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The Efficacy of Sphenopalatine Artery Cauterization with Or Without Ligation in Idiopathic Resistant Posterior Epistaxis

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The Efficacy of Sphenopalatine Artery Cauterization with Or Without Ligation in Idiopathic Resistant Posterior Epistaxis Eur J Rhinol Allergy 2019; 2(1): 17-20 Original Article The Efficacy of Sphenopalatine Artery Cauterization with or without Ligation in Idiopathic Resistant Posterior Epistaxis Hüseyin Barkın Yavuz , Uygar Levent Demir , Fikret Kasapoğlu Department of Otorhinolaryngology, Uludağ University School of Medicine, Bursa, Turkey Abstract Objective: Epistaxis is among the most common emergencies of ear, nose, and throat diseases. Although it can be controlled simply by applying ice and a local decongestant, more durable states and massive hemorrhage may affect the quality of life of the patient or even may be life-threatening accompanied by comorbid conditions. These types of resistant and massive hemorrhages, which we rarely encounter, are seen as posterior epistaxis. In this study, we aimed to retrospectively evaluate the patients who had endoscopic sphenopalatine artery ligation and/or cauterization and were admitted to the Uludağ University School of Medicine Hospital Hospital ENT department with resistant idiopat- hic epistaxis and compare the pre-operative buffer and post-operative pain scores using a visual analog scale (vas). Material and Methods: The patients who were admitted and hospitalized with epistaxis between 2014 and 2018 were evaluated retrospectively. A total of 60 patients were investigated. Cases with factors that may be involved in the etiology such as post-operative trauma, intranasal benign/malignant lesion, and bleeding diathesis were excluded in the first step. Patients who had been hospitalized with idiopathic resistant epistaxis but had not undergone transnasal endoscopic sphenopalatine artery ligation (TESPAL) and/or cauterization under general anesthesia were excluded. As a result, 10 patients were included in this study. Results: In our study, the surgical success rate was found to be 100%. There was a significant difference between vas and post-operative vas in terms of pain during pre-operative tamponade. Cite this article as: Yavuz HB, Demir UL, Conclusion: TESPAL and/or cauterization seems to be an effective method. Its positive contribution to the morbidity Kasapoğlu F. The Efficacy and quality of life of the patient, as in our study, especially its effect on the level of pain, was evident when compared of Sphenopalatine Artery with conservative methods. Cauterization with or Keywords: Sphenopalatine artery, ligation, cauterization, epistaxis,posterior without Ligation in Idiopathic Resistant Posterior INTRODUCTION Epistaxis. Eur J Rhinol Allergy 2019; 2(1): 17-20. Nasal bleeding (epistaxis) is one of the most frequent emergencies of ear, nose, and throat discipline (1-4). Its inci- dence in the community was found to be approximately 60% in different studies (1-3, 5-7) and most of the cases were This study was presented in seen in the Little area as anterior epistaxis. Anterior bleeding can often be controlled by traditional methods. (1, 6, 8) 40. Turkish National Ear, Nose, However, approximately 5%-6% of nosebleeds occur in the form of posterior hemorrhage and require medical or Throat and Head and Neck surgical intervention to the patient (1, 2, 6-8). Surgery Congress, Antalya, Turkey Epistaxis shows bimodal distribution according to the age range. In the pediatric age group, it makes a peak below the age of 10 and in the adult age group over 50 years (1, 5, 8). In terms of gender, it is observed more in males than Address for Correspondence: in females (1, 3, 5). Hüseyin Barkın Yavuz E-mail: The arterial feeding of the nose is provided by internal and external carotid systems. The anterior and posterior ethmoid [email protected] artery branches of the ophthalmic branch of the internal carotid artery contribute to the nasal blood supply. In the exter- Received: 19.01.2019 nal carotid system, the sphenopalatine and major palatine artery branches of the internal maxillary artery and the supe- Accepted: 28.05.2019 rior labial artery branch of the facial artery are involved in the nasal feeding. Anterior epistaxis develops from the DOI: 10.5152/ejra.2019.97 Kiesselbach plexus in the Little region. This plexus is formed by the anterior ethmoid artery, terminal branches of the ©Copyright 2019 by Turkish sphenopalatine artery, major palatine, and superior labial artery (6). The Woodruff plexus defines the vascular network in Rhinologic Society - Available the posterior nasal cavity. The sphenopalatine artery is formed by the posterior nasal artery and pharyngeal branches (4). online at www.eurjrhinol.org 18 Yavuz et al. The Efficacy of Sphenopalatine Artery Cauterization Eur J Rhinol Allergy 2019; 2(1): 17-20 Table 1. Demographic and comorbid disease characteristics and number In this study, patients who were referred to our clinic with posterior epistaxis of buffer applications and blood product replacement quantities of by applying tamponade in external centers and for which they underwent patients transnasal endoscopic sphenopalatine artery ligation (TESPAL) or cauteriza- tion were included. The effectiveness of the intervention was investigated Feature Numerical Data via evaluation of the hemoglobin values, transfusion requirement, and buff- Gender Male 8 ered and after surgery-unbuffered pain scores during hospitalization. Female 2 MATERIAL AND METHODS Age Minimum 34 The patients who were referred to the emergency department of Uludağ Maximum 77 University Medical Faculty Hospital for external epistaxis by tamponade Male gender age average 60.8 were reviewed retrospectively. Sixty patients who were admitted and hos- Female gender age average 64.5 pitalized in the ENT clinic between the years 2014-2018 were evaluated. Average age 61.6 Patients who underwent TESPAL and/or cauterization under general Buffer With local anesthesia 39 times anesthesia were included in the study group. Trauma, bleeding diathesis, nasal mass lesion, and previous surgery were determined as the exclusion With general anesthesia 1 time criteria. The study included 10 patients who underwent TESPAL/cauteriza- No buffer ABSENT tion due to idiopathic resistant posterior epistaxis. Blood product Erythrocyte suspension 14 units In our clinical practice, if ligation of the artery is planned as the surgical replacement technique, a wide view of the foramen is planned by elevating mucosal Fresh frozen plasma 5 units flap following uncinectomy and antrostomy; however, if only cauteriza- No replacement 4 patients tion is considered, surgery is planned according to the opinion that no antrostomy is performed. Comorbid Disease Hypertension 5 patients Diabetes 2 patients Patients’ demographic characteristics, such as age and gender, and Coronary artery disease 2 patients comorbid diseases were documented. In each patient, levels of pain were compared upon scores obtained via visual analog scale (vas) during the Malignancy of distant organs 4 patients pre-operative and post-operative buffered period. Twenty vas scores No additional disease 2 patients were obtained from 10 patients. Patients were asked to indicate the dis- comfort they experienced on the 10 cm 11-point vas scale (0: no pain, 10: the most severe pain). The number of times tamponade was applied 6 before hospitalization, hemoglobin value, blood product replacement, and how many units were performed, hemoglobin values during hospi- 5 talization, and hospitalization periods were recorded. RESULTS 4 Of the 10 patients in our study, 8 were males and 2 were females. The 3 mean age of the patients was 61.6 years, ranging from 34 to 77 years. All patients were in the buffered state during our hospitalization, and 2 patients were observed to have a total of 39 buffers in the external cen- 1 ters (an average of 3.9 per patient). A total of 14 units of erythrocyte sus- pension replacement and 5 units of fresh frozen plasma replacement 0 were performed in 6 patients during the hospitalization period. In terms R.K. Z.B. C.T. N.Ö. S.A. M.K. S.K. B.K. N.G. Z.Y. of comorbid diseases, hypertension was seen as an additional disease in Pre-op hospitalization Post-op hospitalization half of the patients (Table 1). It was calculated that the patients had an average duration of 3 days before the operation and were discharged 2 Figure 1. Duration of hospitalization before and after surgery days after surgery (Figure 1, 2). In most patients presenting with epistaxis, bleeding can be controlled by No post-operative tampon was placed in any patient who underwent conservative and traditional methods. Posterior epistaxis cases were those transnasal endoscopic artery ligation and/or cauterization under general with resistant and severe bleeding. Most of the time, bleeding cannot be anesthesia. No surgical intervention was required in any patient because of recurrent bleeding. The surgical success rate was found to be 100%. In controlled by traditional methods. It is usually seen in the elderly popula- one patient, it was reported that there was a spontaneous hemorrhage tion with comorbid diseases. In posterior epistaxis cases, hospitalization is without any medical intervention after discharge and was not considered usually required. Although tampered with buffer more than once, success- to be a failure because of self-limitation and non-recurrence. ful results cannot be achieved in many cases. In this case, a wide range of treatment algorithm, which extends from posterior buffer placement, The average hemoglobin value of the patients was 12.0 g/dL. The average endoscopic artery ligation, and external interference with vascular attach- pre-operative hemoglobin was 9.64 g/dL, and it was shown to be 10.39 ment to interventional radiology and embolization, emerges (8). g/dL in the post-operative period (Figure 3). Eur J Rhinol Allergy 2019; 2(1): 17-20 Yavuz et al. The Efficacy of Sphenopalatine Artery Cauterization 19 3.5 12 3 10 2.5 8 2 6 1.5 4 1 2 0.5 0 R.K. Z.B. C.T. N.Ö. S.A. M.K. S.K. B.K. N.G. Z.Y. 0 Pre-op Vas Post-op Vas Pre-operation Post-operation Figure 4. Patients' buffered pain vas values and post-operative pain Figure 2.
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