022]
Abstract
Duane's Retraction Syndrome (DRS), a congenital cranial dysinnervation disorder, accounts for 5% of all strabismus. A vascular anomaly in DRS, which became clinically relevant in the context of significant epistaxis, is presented. A 15-year-old girl with DRS underwent a rhinological procedure for traumatic nasal deformity and suffered large volume epistaxis. Using angiography, an anatomical variation was identified, noting the ophthalmic artery was supplied by branches from the sphenopalatine artery, facial artery, and middle meningeal artery; not from the internal carotid artery. Hence epistaxis control was achieved via alternative methods, and unilateral blindness was avoided.
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Affiliation(s)
- Navid Ahmadi
- Department of Pediatric ENT, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| | - June Huang
- Department of Pediatric ENT, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Hannah Jd North
- Department of Pediatric ENT, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - David Lord
- Pediatric Interventional Radiology, Division of Medical Imaging, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Alan T Cheng
- Department of Pediatric ENT, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
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Bui R, Doan N, Chaaban MR. Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department. Am J Rhinol Allergy 2019; 34:100-107. [DOI: 10.1177/1945892419876740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation. Methods A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort. Results Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time. Conclusion Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.
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Affiliation(s)
- Roger Bui
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Nicolette Doan
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Mohamad R. Chaaban
- Department of Otolaryngology, University of Texas Medical Branch at Galveston, Galveston, Texas
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García-Cabo P, Fernández-Vañes L, Pedregal D, Menéndez del Castro M, Murias E, Vega P, Llorente JL, Rodrigo JP, López F. Management of Severe and/or Refractory Epistaxis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019. [DOI: 10.1016/j.otoeng.2018.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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The distribution of bleeding sites in idiopathic hidden arterial epistaxis. The Journal of Laryngology & Otology 2019; 133:309-312. [PMID: 30929656 DOI: 10.1017/s0022215119000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency distribution of bleeding sites in idiopathic hidden arterial epistaxis. METHODS In this retrospective cohort study, 107 patients with hidden arterial epistaxis were endoscopically examined for sites of bleeding. RESULTS All sites of hidden arterial epistaxis were identified by endoscopic examination. Bleeding sites were identified at initial surgery in 103 patients and during the second surgery in 4. The bleeding sites included: the olfactory cleft region in 47 patients, the inferior meatus region in 29, the middle meatus region in 11, multiple bleeding sites (olfactory cleft and anterior septum) in 3, the anterior roof of the nasal cavity in 4, the nasal floor in 11 and the nasopharynx in 2. The bleeding points showed a white or red volcano-like bump in 75 patients, isolated prominent telangiectasia in 21 and mucosal ulceration in 11. CONCLUSION Common sites of hidden arterial epistaxis include the olfactory cleft, inferior meatus and middle meatus. However, there should be awareness of some uncommon bleeding sites (including the anterior roof of the nasal cavity, the nasal floor and the nasopharynx) and of multiple bleeding sites.
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Alyahya K, Alsaad S, Alsuliman S, Alsuliman N. Awareness about first aid management of epistaxis among medical students in Kingdom of Saudi Arabia. J Family Med Prim Care 2019; 8:914-918. [PMID: 31041224 PMCID: PMC6482802 DOI: 10.4103/jfmpc.jfmpc_15_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Epistaxis is the bleeding from nose or nasal cavity and it is considered as one of the most common emergencies presenting in ear, nose, and throat department and accident and emergency department worldwide. Objective and Aim The aim of this study was to assess and evaluate knowledge, attitude, and practice of first aid management of epistaxis among medical students in the Kingdom of Saudi Arabia. Materials and Methods A cross-sectional community-based studies were collected using electronic questionnaire distributed among medical students all over the Kingdom of Saudi Arabia. The study was conducted between September and January 2018. Results Data were collected from 300 medical students from all over the Kingdom of Saudi Arabia using questionnaires, which were filled electronically. Majority of the respondents were females (75.7%), whereas 24.3% of the respondents were males. Most of the participants were from fourth and fifth year with 25.0 and 24.3%, respectively. 39.7% of the participants responded that fingernail trauma as the commonest cause of the epistaxis, followed by bleeding disorder in 17.3%. 64% of the respondents think that epistaxis is an emergency condition that requires early intervention. 71% of the respondents demonstrated the correct position as first aid measure of epistaxis and only 41.3% of respondents demonstrated the correct site for pinching the nose. The main source of the respondent's knowledge regarding first aid management of epistaxis was self-taught (53.67%) followed by medical books (23.33%). Conclusion Medical students in Saudi Arabia have an adequate knowledge about epistaxis and first aid measure that can be used to manage epistaxis.
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Affiliation(s)
- Khalid Alyahya
- College of Medicine, King Faisal University, Al Ahsa, Kingdom of Saudi Arabia
| | - Sara Alsaad
- College of Medicine, King Faisal University, Al Ahsa, Kingdom of Saudi Arabia
| | - Sara Alsuliman
- College of Medicine, King Faisal University, Al Ahsa, Kingdom of Saudi Arabia
| | - Nouf Alsuliman
- College of Medicine, King Faisal University, Al Ahsa, Kingdom of Saudi Arabia
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Abstract
Some of the most common rhinologic disorders that may present to the primary care provider include disorders of hemostasis, such as epistaxis, or sinonasal inflammatory disorders, such as allergic rhinitis and acute or chronic rhinosinusitis. This article is written with the intent to review these common rhinologic conditions for primary care providers and to summarize symptoms, diagnostic testing, differential diagnosis, and management/treatment approaches.
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Affiliation(s)
- Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA.
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Buchberger AMS, Baumann A, Johnson F, Peters N, Piontek G, Storck K, Pickhard A. The role of oral anticoagulants in epistaxis. Eur Arch Otorhinolaryngol 2018; 275:2035-2043. [PMID: 29936627 PMCID: PMC6060781 DOI: 10.1007/s00405-018-5043-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/16/2018] [Indexed: 01/13/2023]
Abstract
Purpose The purpose of this retrospective study was to identify the impact of oral anticoagulants on epistaxis with the focus on new oral anticoagulants. Methods The study was conducted at the Department for Ear- Nose- and Throat (ENT), Head and Neck Surgery, Technical University Munich, Germany. All patients presenting in 2014 with the diagnosis of epistaxis to a specialized ENT accident and emergency department were identified and analyzed in clinical data and medication. Results 600 adult cases, with a median age of 66.6 years were identified with active bleeding. 66.8% of all cases were anticoagulated. Classic oral anticoagulants (COAC) were three times more common in patients than new-generation oral anticoagulants (NOAC). Recurrent bleeding was significantly associated with oral anticoagulants (OAC) (p = 0.014) and bleeding location was most often anterior (p = 0.006). In contrast, severe cases, which required surgery or embolization were significantly more likely in non-anticoagulated middle-aged patients with posterior bleedings (p < 0.05). In our epistaxis cohort, OAC were highly overrepresented (40%) when compared to the general German population (1%) but COAC as well as NOAC played only a minor role in severe courses of epistaxis. Conclusion Oral anticoagulation, especially with new-generation drugs, is not associated with more complicated and severe courses of epistaxis, but rather with recurrent bleeding. One should keep this information in mind when triaging the patient in the emergency room and when planning further procedures.
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Affiliation(s)
- A M S Buchberger
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - A Baumann
- Department of Otolaryngology Head and Neck Surgery, Helios Amper-Klinikum Dachau, Krankenhausstraße 15, 85221, Dachau, Germany.
| | - F Johnson
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - N Peters
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - G Piontek
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - K Storck
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - A Pickhard
- Department for Ear- Nose- and Throat, Head and Neck Surgery, University hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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García-Cabo P, Fernández-Vañes L, Pedregal D, Menéndez Del Castro M, Murias E, Vega P, Llorente JL, Rodrigo JP, López F. Management of severe and/or refractory epistaxis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018; 70:185-191. [PMID: 29784243 DOI: 10.1016/j.otorri.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 02/20/2018] [Accepted: 02/21/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolization were compared. MATERIAL AND METHOD Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively. RESULTS Eleven patients (17%) underwent embolization, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolization was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolization. One patient suffered a hemispheric stroke after embolization. No post-surgical complications were observed. CONCLUSIONS Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient.
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Affiliation(s)
- Patricia García-Cabo
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España.
| | - Laura Fernández-Vañes
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España
| | - Daniel Pedregal
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España
| | | | - Eduardo Murias
- Servicio de Radiodiagnóstico, Hospital Universitario Central de Asturias, Oviedo, España
| | - Pedro Vega
- Servicio de Radiodiagnóstico, Hospital Universitario Central de Asturias, Oviedo, España
| | - José Luis Llorente
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España
| | - Juan Pablo Rodrigo
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España
| | - Fernando López
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, España
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20
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Beck* R, Sorge* M, Schneider A, Dietz A. Current Approaches to Epistaxis Treatment in Primary and Secondary Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:12-22. [PMID: 29345234 PMCID: PMC5778404 DOI: 10.3238/arztebl.2018.0012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 05/15/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment. METHODS This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience. RESULTS There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk. CONCLUSION The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.
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Affiliation(s)
- Rafael Beck*
- * Both authors contributed equally to this paper
- Department of Otolaryngology, University of Leipzig
| | - Martin Sorge*
- * Both authors contributed equally to this paper
- Department of Otolaryngology, University of Leipzig
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Le A, Thavorn K, Lasso A, Kilty SJ. Economic evaluation of floseal compared to nasal packing for the management of anterior epistaxis. Laryngoscope 2018; 128:1778-1782. [DOI: 10.1002/lary.27081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/22/2017] [Accepted: 12/08/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Andre Le
- Department of Otolaryngology–Head and Neck Surgery
| | - Kednapa Thavorn
- School of Epidemiology and Public HealthUniversity of OttawaOttawa Ontario Canada
- Ottawa Hospital Research InstituteOttawa Ontario Canada
- Institute for Clinical and Evaluative SciencesICES@uOttawaOttawa Ontario Canada
| | - Andrea Lasso
- Ottawa Hospital Research InstituteOttawa Ontario Canada
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23
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Masoudian P, McDonald JT, Lasso A, Kilty SJ. Socioeconomic status and anterior epistaxis in adult population. World J Otorhinolaryngol Head Neck Surg 2017; 4:263-267. [PMID: 30564789 PMCID: PMC6284191 DOI: 10.1016/j.wjorl.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 11/09/2022] Open
Abstract
Objective Little was known about the role of socioeconomic status as a risk factor for epistaxis in adult population. The objective of this study was to determine whether socioeconomic status influences the presentation to emergency department for anterior epistaxis in an adult population. Methods Retrospective review of emergency department visits from January 2012 to May 2014. The setting is in an emergency department of a Canadian tertiary care centre. Adult patients with primary diagnosis of anterior epistaxis in the emergency department were included in this study. The main outcome was emergency department visits for anterior epistaxis visits. Results A total of 351 cases of anterior epistaxis were included. The mean age was 70 years and 51% of patients were male. The patients were stratified into two groups based on whether their age was equal to and above, or below 75 years. Our analysis indicated that those 75 years or older in higher income quintiles have an increased risk of anterior epistaxis compared to the subjects in the lower income quintiles (P < 0.05). This association did not hold true for those younger than 75 years or for all age groups combined. Conclusion There is an association between higher socioeconomic status and the presentation to the emergency department with anterior epistaxis in the population older than 75 years but not in younger patients.
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Affiliation(s)
| | - J Ted McDonald
- Department of Economics, University of New Brunswick, Fredericton, NB, Canada
| | - Andrea Lasso
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Shaun J Kilty
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, The University of Ottawa, Ottawa, ON, Canada
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Monga J, Pathania V. THE EFFECTIVENESS OF NASAL ENDOSCOPIC CAUTERIZATION AS FIRST LINE MANAGEMENT FOR EPISTAXIS- A PROSPECTIVE STUDY. ACTA ACUST UNITED AC 2017. [DOI: 10.18410/jebmh/2017/697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Zhang J, Cao L, Wei C. Randomized controlled trial comparing Nd:YAG laser photocoagulation and bipolar electrocautery in the management of epistaxis. Lasers Med Sci 2017; 32:1587-1593. [PMID: 28707034 DOI: 10.1007/s10103-017-2285-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
The objective of this study is to evaluate the efficacy and degree of comfort of Nd:YAG laser photocoagulation compared to bipolar electrocautery in the management of epistaxis. Seventy-two consecutive patients with a history of epistaxis were randomly assigned to receive treatment in an outpatient setting consisting of either bipolar electrocautery (group 1) or Nd:YAG laser photocoagulation (group 2). The study was conducted in university-affiliated teaching hospital. Seventy-two consecutive patients who suffered from anterior epistaxis and presented to the Otolaryngology Department at the Eye, Ear, Nose and Throat Hospital, Fudan University, between June 2015 and August 2015. The following outcome measures were assessed: bleeding intensity, bleeding frequency 4 and 16 weeks after treatment (0 = no bleeding, 1 = reduced bleeding, 2 = the same, and 3 = worse), participant perception of discomfort during treatment (grade 0-10, where 10 is the worst pain), and therapy duration and complications. At 16 weeks, 91% of the laser patients versus 91% of the bipolar electrocautery patients had no reported bleeding. The outcome scores at 4 and 16 weeks after treatment showed no significant difference between the two groups (P = 0.5 and P = 0.98, respectively; P > 0.05). The median pain levels experienced during the office laser and bipolar electrocautery procedures were 3.0 and 4.0, respectively, and the median durations of the laser and electrocautery therapies were 3.0 and 4.0, respectively. Neither groups had complications. It can be concluded that Nd:YAG laser photocoagulation and bipolar electrocautery are both effective in the treatment of epistaxis. These two therapies are recommended. As a whole, these two therapies, performed in an office setting, are timely, efficacious, and well tolerated in the treatment of epistaxis.
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Affiliation(s)
- Jing Zhang
- Departments of Laser Plastic Surgery, Fudan University, Shanghai, China.
| | - Luhong Cao
- Otolaryngology Department at the Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wei
- Departments of Otolaryngology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Sichuan, China.
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Hajimaghsoudi M, Largani HA, Baradaranfar MH, Aghabagheri M, Jafari MA, Saeedi M. A novel method for epistaxis management: Randomized clinical trial comparing nose clip with manual compression. Am J Emerg Med 2017; 36:149-150. [PMID: 28736091 DOI: 10.1016/j.ajem.2017.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Majid Hajimaghsoudi
- Trauma Research Center, Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Amiri Largani
- Emergency Department, Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Baradaranfar
- Department of otolaryngology Head and Neck Surgery, Otorhinolaryngology Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahdi Aghabagheri
- Meybod Nursing School, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Ali Jafari
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Morteza Saeedi
- Tehran University of Medical Sciences, Emergency Medicine Research Center, Shariati Hospital; Emergency Medicine Department, Tehran, Iran.
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27
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Maxwell AK, Barham HP, Getz AE, Kingdom TT, Ramakrishnan VR. Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis. ALLERGY & RHINOLOGY 2017; 8:63-66. [PMID: 28583229 PMCID: PMC5468758 DOI: 10.2500/ar.2017.8.0196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery. Objective: This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen. Methods: By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis. Results: Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (−9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor. Conclusion: Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.
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Affiliation(s)
- Anne K. Maxwell
- From the Department of Otolaryngology—Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Henry P. Barham
- From the Department of Otolaryngology—Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Anne E. Getz
- From the Department of Otolaryngology—Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Todd T. Kingdom
- From the Department of Otolaryngology—Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Vijay R. Ramakrishnan
- From the Department of Otolaryngology—Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Mayer C, Hattingen E, Schild H, Bootz F, Schröck A. [Interventional radiology in the head and neck region]. HNO 2017; 65:482-489. [PMID: 28451716 DOI: 10.1007/s00106-017-0354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In interventional neuroradiology, endovascular embolization represents an important and helpful tool in the treatment of multiple head and neck diseases. These interventional procedures may be performed with curative intent, to reduce the surgical risk within a multimodal treatment concept, or to improve or at least maintain a good quality of life within a palliative therapy concept. In addition to a good understanding of disease pathology, knowledge of vascular anatomy, including collateral vessels and dangerous extracranial-intracranial anastomoses, is essential for successful treatment, as is implementation of an established technique using appropriate material. Indications for endovascular embolization are i. otherwise unmanageable bleeding (caused by e. g., trauma, vascular malformation, or tumor), ii. reduction of perioperative bleeding by preoperative embolization in case of a hypervascularized tumor, iii. selective induction of tumor necrosis by palliative embolization to enhance local tumor control. Major complications such as stroke, loss of vision, and cranial nerve palsy are mostly due to a lack of preinterventional evaluation. Regarding neurological deficits, interventions within the supply region of the external carotid artery have a complication rate below 1%.
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Affiliation(s)
- C Mayer
- Klinik für Radiologie, Universität Bonn, Bonn, Deutschland
| | - E Hattingen
- Klinik für Radiologie, Universität Bonn, Bonn, Deutschland
| | - H Schild
- Klinik für Radiologie, Universität Bonn, Bonn, Deutschland
| | - F Bootz
- Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde/Chirurgie, Universität Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Deutschland
| | - A Schröck
- Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde/Chirurgie, Universität Bonn, Sigmund-Freud Straße 25, 53127, Bonn, Deutschland.
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Ferrari M, Pianta L, Borghesi A, Schreiber A, Ravanelli M, Mattavelli D, Rampinelli V, Belotti F, Rodella LF, Maroldi R, Nicolai P. The ethmoidal arteries: a cadaveric study based on cone beam computed tomography and endoscopic dissection. Surg Radiol Anat 2017; 39:991-998. [PMID: 28299444 DOI: 10.1007/s00276-017-1839-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/27/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the anatomical variability of the ethmoidal arteries (EAs). To evaluate the reliability of cone beam computed tomography (CBCT) in preoperative assessment of EAs. METHODS Fourteen cadaver heads underwent CBCT and endoscopic dissection. The following anatomical features were evaluated for anterior (AEA), middle (MEA), and posterior (PEA) EAs: presence, cranio-caudal position, antero-posterior position, and dehiscence of the bony canal. Accuracy of radiological assessment was calculated. RESULTS AEA, MEA, and PEA were identified in 100, 28.6, and 100% of sides. They were caudal to the skull base in 60.7, 25, and 17.9%, respectively. CBCT showed a high accuracy in identifying these features. The antero-posterior position of EAs, which was highly variable, was correctly assessed by CBCT. A dehiscent bony canal of AEA, MEA, and PEA was found in 46.4, 12.5, and 28.6% of sides, respectively. Accuracy of CBCT in picking up this feature was poor but negative predictive value was high. CONCLUSIONS CBCT was adequate in identifying and localizing EAs. In addition, it can be used to exclude the presence of MEA and dehiscence of ethmoidal canals, whereas the accuracy in detecting these anatomic variants was low.
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Affiliation(s)
- Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy.
| | - Luca Pianta
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Andrea Borghesi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Largo Spedali Civili, 1, 25123, Brescia, Italy
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Recurrent Massive Epistaxis from an Anomalous Posterior Ethmoid Artery. Case Rep Otolaryngol 2016; 2016:8504348. [PMID: 28025632 PMCID: PMC5153481 DOI: 10.1155/2016/8504348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 11/16/2016] [Indexed: 12/03/2022] Open
Abstract
A 50-year-old man, with no previous history of epistaxis, was hospitalized at our facility for left recurrent posterior epistaxis. The patient underwent surgical treatment three times and only the operator's experience and radiological support (cranial angiography) allowed us to control the epistaxis and stop the bleeding. The difficult bleeding management and control was attributed to an abnormal course of the left posterior ethmoidal artery. When bleeding seems to come from the roof of the nasal cavity, it is important to identify the ethmoid arteries always bearing in mind the possible existence of anomalous courses.
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Wakelam OC, Dimitriadis PA, Stephens J. The use of FloSeal haemostatic sealant in the management of epistaxis: a prospective clinical study and literature review. Ann R Coll Surg Engl 2016. [PMID: 27490981 DOI: 10.1308/rcsann.2016.0224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION It is standard practice in the UK that if conservative measures or chemical cautery fail to control epistaxis, patients receive nasal packing which is often uncomfortable, requires admission and has well documented associated morbidity. Our study aims to evaluate the use of FloSeal haemostatic sealant in managing patients with epistaxis. MATERIALS AND METHODS Patients were identified from those referred with active epistaxis. A successful outcome was defined as complete haemostasis with FloSeal alone, with no further significant bleeding requiring admission or further interventions in the subsequent 7 days. Patients reported satisfaction using a ten-point visual analogue scale. Ear, nose and throat doctors recorded patient demographics, time to prepare FloSeal, length of stay, need for further treatment and adverse events on an electronic database. RESULTS 30 patients were enrolled in the study. The mean time to prepare FloSeal was 5 minutes. The success rate of FloSeal was 90%. The mean length of stay was 2.75 hours. The mean patient satisfaction with FloSeal was 8.4/10. No adverse events occurred. DISCUSSION FloSeal was found to be effective in controlling anterior epistaxis. There was a single case of posterior epistaxis which required operative management. The literature largely supports FloSeal in anterior epistaxis, but indicates sphenopalatine artery ligation as the definitive management of posterior epistaxis. CONCLUSIONS Our data support the use of FloSeal in patients with anterior epistaxis not controlled with conservative measures or chemical cautery. It was found to be easy to use, is well tolerated by patients and is efficient in financial terms.
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Affiliation(s)
- O C Wakelam
- ENT Department, Lister Hospital , Stevenage , UK
| | | | - J Stephens
- ENT Department, Lister Hospital , Stevenage , UK
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Yukitatsu Y, Tsuzuki K, Takebayashi H, Sakagami M. Clinical Study of 1,515 Patients Presenting with Epistaxis Over the Last 6 Years. ORL J Otorhinolaryngol Relat Spec 2016; 78:232-40. [PMID: 27438263 DOI: 10.1159/000446187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Yoriko Yukitatsu
- Department of Otolaryngology-Head and Neck Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Vosler PS, Kass JI, Wang EW, Snyderman CH. Successful Implementation of a Clinical Care Pathway for Management of Epistaxis at a Tertiary Care Center. Otolaryngol Head Neck Surg 2016; 155:879-885. [PMID: 27352889 DOI: 10.1177/0194599816657045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/08/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost. STUDY DESIGN Single prospective analysis with historical control. SETTING Tertiary academic hospital. SUBJECTS AND METHODS Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing. RESULTS Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented. CONCLUSIONS Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.
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Affiliation(s)
- Peter S Vosler
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason I Kass
- Department of Otolaryngology-Head and Neck Surgery, Boston University, Boston, Massachusetts, USA
| | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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İsmi O, Vayisoğlu Y, Özcan C, Görür K, Ünal M. Endoscopic Sphenopalatine Artery Ligation in Posterior Epistaxis: Retrospective Analysis of 30 Patients. Turk Arch Otorhinolaryngol 2016; 54:47-52. [PMID: 29392016 DOI: 10.5152/tao.2016.1713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/13/2016] [Indexed: 11/22/2022] Open
Abstract
Objective Although posterior epistaxis is rarely seen, it is an important medical problem that both decreases the quality of life of the patient and causes difficulties in the management for otorhinolaryngologists. In this study, we aimed to present the results of 30 patients who underwent transnasal endoscopic sphenopalatine artery ligation (TESPAL) for posterior epistaxis in our department. Methods The records of 30 patients who underwent TESPAL from January 2014 to April 2016 were analyzed retrospectively, and the relationship between perioperative factors and need for revision surgery was assessed. Results The success rate of TESPAL in posterior epistaxis was 90%. There was no relationship between surgical failure and antiaggregant use (p=0.224), anticoagulant use (p=0.534), hypertension (p=0.564), previous nasal surgery (p=0.279), and bilateral TESPAL application (p=0.279). TESPAL was seen to be effective in cases with Osler-Weber-Rendu disease, pregnancy, and uncontrollable epistaxis after rhinoplasty surgery. Mortality was seen in one of our patients not related to endoscopic ligation in the follow-up period. Conclusion TESPAL is an effective method in the treatment of posterior epistaxis. Hypertension, antiaggregant or anticoagulant use, bilateral sphenopalatine artery ligation, and previous nasal surgery do not seem to be factors leading to surgical failure.
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Affiliation(s)
- Onur İsmi
- Department of Otorhinolaryngology, Mersin University School of Medicine, Mersin, Turkey
| | - Yusuf Vayisoğlu
- Department of Otorhinolaryngology, Mersin University School of Medicine, Mersin, Turkey
| | - Cengiz Özcan
- Department of Otorhinolaryngology, Mersin University School of Medicine, Mersin, Turkey
| | - Kemal Görür
- Department of Otorhinolaryngology, Mersin University School of Medicine, Mersin, Turkey
| | - Murat Ünal
- Department of Otorhinolaryngology, Mersin University School of Medicine, Mersin, Turkey
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Our Approach to Adult Patients With Epistaxis. J Craniofac Surg 2016; 27:e298-301. [PMID: 27054432 DOI: 10.1097/scs.0000000000002545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Epistaxis is one of the most frequently encountered emergency problems in our country, as it is throughout the world. In epistaxis, the benefits of implementing clinical guidelines are evident in both daily practice and medical education. In this article, the authors aimed to present their approach to adult patients with epistaxis and to share their experience, which considered the life quality of the patients to be at the forefront, based on some of their patients. In management of epistaxis, the implementation of the simplest method, minimally affecting the life quality of the patient, may be easier with a stepped approach. The authors consider that the stepped approach that they have implemented and presented in their study may lead to using less invasive methods and may accordingly improve the life quality of the patient.
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Evaluating the use of Floseal haemostatic matrix in the treatment of epistaxis: a prospective, control-matched longitudinal study. Eur Arch Otorhinolaryngol 2016; 273:2579-84. [DOI: 10.1007/s00405-016-3948-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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Evaluation of Etiology and Treatment Methods for Epistaxis: A Review at a Tertiary Care Hospital in Central Nepal. Int J Otolaryngol 2015; 2015:283854. [PMID: 26346242 PMCID: PMC4546759 DOI: 10.1155/2015/283854] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/22/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction. Epistaxis is one of the most common emergencies in Otorhinolaryngology.
It is usually managed with simple conservative measures but occasionally it is a life threatening condition. Identification of
the cause is important, as it reflects the management plan being followed. Aims and Objectives. To analyze the
etiology and treatment methods for patients with epistaxis. Methods. A retrospective study was done in a tertiary care
hospital in central Nepal. The study period was from May 2014 to April 2015. Results. A total of
84 patients had epistaxis; 52 were males and 32 were females. The most common cause of epistaxis was idiopathic
(38.09%) followed by hypertension (27.38%), trauma (15.47%), and coagulopathy (8.33%). Regarding
treatment methods, most (52.38%) of our patients required anterior nasal packing. Chemical cautery was sufficient to stop
bleeding in 14.28% of patients while electrocautery and posterior nasal packing were performed in 2.38% and 16.66%
patients, respectively. Two (2.38%) patients required endoscopic sphenopalatine arterial ligation. Conclusion.
Hypertension, trauma and coagulopathy were the most common etiological factors among the patients in whom etiology was found
although in most of the patients etiology could not be found. Anterior nasal packing was the most common treatment method applied
to these patients.
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Camus M, Jensen DM, Matthews JD, Ohning GV, Kovacs TO, Jutabha R, Ghassemi KA, Machicado GA, Dulai GS. Epistaxis in end stage liver disease masquerading as severe upper gastrointestinal hemorrhage. World J Gastroenterol 2014; 20:13993-13998. [PMID: 25320538 PMCID: PMC4194584 DOI: 10.3748/wjg.v20.i38.13993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/08/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH).
METHODS: This observational single center study included all consecutive patients with ESLD and epistaxis identified from consecutive subjects hospitalized with suspected UGIH and prospectively enrolled in our databases of severe UGIH between 1998 and 2011.
RESULTS: A total of 1249 patients were registered for severe UGIH in the data basis, 461 (36.9%) were cirrhotics. Epistaxis rather than UGIH was the bleeding source in 20 patients. All patients had severe coagulopathy. Epistaxis was initially controlled in all cases. Fifteen (75%) subjects required posterior nasal packing and 2 (10%) embolization in addition to correction of coagulopathy. Five (25%) patients died in the hospital, 12 (60%) received orthotopic liver transplantation (OLT), and 3 (15%) were discharged without OLT. The mortality rate was 63% in patients without OLT.
CONCLUSION: Severe epistaxis in patients with ESLD is (1) a diagnosis of exclusion that requires upper endoscopy to exclude severe UGIH; and (2) associated with a high mortality rate in patients not receiving OLT.
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Dubel GJ, Ahn SH, Soares GM. Transcatheter embolization in the management of epistaxis. Semin Intervent Radiol 2014; 30:249-62. [PMID: 24436547 DOI: 10.1055/s-0033-1353478] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cautery, posterior packing, surgical ligation, or embolization. Embolization has been used to treat epistaxis for more than 30 years and success can be achieved in approximately 90% of patients, with major complications occurring in approximately 2%. These excellent results require thorough knowledge of the regional anatomy, familiarity with the equipment and various agents used to achieve this type of embolization, as well as attention to detail and meticulous technique. There remains debate on several aspects of embolization, including the agent of choice, preferred size of the embolic, and the number of vessels to embolize. Advances in endoscopic surgery have evolved to the point that similar success rates for embolization and modern surgical techniques in treating epistaxis may be expected. This detailed review of pertinent vascular anatomy, embolization technique, and surgical alternatives should allow practitioners to formulate treatment algorithms that result in optimal outcomes at their institutions.
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Affiliation(s)
- Gregory J Dubel
- Department of Diagnostic Imaging, Division of Interventional Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sun Ho Ahn
- Department of Diagnostic Imaging, Division of Interventional Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Gregory M Soares
- Department of Diagnostic Imaging, Division of Interventional Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
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Abstract
Epistaxis is a common problem that may range in severity from a minor nuisance to hemodynamically significant bleeding. Vascular anatomy allows for predictable identification of suspicious bleeding sites. Historically, packing was the workhorse of management, but, currently, more directed interventions have become available. These modalities may result in improvements in both cost-effectiveness and patient comfort.
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Affiliation(s)
- Raymond Sacks
- Australian School of Advanced Medicine at Macquarie University, Sydney, Australia.
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Epistaxis management at Guy's Hospital, 2009-2011: full audit cycles. The Journal of Laryngology & Otology 2013; 128:82-5. [PMID: 24290872 DOI: 10.1017/s0022215113003137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess management of epistaxis at a tertiary ENT referral hospital against a recently published standard of best practice. METHODS Fifty consecutive cases of acute epistaxis that required admission to Guy's Hospital in 2009 were evaluated. Epistaxis education sessions were held to introduce our algorithm of best practice in tandem with an emphasis on emergency department care. Similar retrospective reviews were carried out in both 2010 and 2011 (on groups of 50 patients). RESULTS AND CONCLUSION The first audit cycle demonstrated that only 8 per cent of patients underwent a suitable nasal examination in the emergency department prior to transfer, with no documented attempts at nasal cautery. Surgical intervention procedures were performed on only 40 per cent of eligible patients. The audit cycles that followed the introduction of the epistaxis algorithm demonstrated continued improvement in initial evaluation and management of epistaxis. In select patients, sphenopalatine artery ligation can provide timely, definitive management of refractory epistaxis.
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[Hemostatic absorbable gel matrix for severe post-traumatic epistaxis]. ACTA ACUST UNITED AC 2013; 114:310-4. [PMID: 24028779 DOI: 10.1016/j.revsto.2013.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/13/2013] [Accepted: 07/15/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The management of traumatic epistaxis is an important issue for maxillofacial trauma patients, because of their frequency and severity. We assessed a single use sterile hemostatic gel matrix (surgiflo© [SF], Floseal © [FS]) available for this indication. MATERIALS AND METHODS Ten patients were managed between 2008 and 2012 by the same surgeon. The following data was documented for each patient: gender, age, mechanism of trauma or type of surgery, characteristics of epistaxis, the various hemostatic techniques used before using SF, and its effectiveness. The primary endpoint was SF effectiveness compared with usual techniques. The secondary endpoint was the evaluation of patient comfort compared to other hemostatic methods, using a visual analogue scale (VAS). RESULTS In nine out of ten cases, epistaxis was controlled after endonasal instillation of SF after failure of wicking, or double balloon catheter in first line treatment, or use of SF directly as first line treatment. The mean post procedure VAS was: 7/10 for wicking (eight patients), 9.3/10 for the double balloon catheter (three patients), 3.2/10 for SF (ten patients). DISCUSSION Our study highlights the effectiveness of hemostatic gel matrix in the management of post-traumatic epistaxis compared to usual methods. It also pointed out better patient comfort. A prospective comparative study on a larger cohort of patient would support the legitimacy of SF as first-line treatment for severe posttraumatic epistaxis.
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Gede LL, Aanaes K, Collatz H, Larsen PL, von Buchwald C. National long-lasting effect of endonasal endoscopic sphenopalatine artery clipping for epistaxis. Acta Otolaryngol 2013; 133:744-8. [PMID: 23472923 DOI: 10.3109/00016489.2013.773596] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION We consider sphenopalatine artery ligation to be a safe and effective treatment of posterior epistaxis as the long-term need for revision surgery and the complication rates are low. Surgery should be considered earlier in the treatment of posterior epistaxis. OBJECTIVES Posterior epistaxis is common and surgical endoscopic ligation of the sphenopalatine arteries is indicated in severe cases. Knowledge about long-term effects and complications is sparse. METHODS Within 2001-2006, 78 patients underwent endonasal endoscopic-guided surgery for posterior epistaxis in one of the eight ENT clinics in Denmark treating these patients. In 2011, 45 patients were still alive and eligible for the study. Patients were contacted by telephone and invited to complete an interview questionnaire on late adverse affects and recurrence. RESULTS In all, 42 of 45 patients participated in the mean follow-up. The mean follow-up was 6.7 years: 90% of patients (n = 38) obtained an effect of the treatment during follow-up; 78% (n = 33) had no recurrent epistaxis, 12% (n = 5) had recurrent epistaxis but only needed non-surgical specialized treatment; 10% (n = 4) required revision surgery due to recurrent epistaxis within the 6.7 mean years of follow-up; and 26% of the patients had minor postoperative complications, permanent nasal crusting being most persistent and frequent.
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Affiliation(s)
- Lisbeth Ludvigsen Gede
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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George A, Smatanova K, Joshi H, Jervis S, Oluwole M. Sphenopalatine, anterior ethmoid and internal maxillary artery intervention in the management of refractory epistaxis: their efficacy in 25 patients. Clin Otolaryngol 2013; 37:321-5. [PMID: 22925099 DOI: 10.1111/j.1749-4486.2012.02499.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Falcon-Chevere JL, Giraldez L, Rivera-Rivera JO, Suero-Salvador T. Critical ENT skills and procedures in the emergency department. Emerg Med Clin North Am 2013. [PMID: 23200328 DOI: 10.1016/j.emc.2012.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Injuries and illness to the ears, nose, and throat are frequently seen in the emergency department. The emergency medicine physician must be proficient in recognizing these injuries and their associated complications and be able to provide appropriate management. This article discusses the most common otorrhinolaringologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. A description of each procedure is discussed, as well as the indications, contraindications, equipment, technique and potential complications.
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Affiliation(s)
- Jorge L Falcon-Chevere
- Department of Emergency Medicine, University of Puerto Rico School of Medicine, 65th Inf. Station, San Juan, PR 00929, USA.
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Murer K, Ahmad N, Roth BA, Holzmann D, Soyka MB. THREAT helps to identify epistaxis patients requiring blood transfusions. J Otolaryngol Head Neck Surg 2013; 42:4. [PMID: 23663751 PMCID: PMC3646554 DOI: 10.1186/1916-0216-42-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/25/2012] [Indexed: 11/10/2022] Open
Abstract
Objective To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors. Design Retrospective cohort study. Setting A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions. Methods The clinical charts and medical histories of these patients were evaluated. Main outcome measures Common parameters that increase the risk for severe anemia due to epistaxis. Results Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach. Conclusions Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.
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Affiliation(s)
- Karin Murer
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, 8091, Switzerland.
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Lakhani R, Syed I, Qureishi A, Bleach N. The Wexham Criteria: defining severe epistaxis to select patients requiring sphenopalatine artery ligation. Eur Arch Otorhinolaryngol 2012; 270:2039-43. [PMID: 23254397 DOI: 10.1007/s00405-012-2318-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
This study aims to provide guidance regarding patient selection and timing of intervention with sphenopalatine artery (SPA) ligation by defining 'severe epistaxis'. An analysis of all patients undergoing SPA ligation (January 2002-2010) was performed. SPA ligation was deemed necessary if at least one of the four identified criteria was fulfilled. The same analysis was also performed on all patients admitted with epistaxis who did not undergo SPA ligation over a 6-month period. All 27 patients who underwent SPA ligation met at least one of the criteria selected. Uncontrolled epistaxis (21/27) was fulfilled most often. In comparison, only 4/71 patients admitted with epistaxis who did not undergo SPA ligation fulfilled any single criterion. All criteria were satisfied in a significantly higher number of cases in the SPA group (p < 0.001) The criteria studied proved helpful in identifying patients admitted to hospital with epistaxis who had failed conservative measures.
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Affiliation(s)
- Raj Lakhani
- Department of ENT, Wexham Park Hospital, Slough, SL2 4HL, UK.
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Kourelis K, Shikani AH. Effectiveness of chitosan-based packing in 35 patients with recalcitrant epistaxis in the context of coagulopathy. Clin Otolaryngol 2012; 37:309-13. [DOI: 10.1111/j.1749-4486.2012.02488.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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