Endoscopic Reccurent Italy

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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: [email protected]

(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).

Endoscopic management for recurrent epistaxis 1049


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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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