Trans-nasal Endoscopic Sphenopalatine Artery Ligation in Epistaxis: Coblation Versus Electrocauterization

Abstract

Epistaxis is one of the most common emergencies encountered by otorhinolaryngologist. Although anterior epistaxis is easy to manage but posterior epistaxis is usually refractory. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) is now a well established surgical technique for the management of refractory epistaxis. Electrocauterization and clipping are the most common methods used for ligation. Coblation is an upcoming tool with promising results in endoscopic skull base surgeries and tonsillectomies but has not been explored much in TESPAL. It was a randomised observational study.50 patients of refractory epistaxis were included in the study. The patients were divided into 2 groups. Group A underwent TESPAL using electrocauterization while Group B underwent TESPAL using coblation. The data was collected and analysed for various parameters like experience of the surgeon, time taken for surgery, episodes of rebleeding and postoperative crusting. Out of 50 cases in our study 27 were males and 23 were females. Most common age group was 60–70 years (68%). Most common cause was hypertension (86%). Surgeons were happy 21/25 times in coblation group compared to 9/25 times in electrocauterization group. There were 4/25 rebleeding episodes in electrocauterization group compared to none in coblation group. Post-operative crusting was also less in coblation group compared to electrocauterization. Though electrocauterization is a well established method for TESPAL our experience with coblation in TESPAL has been extremely satisfying. We suggest our colleagues to conduct more research studies on use of coblation in TESPAL to reach a consensus.

Introduction

Lifetime incidence of epistaxis is about 60% and it is one of the most common emergency otolaryngologists encounter [1]. Most episodes of epistaxis are minor in severity and are self-limiting. Such bleeding usually originates from Kiesselbach's plexus on the anterior nasal septum. Majority of the patients with epistaxis can be treated with chemical cauterization, hemostatic agent application and short-term application of anterior nasal packing, which are the first-line treatment methods. However, there is a group of patients with posterior epistaxis whose bleeding does not stop with these methods; though the incidence of such a bleeding is low (5–10%). Such severe episodes of epistaxis originate posteriorly, from branches of the sphenopalatine (SPA) and anterior ethmoid arteries. Such cases often require aggressive intervention, including anterior and posterior nasal packing, endoscopic electrocautery, angiography with embolization, or surgical ligation of the nasal blood supply. Although posterior nasal packing can be applied in patients with posterior epistaxis, both the morbidity and duration of hospitalization of these patients have been reduced through the Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and arterial embolization methods in recent years. Various methods including bipolar or monopolar forceps cauterization and clip application are being used for Transnasal endoscopic sphenopalatine artery ligation (TESPAL) [2–5].

Electrocauterization involves the application of electric energy directly to the tissue, creating temperatures in excess of 400 °C, which induces coagulative tissue necrosis and the formation of a black crust, with diastasis of the necrotic tissue potentially causing rebleeding [6]. Coblation works through the application of radiofrequency energy to a conductive medium (e.g. normal saline), which produces a localized plasma field that breaks molecules into inert, low molecular weight gases at a low temperature by conventionally targeting tissue to locally obtain an average consistent temperature of 60 to 70 °C and thus coagulating tissue but cost, angulation and width of instrument can be the limiting factors [7, 8]. Similarly there are high chances of rebleeding in cases where surgical clip are applied by clip applicator mainly due to failure to clip the posterior septal branch of the SPA and dislocation of the hemoclips [6]. Despite many methods being described for TESPAL there are still many lacunae in the existing literature for ideal and best method for sphenopalatine artery ligation. To address the deficiencies in existing literature the present observation study was planned to compare electric cauterization (bipolar/Monopolar) versus coblation for TESPAL in terms of surgeons preferability and certain post- operative parameters.

Methods and Materials

Study setting and place:Present Study “Trans-nasal endoscopic sphenopalatine artery ligation in Epistaxis: Coblation versus Electrocauterization” was conducted in department of ENT of Sri Guru Ram Das University Of Health Sciences, Sri Amritsar from November 2018 to March 2020.

It is an observational study comparing efficacy of Bipolar/Monopolar cautery versus Coblation method for TESPAL (Transnasal Endoscopic Sphenopalatine Artery Ligation) All necessary ethical clearance involving human subjects were obtained from ethical committee of institution before recruitment of subjects and studied complied with principles of declaration of Helsinki and all guidelines issued by ICMR for research on human subjects were followed. It was ensured that patient confidentiality was maintained at all points in the study. Patient was explained in language best understood by him / her and written informed consent was obtained regarding participation in study and about merits and demerits of both surgical techniques. Also consent was obtained regarding recording of surgery for documentation purposes. STROBE guidelines were followed for reporting the study.

All Adult Patients who were having refractory epistaxis or recurrent epistaxis not responding to conventional methods of management were recruited in study.

Total of 50 patients were included in study from November 2018 to March 2020 who underwent TESPAL by one of methods.

Inclusion Criteria

All adult patients were having refractory bleeding not responding to conventional methods of management or severe paroxysmal bleeding were included in the study.

Exclusion Criteria

1. History of hematological diseases or

2. Trauma.

3. Nasal tumor (nasopharyngeal angiofi- broma, hemorrhagic necrotizing polyp of nasal sinus,)

4. Bleeding of Kiesselbach’s area,anterior nasal septal bleeding which was easily controlled with anterior nasal packing.

Group Allocation

Two groups were formed and patients were allocated to these groups by using computer generated random numbers. Group A patients underwent TESPAL by electrocauterization while group B patients underwent TESPAL by coblation. The surgical package of both the techniques were subsidized to remove cost as a confounding variable between the two methods.

Surgical Technique

The procedure was performed in the operation theatre with the patient under general anaesthesia. The setup was as usual for endoscopic sinus surgery using a 0° or 30° endoscope (4 mm in diameter).The nasal cavity was decongested with 1:1000 epinephrine on cotton pledgets to achieve mucosal shrinkage and hemostasis. Injection with 2% xylocaine with 1:200,000 units of adrenaline was performed in the operative field (i.e., middle turbinate and lateral wall of the posterior part of the middle meatus). A vertical incision was made through the mucosa and periosteum 1-cm anterior to the posterior tip of the middle turbinate. If access to this area is limited, a partial resection of the uncinate process was helpful. To ensure anatomic topography, the ostium of the maxillary sinus can be widened backward to outline the posterior wall of the maxillary sinus. A Freer is used to raise a mucoperiosteal flap posteriorly and upward. Typically, a bony ethmoidal crest is exposed just anterior to the sphenopalatine foramen. The neurovascular bundle is identified exiting the foramen emerging in a horizontal plane.

After identifying the artery, which at this point might be bifurcated into 2 branches, diathermy using a bipolar /monopolar suction cautery or coblation wand (Fig. 1) was used. After coblation or electro cauterization, the mucoperiosteal flap was replaced to its original position. There was no need for a packing of the nasal cavity. The duration of surgery was noted for both techniques. After the completion of the procedure surgeon was asked to fill questionnaire asking ease of surgery ranging from comfortable and happy, difficult and unhappy. Post op pain score was noted for both techniques. The patient was normally discharged day after surgery and routine follow up care was taken. On follow up crusting in nasal cavity and any rebleed episodes upto 2 weeks were noted for both techniques.

Fig. 1.

The coblation wand at the Sphenopaltine foramen in process of TESPAL

Parameters studied: The data was collected and analysed by the observer who was blinded to the method used during the surgical technique. Following parameters were studied.

Primary Outcomes

1. Ease of surgery and surgeon comfort: According to questionnaire given to surgeon. Comfortable and Happy; Not Comfortable; Difficult and Unhappy.

2. Duration of surgery by both techniques: The duration was calculated from the start of the procedure commencing with diagnostic nasal endoscopy till the time of Sphenopalatine artery ligation.

3. Pain Score: Wong Baker Pain score.

4. Rebleed episodes.

5. Crusting on follow up visits.

Secondary Outcomes

1. Causes Of Epistaxis.

Results

In the present study there was an average of 27 males and 23 females. The mean age was 56.72. Hypertension was diagnosed in 43 cases; 17 being newly diagnosed. & patients had history of nasal surgery; 3 patients were on antiaggregants and 2 patients were on anticoagulants (Table 1). The bleed was right sided in 27 cases versus 19 cases which were left sided. Bilateral TESPAL was required in 4 cases (Fig. 2). Maxillary antrostomy was done in 43/50 cases. 04/50 cases required septoplasty before TESPAL in same setting. The Surgeon was 21 times happy and comfortable in Group B compared to 09 times in Group A. The surgeon felt difficult and unhappy 04 times in Group B compared to 16 times in Group A. Duration of surgery was 17 ± 0.8 min in Group B while it was 39 ± 0.7minutes in Group A. Crusting was seen in 19 patients in Group A compared to only 06 patients in group B. Rebleed episodes were seen in 04 patients in Group A while none were seen in Group B. Average Pain score in both groups was 2 (Table 2).

Table 1.

Various causes of refractory epistaxis in patients undergoing TESPAL

Cause of epistaxis	Number of patients (n = 50)
Hypertension	43
Use of antiaggregant drugs	03
Use of anticoagulant drugs	02
Previous nasal surgery	07
Idiopathic	01

Fig. 2.

Showing the laterality of bleed in patients undergoing TESPAL

Table 2.

Comparasion of various parameters studied

Parameter	Group A (Electro-cauterization)	Group B (Coblation)
Surgeon’s experience
Surgeon comfortable and happy	09/25	21/25
Surgeon felt difficult and unhappy	16/25	04/25
Duration of surgery	39 ± 0.7 min	17 ± 0.8 min
Average pain score	2	2
Rebleeding	04	0
Post operative crusting	19/25	06/25

Discussion

The present observational study was conducted to compare the two methods i.e. Coblation coagulation versus monopolar/bipolar cauterisation for endoscopic sphenopalatine artery ligation (TESPAL) in in refractory cases of epistaxis. Total of 50 cases were recruited in the present study where by 25 cases were done with coblation method (Group B) and 25 cases were done with Monopolar/bipolar cauterisation. (Group A) It is found that coblation method is better method in terms of surgeon comfortability, average time taken and post-operative results.

Although there are many strengths of the present study like well planned protocol for inclusion and exclusion of cases, homogenous population, highly specific well designed parameters to complete the study, observer blind to remove any bias in results and it was ensuring that surgeon s who were conducting well well trained with both methods there were many limitation in present study like small cohortnand concerns about internal and external validity and generalizibility of results. Although it is a simple observational study but this study can open gates to to further research on this topic as it has raised a very important question of effective tool for refractory epistaxis so that atleast the upcoming junior otolaryngologists have enough evidence for accurate decision making.

Most common age group affected was between 60–70 years followed by 50–60 years and 40–50 years (Table 1). Out of 50 cases 23 were females and 27 were males (Table 1).

The key findings pointed that hypertension was the most common cause of refractory epistaxis where in present study all patients had hypertension. Out of 50 cases all 43patients were having hypertension and out of these 50 patients 17 patients were newly diagnosed cases of hypertension. Other causes were use of anti antiaggregrant mostly clopidogrel and aspirin (03) drugs, use of anticoagulant (02) drugs mostly warfarin,previous nasal surgery (01) and idiopathic cases (01) (Table 1).

Epistaxis in elderly have a diverse etiology with hypertension as the common etiological factor.In a retrospective study conducted on etiology of refractory epistaxis by Sharma et al. reported that 59.2% cases who presented with refractory epistaxis had hypertension with most common age group being 60–70 years [9]. Similar findings were also reported in studies conducted by Chaiyasate et al. and Saxena et al. [10, 11]. Findings of above mentioned studies are in accordance with our present study where hypertension is most common cause of refractory epistaxis and most common age group presented was between 60–70 years. In present study 21 one out of 25 times surgeon reported themselves to be comfortable and happy operating with coblation as compared to monopolar/bipolar cauterisation where only 9 out of 25 times surgeons were happy using the tool (Table 2). The main reason was the use of bipolar was difficult in the narrow and posterior area and they required switching over to insulated monopolar cautery and monopolar cauterisation was not as precise. Odat and Alqudah in their study also mention the difficulty of use of bipolar cautery forceps in this region [12].

Average duration of surgery with coblation (avg 17 ± 0.8 min) was much less than monopolar/bipolar (39 ± 0.7mins);however this time excluded the set up time for coblation (Table 2).

Though there was not much difference in pain score but there was significant reduction in crusting on follow up with coblation cases. Also there was no episodes of rebleed with coblation as compared with Monopolar/ Bipolar cauterisation.The success rate of procedure with coblation was 100% while that with electrocauterization was 84%and we can attribute a 100% rate for coblation to our small cohort and this may differ as the sample size increases (Table 2).

Though there is no study directly comparing coblation with electro-cauterization in TESPAL probably as coblation is relatively a new tool however there are numerous studies in literature comparing the efficacy of electrocauterization and clips. Shehahta et al. in their study on sphenopalatine artery ligation comparing clipping versus electrocauterization found both methods effective but complication rate with clipping was better than electrocauterization. In their study the group who had SPA cauterization 5 patients (25%) had recurrent epistaxis, 1 patient (5%) had paresthesia in soft palate, 3 patients (15%) had nasal crustation, 3 patients (15%) had synechia and 2 patients (10%) had sinusitis. While the other group of patients who had SPA clipping 2 patients (10%) had recurrent post-operative epistaxis while the other 18 patients (90%) showed no postoperative complication [13].

In systematic review by Kitamura et al. the pooled complication rate in the cauterization group was 10.2% (95% CI, 3.8–214.5), whereas the rate in the ligation group was6.4% (95% CI, 1.8–20.9) [14].

Rockey and Anand reviewed their experience of sphenopalatine artery clipping inten patients. Two patients had ongoing epistaxis within the first twenty-four hours postoperatively. They attributed this failure to incorrectly closed clips [15].

Ismi et al. in their study mention that there are high chances of rebleeding in cases where surgical clip are applied by clip applicator mainly due to failure to clip the posterior septal branch of the SPA and dislocation of the hemoclips. However they also emphasis that insufficient coagulation time during cauterization in TESPAL can cause re-bleeding and the vascular lumen to remain patent [16].

Joshi et al. in their study on use of coblation in haemorrhagic telengectasia conclude that the limitations of monopolar/bipolar cautery like high thermal injury, with secondary crusting, mucosal damage and an inevitable reduction in mucociliary function are not present with coblation method making it more efficient tool. They also mention studies which state that coblation has been demonstrated to promote good healing and to preserve surrounding normal tissue. Despite low temperatures generated during coblation, small blood vessels are sealed by the plasma fiels so generated [7, 8].

The key to managing posterior epistaxis efficiently is precise identification of the sphenopalatine artery. Use of coblation enables efficient tracing of sphenopalatine artery and haemostasis, with the same instrument at the same point of time due to its inbuilt suction along with coagulation port. The low temperatures minimise the risk of septal perforation and excessive post op crusting which is generally a routine problem with monopolar/bipolar cautery. Although we used traditional coblation probes (e.g. the Evac 70; Arthrocare ENT, TX, USA), newer probes designed for the nasal wall are now available (e.g. the PROcise EZ View Sinus; Arthrocare ENT, TX, USA)which have appropriate size and width for nasal cavity making it a very useful tool [7].

Conclusion

Coblation is an emerging tool in otorhinolaryngology. Its role in TESPAL seems to be promising because of its dual ability to do suction and coagulation at same time without charring the tissue. We highly recommend the use of Coblation in TESPAL and also encourage more studies to generate more evidence comparing various methods used in this technique to establish a worldwide consensus.

Funding

It was non-funded study.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Before starting the study ethical clearance was taken from institutional ethical committee as per Declaration of Helsinki.

Informed Consent

Informed consent was taken by all the patients before surgery and enrolment into the study.