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Experimental Surgical Treatmentfor Recurrent EpistaxisIsaac Dano, MD, Eric Dangoor, MB, BS, MRCGP, Jean-Yves Sichel, MD,Ron Eliashar, MD

Purpose: To evaluate a new technique of submucosal supraperichondrial (SMSP) dissectionof the nasal septum and its subsequent effect on the vascularity of the muco sa. A reductionmay decrease the rate of recurrent anterior epistaxis.Materials and Methods: The procedure was performed on one side of the nasal septum of 16laboratory rabbits. After healing occurred 3 months later, the animals septa were excised andstained. Both sides were then compared by using standardized microscopic f ie ld analysis.Results: The reduction in both the number of blood vessels on the operated side of theseptum and the proportion of area occupied by these vesse ls was stat ist ically signif icant(P < .004).Co nclusion : This technique led to a reduction in the vascu larity of the nasal septalmucos a, 3 months after dissection was performed. Healing, which occurs by a process off ibrosis, yielded a less vascularized t issue.Although further laboratory and clinical assessm ent is recommended, this technique mayprove valuable in reducing the rate of recurrent anterior epista xis.Copyright 0 1998 by W.B . Saunders Com pany.

Epistaxis is one of the most common condi-tions encountered by the otolaryngologist, bothin the emergency room and in outpatientdepartments.

It is estimated that 60% of individuals suffer-ing from epistaxis have had at least one epi-sode of nasal bleeding in their lifetime, and ofthose persons, only 10% seek medical atten-tion.lJ Generally, the exact cause of bleedingis unknown except for cases in which there isan underlying condition, such as a hemato-logic clo tting disorder, the presence of a tu-mor, or a primary cause such as Osler-Weber-Rendu disease.

Furthermore, anterior bleeding from Kiessel-baths area of the nasal septum is encounteredmore commonly in the young and is usuallyfrom either an arterial or a venous source. Incontrast, posterior epistaxis is more commonin older patients,3l4 and is more like ly to beisolated and of a severe and prolonged nature.5

From the Department of Otolatyngology/Head andNeck Surgery, Hadassah University Hos pital, Jerusalem,Israel.Address reprint requests to Isaac Dano, MD , Depart-ment of Otolaryngology/Head and Nec k Surgery, Hadas-sah Universitv Hosoital. Jerusalem, Israel.Copyright 0 1998 byW .6. Saunders Company0196-0709/98/l 906-0002$8.00/O

Anterior nasal bleeding is usually not lifethreatening, although frequently recurringcases can harm ones quality of life. Treatmentof epistaxis ranges from relatively conserva-tive procedures, such as cautery, and insertionof packs and balloons, to surgical approachessuch as ligation of ethmoidal, maxil lary, orexternal carotid arteries.j Other proceduresinclude local injection of lidocaine in theposterior palatine canal and select ive arteria lembolization.7

There are isolated reports in the medicalliterature on the use of septoplasty for epi-stax is. The recommendations for this proce-dure are not only to allow better access andtreatment of areas behind a deviated septum,3but also to reduce the nasal septal vascularity8for cases in which the septum is relativelystraight. On review of the literature, this lattereffect has been shown to be of limited success.Its mechanism of action is thought to bedisruption of the blood supply to the mucosaafter elevation of the mucoperichondrium fromthe septal cartilage (in the subperichondrialplane).

However, to our knowledge, there has beenno detailed study to date analyzing the effi-cacy of septoplasty for recurrent epistax is.Furthermore, the subperichondrial plane used

American Journal of Otolaryngology, Vol 19 , No 6 (November-Decem ber), 1998: pp 357-359 35 7

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358 DAN0 ET AL

in this procedure is known to be much lessvascu lar than between the perichondrium andthe overlying mucosa.3

This animal study was therefore conductedto analyze the outcome of elevation of thenasal septal mucosa in this submucosal supra-perichondrial (SMSP) plane.MATERIALS AND METHODS

We used 16 rabbits (8 males and 8 females) in ourstudy. Following anesthetizat ion, the nasal septa ofall rabbits were infiltrated with lidocaine 2% solu-t ion on the right side. The mu cosa was subse-quently separated from the perichondrium by dis-section with ir is scissors, a technique that we callSMSP dissection. A Telfa gauze pack (KendallHealthcare, Mansfield, MA) was then inserted inthe nostril of each rabbit for 2 days and thenremoved.Three months after this procedure, the nasalseptum of each animal was excised and histologi-cally s ectioned in a coronal plane by using hema-toxylin and eosin s tain. Each slide w as examinedunder a l ight microscope by using standardizedfields over the t issue section. Information was thengathered over a randomly chosen area as follows:1 By using a computerized morphometric tech-nique, we calculated the total area of bloodvessels in each microscope f ield in both thedissected and the nondissected port ion of the

animal septum. The overall percentage of thef ield occupied by blood vessels w as then ob-tained. We termed this percentage as the propor-t ionate vascular area (PVA).2. In each f ield, we counted the number of bloodves sels seen in both the operated and nonoper-ated sides of each septum .RESULTS

Al l rabbits underwent the same procedurein which their septal PVA and the number ofblood vessels were calculated at the end of thes-month period. The results were tabulated(Table 1) and stat istically analyzed using t-testsfor paired samples and Wilcoxon matched-paired signed rank tests.We compared the PVA in both the male andfemale groups. There was no statis tical differ-ence between both sexes within the operatedgroup (P < .l) o r the unoperated group (P < .l)(Table 1).

Similarly , we compared the number of bloodvessels in the male and female groups. Here,again, there was no significant statis tical differ-

TABLE 1. Postoperative Comparison of ProportionateVascular Area (PVA) as a Percentage and Blood VesselNo. in Male and Female Rabbits

Operated Side Nonoperated SideNo. of Blood No. of Blood

PV A Vessels PVA VesselsMale Rabbits

6 20 193 18 142 25 135 10 113 30 207 26 244 13 96 20 17

Female Rabbits7 3 17 9

10 9 14 116 6 8 115 2 14 101 2 9 132 5 16 16

10 6 25 218 7 20 15

ence in the operated group of both sexes(P < .7). Likewise, there was no appreciabledifference in the nonoperated side in both sexgroups (P < .2) (Table 1).

We then compared the percentage PVA andthe number of blood vessels in all animalsbetween the operated and nonoperated sides.Here, there was a clear statistica l difference(P < .004) in that the operated side of septumcontained a significantly smaller PVA andnumber of blood vessels .DISCUSSION

This study shows that use of the SMSPdissection technique significantly reduces thetotal number of blood vessels and the percent-age area occupied by blood vessels, PVA,when compared with the nonoperated side ofthe nasal septum. We found no significantstatistical differences between the sexes.

The basic assumption of this study was thatareas of the nasal septum with a richer vascu-lar supply have a higher likelihood of bleed-ing. The fundamental basis of our surgicalapproach was the known physiologic process

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EXPERIMENTAL SURGERY FOR RECURRENT EPISTAXIS 359

of scar formation, the final phase of which hasa relatively poor vascular supply.gCONCLUSION

We propose that by using this new SMSPtechnique, the number of septal blood vesselsand proportion of tissue area occupied byblood vessels are signif icantly reduced in therabbit model. This outcome is thought tooccur as a result of direct disruption of theblood supply to the septal mucosa from theirorigin in the mucoperichondrium, which ishighly vascular. Furthermore, the traumaticprocess of dissection induces a healing pro-cess that ultimately gives rise to fibrosis andthus less vascular tissue. Therefore, longerterm recurrent epistaxis may be diminished.We found no statis tical difference betweenboth sexes and propose that the healing pro-cess occurs similarly in both groups.

The use of this technique in humans suffer-ing with recurrent anterior epistax is, shouldbe considered further, and future clin ica l trialsshould be conducted to prove its efficacy andvalidi ty. If successful, the technique may con-

tribute to treatment and improvement in thequality of life of those suffering from recurrentanterior epistaxis.REFERENCES

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