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Acta Oto-Laryngologica, 2010; 130: 1048 – 1052
ORIGINAL ARTICLE
Endoscopic management of recurrent epistaxis: The experience of twometropolitan hospitals in Italy
ANTONIO MINNI1, ALBERTO DRAGONETTI2, ROBERTO GERA2, MARCO BARBARO1,GIUSEPPE MAGLIULO1 & ROBERTO FILIPO1
1Dipartimento Testa e Collo Azienda Policlinico Umberto I, Università degli Studi di Roma “Sapienza” , Roma and
2SC
Otorinolaringoiatria 1 Ospedale San Giuseppe, Milano, Italy
Abstract
Conclusion: Endoscopic cauterization of the sphenopalatine artery and anterior ethmoid artery is a rst-line standard of care in
managing intractable epistaxis, after the failure of previous packing. Epistaxis occurs in 12% of the population. Treatment is
often based on nasal packing that could be poorly effective in the treatment of severe posterior epistaxis. Objective: To evaluate
the effectiveness of the endoscopic approach for posterior epistaxis. Methods: We report the experience of endoscopic
cauterization in two metropolitan hospitals in Italy: 48 patients with at least one nasal packing in the 3 weeks before hospital
admission. They underwent endoscopic cauterization of the sphenopalatine artery or of the anterior ethmoid artery. Results:
The patients’ mean age was 58.7 years; the mean hospital stay was 2.97 days. In 42 cases (87.5%), cauterization of the
sphenopalatine artery was performed, and 6 (12.5%) were subjected to anterior ethmoid artery treatment. Epistaxis control was
achieved in 93% of cases; 3 patients had a recurrent nasal bleeding, and were treated with anterior nasal packing. Minor
complications occurred in 27.1%. We achieved a shorter hospital stay compared with patients who underwent anteroposterior
packing.
Keywords: Epistaxis, endoscopic cauterization, sphenopalatine artery, anterior ethmoid artery, emergency, nose bleeding
Introduction
Epistaxis is the most common emergency in otorhino-
laryngology, involving approximately 12% of the pop-
ulation [1], with 10% of cases requiring medical
treatment and only 1 – 2% needing surgery [2]. In
most cases, bleeding rst occurs anteriorly in
Kiesselbach’s vascular plexus and may be treated by
nasal packing or with chemical or electrical cautery.
Posterior epistaxis occurs less frequently than ante-
rior epistaxis (10 –
15%) [3] and involves the areaaround Woodruff ’s plexus [4]; it is more severe and
often requires specialist care. In these cases bleeding
originates from branches of the sphenopalatine artery
(SPA), the vidian artery (VA), or ethmoid arteries
(EA) [5]. Treatment requires a more invasive tech-
nique, which may include anteroposterior packing,
angiography with embolization or surgical treatment
by endoscopic ligation or cauterization [6]. The oto-
laryngologist will decide when a recurrent bleeding
should call for surgery; such is the case with posterior
persistent epistaxis [7].
In addition to possible complications observed in
patients with anteroposterior nasal packing [8], it
should be considered that these patients may need
to be hospitalized. In view of particular logistics,
patients with posterior epistaxis and/or ineffective
packing are referred to our hospital for a denitivetreatment. In such patients, the treatment must be
nal, early, and with the lowest percentage of failure or
recurrence, hence leading to a short hospital stay. In
recent years, several authors have proposed the use of
endoscopic techniques for the treatment of epistaxis.
The process for the validation of the endoscopic
Correspondence: Antonio Minni, Università degli Studi Sapienza, Policlinico Umberto I, Viale del Policlinico 15,5 00100, Rome, Italy. Tel: +39 064454607.
E-mail: antonio.minni@uniroma1.it
(Received 2 November 2009; accepted 21 December 2009)
ISSN 0001-6489 print/ISSN 1651-2251 online 2010 Informa Healthcare
DOI: 10.3109/00016481003621538
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treatment of posterior epistaxis was undertaken about
30 years ago. In 1976, Prades [9] described the micro-
surgical approach to ligate the SPA to the foramen
from which it emerges as a landmark for the vidian
nerve; SPA endoscopic ligation or cauterization tech-
niques (SEC) have been perfected in recent years [10].Several studies with a 10-year follow-up have also been
published [11]. The introduction of SPA and anterior
ethmoid artery (AEA) cauterization considerably
improved the success rate of the treatment of posterior
epistaxis. Indeed, cauterization determines an inter-
ruption of nasal blood supply in a suf ciently distal
area that does not allow for a compensatory anasto-
motic blood ow by the ipsilateral carotid system for
possible revascularization (by internal maxillary artery
or revascularization of pharyngopalatine branches
from the internal carotid by the homolateral vidian
artery) [7,10].
According to this strategy, several cases of recurrentepistaxis have been treated endoscopically in our
centers since 1996, and have recently been subjected
to thorough follow-up.
Material and methods
Clinical charts of patients admitted for recurrent
epistaxis, between January 2004 and December
2006, at the Otolaryngology Department of the
Azienda Policlinico Umberto I of Rome (third-level
reference hospital) and at the Otolaryngology Depart-
ment of the Ospedale S. Giuseppe in Milan (localhospital), were analyzed. We evaluated 48 patients
with a history of at least one nasal packing due to
epistaxis in the 3 weeks before hospital admission;
during their hospital stay they underwent endoscopic
cauterization of the SPA or of the AEA, performed by
senior otolaryngologists. Patients with an Interna-
tional Normalized Ratio (INR) > 2 had to wait until
the INR decreased before they had surgery.
All patients were treated under general anesthesia.
After removing the tamponade under endoscopic
control (0 scope), cottonoids soaked in 2 ml of
2% lidocaine with adrenaline 1:100 000 were placed
in the middle meatus and in the olfactory ssure.
Endoscopy evidenced the area of probable bleeding,
showing excessive varicosity in the intranasal AEA or
slight bleeding from the bulla (intra-ethmoidal branch
of AEA) or in the area of the posterior fontanelles
(SPA), and nally from the sphenoethmoidal recess
(vidian artery). In case of bleeding in the AEA,
extramucosal cauterization was performed with bipo-
lar forceps. Alternatively, after performing an anterior
ethmoidectomy and identifying the frontal recess,
cauterization was performed on the AEA, in its
passage through the crest between the rst and second
foveola. The procedure to identify SPA included
slight medialization of the middle turbinate, the local-
ization of the posterior medial wall of the maxillary
sinus in the area of the posterior fontanelles (some-
times it may be useful to perform a medial anthro-
stomy starting from the natural ostium of the
maxillary bone in the posterior direction), and its
posterior detachment subperiosteally all the way to
the small bony crest formed by the conjunction
between the maxillary bone and the palatine bone.This bony angle is almost always present, and is
considered a pointer for the identication of SPA.
The emerging artery is generally quite visible, thus
making it unnecessary to shave the crest. Cauteriza-
tion is performed at its origin with endoscopic bipolar
forceps 45 (mod. Take-Apart* Storz n.28164 BGL)
(Figure 1). Endoscopic control is maintained until
arterial blood pressure is normalized. No packing is
performed, but surgicel strips are tted in the sphe-
nopalatine foramen. Patients were followed up by
periodic endoscopy with a follow-up ranging from
30 to 60 months.
Results
The mean age of the patients was 58.7 years (range
26 – 77 years), the M/F ratio was 10:1; the mean length
of hospital stay was 2.97 days (range 2 – 5). Twenty-
two patients (45.8%) had been previously subjected in
the previous 3 weeks to 1 nasal packing, 18 (37.5%) to
2, and 8 (16.6%) to more than 2 packings. In 64.3%
of cases, an anterior packing was performed with
Figure 1. Cauterization of sphenopalatine artery at the origin with
bipolar forceps (Take-Apart* Storz).
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Merocel strip (10 cm), while in the remaining 35.7%
an anteroposterior packing was performed with a
Brighton epistaxis double balloon. In all, 19
(39.5%) patients had been subjected to previous
treatment at our hospital, while the remaining 29
(60.4%) were referred to us by other hospitals. Anam-nestic data for our patients included frequency of
epistaxis, work history, associated comorbidity (dia-
betes, hypertension, hematological disorders), the use
of anticoagulants (Table I), previous trauma or pre-
vious surgery of the nose and sinuses (Table II).
During hospitalization, no patient had to undergo
blood transfusion.
In 42 cases (87.5%), cauterization of the SPA was
performed, and 6 (12.5%) were subjected to AEA
treatment (Table III).
The mean duration of the surgical procedure was
40 min, after which no patients were subjected to
nasal packing. Patients were discharged on day 1postoperatively with broad-spectrum antibiotic ther-
apy and nasal irrigation with saline solution.
At the end of the follow-up period, epistaxis control
was achieved in 93% of cases. Three patients (6.2%),
treated with anticoagulant, had a recurrent nasal
bleeding over 6 months after surgery, and were trea-
ted with anterior nasal packing. Until 1 month post-
operative minor complications occurred in 27.1% of
patients (Table IV).
Discussion
The current treatment of epistaxis often continues to
be based on the so-called “conservative treatments”
such as nasal packing, and often surgery is still
employed as a last resource. It is important to stress
that nasal packing is not only poorly effective in the
treatment of severe posterior epistaxis (50%) [12,13],
but it also has a high morbidity rate. It is very uncom-
fortable for the patient, and may cause complications,such as lesions of the septal mucosa (necrosis and
perforations) or of alar cartilage, sinusitis, syncope,
and very rarely septic shock syndrome. It may even
cause hypoxic complications of vital importance for
the patient.
It should also be considered that most patients with
severe epistaxis have associated comorbidities, espe-
cially hypertension, and that we often treat elderly
subjects. In the literature cases have been described in
which the cuff occludes the nasopharyngeal airways
[14] in elderly patients, causing episodes of hypoxia
that generated fatal arrhythmias [1].
According to our experience [15] in ENT emer-
gency, patients with anteroposterior packing can
develop a recurrent bleeding in 50% of cases, which
increased to 70% in patients with coagulation disor-
ders. The mean hospital stay for these patients was
6.4 days. Considering that one of our hospitals is
located in the downtown area of a large metropolitan
city (Ospedale S. Giuseppe, Milan), and that the other
is a university hospital in another major city (Azienda
Policlinico Umberto I, Rome), we decided to change
the therapeutic approach from a ‘passive’ method
Table I. Anamnestic data regarding comorbidities and nasal
surgery/trauma.
Anamnestic data No. of patients
Hypertension 7 (14.6%)
Anticoagulant or antiaggregant therapy 21 (43.7%)
INR > 2 11 (22.9%)
Diabetes 11 (22.9%)
Previous nasal surgery 10 (20.8%)
Maxillofacial trauma 1 (2.1%)
Table II. Types of surgery undergone by patients before
starting bleeding.
Surgery
No. of patients
(total = 48)
Inferior turbinate surgery according
to Sulsenti
2
Endoscopic sinus surgery 7
Septoplasty according to Cottle 1
Total 10
Table III. Endoscopic surgical approach for recurrent epistaxis.
Endoscopic approach No. of patients (total = 48)
Cauterization of
SPA
42 (87.5%)
AEA treatment 6 (12.5%): 4 extramucosal
coagulation, 2 cauterizationbetween rst and
second foveola
Treatment of the anterior ethmoid artery is also divided according
to technique used (see Material and methods).
Table IV. Minor complications.
Minor complication No. of patients (total = 48)
Nasal eschar 4
Craniofacial pain 1
Acute rhinitis 3
Acute sinusitis 5Total 13 (27.1%)
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(anteroposterior packing), which might not solve the
problem, to an ‘active method’, i.e. endoscopically
controlled cauterization. In addition to proving its
effectiveness, endoscopically controlled cauterization
shortened the patients’ hospital stay to about 3 days,
thus allowing a general cost saving, and an increasedbed rotation index, which generated a further cost
saving.
Endoscopically controlled cauterization requires a
‘learning curve’ [16], which may easily be acquired by
specialists dealing with nasosinusal endoscopic sur-
gery. The localization of the sphenopalatine foramen
posterior to the ‘bone pointer’ (crista ethmoidalis) on
the nasal lateral wall is constant [17], while anatomical
variability may dueto the branches of the SPA [17,18],
which may form two, three, or even four branches
[19]. However, as previously stressed, the treatment of
the artery right where it emerges from the foramen
prevents the occurrence of revascularization or rea-nastomosis (Figure 2). In our series, we observed a
single SPA in 40% of cases, an SPA with two branches
in another 40% of cases, and an SPA with three
branches in 11% of cases, while in 9% of cases the
SPA originated from two adjacent foramina.
Some authors have reported that ligation and cau-
tery of the SPA are equally effective [11]. We prefer
cauterization because we believe that it is more ver-
satile, as it may be used concomitantly for any vari-
cosities occurring in the septum, lower turbinate, and
oor.
Kumar and others [20] reviewed the ef cacy of
ligation/cauterization of the SPA in the treatment of epistaxis. Eleven studies were identied with a total
of 27 patients, and positive results ranged from 92 to
100%, with a mean of 98%. Ligation was ef cacious
in 96% of cases and cautery in 100% of cases. In some
studies, however, the number of patients was small,
and in particular the follow-up period was rather
short. In their study, Reza Nouraei et al. conrmed
a 90% ef cacy rate at 5 years for SPA cautery, without
observing any signicant differences between cauter-
ized SPAs and SPAs rst cauterized and then sub-
jected to ligation. The authors concluded that they
had no evidence to advise the abandonment of SPA
ligation [11].
Our case series reveals that in 20.8% of cases the
cause of posterior epistaxis was related to a previous
surgical trauma (endoscopic surgery/turbinate sur-
gery). The arteries most frequently involved in post-
operative epistaxis are SPA branches of the middle
and lower turbinate.
Cases of epistaxis following endoscopic sinusal
surgery (ESS) are mostly due to a lesion of the
posterolateral branch of the SPA in the preparation
of the anthrostomy of the maxillary sinus (in over 20%
of cases this branch runs anteriorly to the posterior
wall of the maxillary sinus). Special attention is thus
required when performing this surgical step, which as
we have already discussed, may also be used for the
treatment of SPA. Another cause of arterial bleeding
during ESS is the lesion of the septal branch of the
SPA, which may occur during sphenoidotomy if it is
performed in an excessively caudal direction.
Non-iatrogenic bleeding of the AEA during ESS
has always occurred spontaneously in patients suffer-
ing from hypertension or coagulation disorders.
Conclusion
Considering the method’s ease of extension and
learning, its limited costs and cost-effectiveness, its
safety (over 90%), and low complication rates, we
recommend early endoscopic cauterization of the
sphenopalatine and anterior ethmoid arteries as a
rst-line standard of care in managing intractable
epistaxis, after the failure of previous packing.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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