Eur J Rhinol Allergy 2019; 2(1): 17-20 Original Article

The Efficacy of Sphenopalatine 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 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 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 and the supe- Accepted: 28.05.2019 rior labial artery branch of the 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 (6). The Woodruff plexus defines the vascular network in Rhinologic Society - Available the posterior . 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. Average length of hospitalization before and after operation vas values. vas: visual analog scale

9 8.4 Average HB at entry The lowest average HB during preop Average post-op HB 8

7 12 6 10.39 9.64 5 4

3

2 1.30 1

0 Average Pain Vas Values

Pre-op Post-op

HEMOGLOBIN (GR/DL) Figure 5. Average pain vas values in pre-operative buffered period Figure 3. Average hemoglobin values of patients. and average pain vas values in the pre-operative period HB: hemoglobin vas: visual analog scale

While the total pain value of the patients was 84 in the pre-operative buff- reported that in patients hospitalized for epistaxis, TESPAL as a first step ered period, the total post-operative pain vas value was 13 (Figure 4). The would be more cost-effective if the nasal tampon was stopped for 3 days average pain value was significantly decreased where pre-operative and or more, and that the nasal tampon would be advantageous as a first step post-operative pain were calculated as 8.4 and 1.3, respectively (Figure 5). if it was to stay 48 hours or less.

DISCUSSION Bleeding control was successfully achieved in all patients who underwent TESPAL in our study group. After the procedure, the patients were dis- Traditional treatment methods are usually applied to a patient presenting charged shortly after 2 days. Therefore, in patients presenting with epi- with posterior epistaxis (1, 4, 6). Even though conservative methods are staxis, there is no morbidity and cost due to unnecessary recurrent tam- effective in anterior epistaxis cases, the success rate in cases with posteri- ponade by determining the location of bleeding focus and bleeding or epistaxis decreases to 26-50% (2, 9). If traditional methods fail, surgical severity and TESPAL can be used as the first-line treatment option in case treatments, especially TESPAL, must be preferred (1, 4, 6). of indication.

The success rate with TESPAL is reported to be 85-98% in the literature (1, Normalizing blood pressure and providing hemodynamics in people with 3, 4, 6, 7, 9, 10). With TESPAL treatment, the hospitalization time shortened, hypertension is important for success. Anatomic variations are another bleeding control rate increased, complication rates decreased, and cost important factor affecting the surgical success rate after sphenopalatine effectiveness was better (1, 4-6). McDermott et al. (10) showed that the artery ligation. is present in 87% of the mid-su- duration of hospitalization was 3 days when TESPAL was administered in perior meatus transitional zone, whereas an accessory foramen can be the first 24 hours, whereas it was 6 days in the case where TESPAL was found in the upper meatal region in 10% (7). Variations may cause difficul- applied in a late step following tampering with a buffer in the first step. In ty in finding the origin of the sphenopalatine artery, which may reduce the same study, it was stated that the application of TESPAL was more the surgical success rate. Although there are centers that routinely recom- cost-effective in the early period. In another similar study, Dedhia et al. (5) mend and perform uncinectomy and antrostomy during surgery (8), 20 Yavuz et al. The Efficacy of Sphenopalatine Artery Cauterization Eur J Rhinol Allergy 2019; 2(1): 17-20

there are also studies that do not recommend routine antrostomy (1). Informed Consent: Informed consent was not taken from patients due to the Separation of the sphenopalatine artery into the terminal branches retrospective nature of the study. before the foramen or branching the distal branches after the foramen is Peer-review: Externally peer-reviewed. among the factors affecting the surgical success rate. The sphenopalatine artery is separated from the foramen by 60-75% as a single branch, Author Contributions: Concept - U.L.D.; Design - U.L.D., H.B.Y.; Supervision - U.L.D., 20–30% as two branches, and 10% as 3 or more branches (6, 7). During F.K.; Fundings - H.B.Y.; Materials - H.B.Y.; Data Collection and/or Processing - H.B.Y.; the ligation or cauterization of the artery, the presence and cauterization Analysis and/or Interpretation - U.L.D., F.K.; Literature Search - H.B.Y.; Writing of the main trunk are very important. If the artery is divided into branches Manuscript - H.B.Y., U.L.D., F.K.; Critical Review - H.B.Y., U.L.D., F.K. before exiting the foramen, especially cauterization of the posterior septal Conflict of Interest: The authors have no conflicts of interest to declare. artery, which is the terminal branch, the success rate is significantly affect- ed (4). It has been shown in the literature that head elevation and anes- Financial Disclosure: The authors declared that this study has received no finan- thesia-controlled hypotension reduce the amount of bleeding during cial support. surgery (7,8). In a study comparing blood loss with a head height angle of REFERENCES 10°, 15°, and 20°, 231 mL, 230 mL, and 135 mL blood losses were found, respectively. 1. İsmi O, Vayisoğlu Y, Özcan C, Görür K, Ünal M. Endoscopic Sphenopalatine Ar- tery Ligation in Posterior Epistaxis: Retrospective Analysis of 30 Patients. Turk Similar to our study, Nikolaou et al. 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