Abstract
Epistaxis is a commonly occurring phenomenon which is defined as “bleeding from inside the nose” and often presents as an emergency. The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly. Endoscopic sphenopalatine artery cauterization is a safe, simple and effective procedure in the management of refractory epistaxis. Moreover, in view of minimal morbidity, higher success rate, shorter hospital stays and higher patient satisfaction, our current practice is to consider this treatment option in the management of cases not responding to conservative treatment modalities. A total of 11 patients (8 males and 3 females) underwent sphenopalatine artery cauterization during the study period. All patients were hypertensive and were refractory to treatment with general measures, anterior nasal packing and Foley catheter. The mean age of the study population was 58.36 and the range was 39–70 years. The epistaxis was rapidly controlled in all patients without any intraoperative or postoperative complications. The follow up period was 60–90 days. Strict control of hypertension was done throughout the follow up period. None of the patients developed epistaxis in the follow up period. The sphenopalatine artery cauterization technique using nasal endoscope was safe, simple, fast and effective with low rates of morbidity and complications for the management of refractory epistaxis. It was concluded that endoscopic sphenopalatine artery cauterization should be considered as an immediate second line treatment where conservative measures fail and it is proved to be of low morbidity and cost effective.
Keyword: Hypertensive epistaxis, Treatment modalities, Endoscopic sphenopalatine artery cauterization
Introduction
Epistaxis is a commonly occurring phenomenon which is defined as “bleeding from inside the nose” and often presents as an emergency. It is a problem which may cause great anxiety to the patients. It is estimated to affect 60% of the population, of which 6% may need medical attention [1]. It is observed that intervention is required only for a small population. Common aetiologies of epistaxis include trauma, hypertension, infection, nasal polyp, malignancy, deviated nasal septum, hypothyroidism, bleeding abnormality and angioma [2].
The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. There should be a complete understanding of the available treatment modalities and a step wise plan before initiating the management [3]. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly.
Treatment of epistaxis can be divided into two groups—conservative and interventional. Any patient with epistaxis must be given the best treatment modality whether it may be conservative or interventional.
Endoscopic sphenopalatine artery ligation is a safe, simple and effective procedure in the management of refractory epistaxis. Moreover, in view of minimal morbidity, higher success rate, shorter hospital stays and higher patient satisfaction, our current practice is to consider this treatment option in the management of cases not responding to conservative treatment modalities [4].
Materials and Methods
The study was conducted in the department of otorhinolaryngology in a tertiary care centre in South Kerala. The duration of the study was 18 months after obtaining the institutional ethics committee clearance. Data collection period was from November 2018 to April 2020. The study included 11 patients as per the inclusion and exclusion criteria.
Inclusion Criteria
Patients presenting with hypertensive epistaxis in the outpatient and emergency department of ENT in the age group of 18–70 years who gave consent for the study.
Exclusion Criteria
Pregnancy and lactation
Altered mental status
Intra cranial injury
Post-operative epistaxis after surgeries like septoplasty and functional endoscopic sinus surgery (FESS).
Informed written consent mentioning the type of procedure, possible outcome and associated risks was obtained from the patients and appropriate councelling was done.
Results
All 11 cases were initially treated with conservative methods like general first aid and anterior nasal packing for 48 h along with strict control of blood pressure. As the bleeding persisted, some required a Foley balloon catheter which kept in place for 24–48 h. These are summarized in Table 1 given below.
Table 1.
Outcomes of conservative modalities in the management of epistaxis
| Patient characteristics | Treatment modality used | Outcome |
|---|---|---|
| 39/m | General measures, anterior packing, foley catheter | Rebleed |
| 43/m | General measures, anterior packing | Patient did not tolerate |
| 43/m | General measures, anterior packing | Rebleed |
| 45/m | General measures, foley catheter | Rebleed |
| 47/f | General measures, anterior packing, foley catheter | Rebleed |
| 48/m | General measures, anterior packing | Patient did not tolerate |
| 50/f | General measures, anterior packing | Patient did not tolerate |
| 55/m | General measures, anterior packing, Foley catheter | Rebleed |
| 59/m | General measures, anterior packing | Patient did not tolerate |
| 61/f | General measures, foley catheter | Rebleed |
| 69/m | General measures, anterior packing | Patient did not tolerate |
All these cases had associated comorbid conditions, with hypertension in common.
Removal of Foley catheter on day 2 led to rebleeding, requiring packing again and then they were offered the option of endoscopic cauterization of sphenopalatine artery.
No patient had an identifiable alternate cause for epistaxis.
Surgical Procedure
Under general anaesthesia, after decongesting with adrenaline packs in both nostrils for 10 min, middle turbinate was medialized and infiltration given over sphenopalatine region with 2% xylocaine and adrenaline. A vertical incision made posterior to the posterior fontanellae over the palatine bone and mucosl flaps raised and crista ethmoidalis identified. The sphenopalatine foramen is situated posterior to crista ethmoidalis. By using 1 mm Kerrison's punch, the crista ethmoidalis was gently punched out, so that the sphenopalatine artery was very well visualized, coming out of sphenopalatine foramen, which was cauterized with bipolar.
The time taken to complete the procedure was about 30–45 min. There were no intraoperative complications. The merocele nasal packs kept at the end of the procedure, were removed on post op day 2.
All patients were kept in ICU for 2 days and observed for rebleeding and any other complications. The course of hospital stay was uneventful.
All patients were discharged on post op day 3 with antibiotics and post-operative advice.
Discussion
The arterial supply of nasal septum is from external and internal carotid arteries. Anastomotic connections occur in two places of the nasal cavity. On the antero-inferior part of septum “Little’s area” or “Kiesselbach” plexus and on the posterior part of nasal cavity “Woodruff plexus” [5].
The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. Understanding the etiology helps in better evaluation. As hypertension is the commonest etiology in older patients, regular blood pressure checkup in epistaxis patients and due address to blood pressure control through regular medication is recommended.
There should be a complete understanding of the available treatment modalities and a step wise plan before initiating the management [5]. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly. Treatment of epistaxis can be divided into two groups—conservative and interventional. Any patient with epistaxis must be given the best treatment modality whether it may be conservative or interventional [6].
Conservative management options include, first aid measures, chemical cauterization, anterior nasal packing and posterior nasal packing. In 65–75% cases of epistaxis, simple first aid measures stop the bleeding [6].
The sphenopalatine artery (SPA) cauterization technique was safe, simple, fast and effective with low rates of morbidity and complications for the management of refractory hypertensive epistaxis. It was concluded that endoscopic sphenopalatine artery cauterization should be considered as an immediate second line treatment where conservative measures fail and it is proved to be of low morbidity and cost effective [7, 8].
The surgical approach to sphenopalatine artery was first described by Prades [9]. Later advances in the techniques of nasal endoscopy resulted in the favourable outcome and subsequent popularization of ESPAL. Sharp et al. [10] studied and concluded about the success rate of ESPAL which was more than 90% without any significant complications. Srinivasan et al. [11] in an audit of results showed that ESPAL is a safe and effective management for intractable epistaxis with reduced morbidity and shortened hospital stay. Also it was proved that endoscopic sphenopalatine artery ligation is the best practice in persistent epistaxis with immediate success rate, shorter hospital stays and recurrence and patient satisfaction [4].
Surgical interventions can be done after conservative methods fail. However, ease of use, high success rate and low complication rates of endoscopic sphenopalatine artery ligation have led to the revision of the management of epistaxis by early intervention with endoscopic sphenopalatine artery ligation [12].
We were able to control the epistaxis successfully in all the 11 patients, with strict control of hypertension, without any surgical complications, and avoiding the need and complications of nasal packings.
Endoscopic sphenopalatine artery (ESPA) cauterization is simple, cost effective, safe and successful procedure in the management of refractory hypertensive epistaxis. In view of this, we propose a new practice with consideration of SPA cauterization early in the management of epistaxis.
Abbreviations
- SPA
Spheno Palatine Artery
- ESPA
Endoscopic SphenoPalatine Artery
- ESPAL
Endoscopic SphenoPalatine Artery Ligation
Funding
There was no funding or grants involved.
Compliance with Ethical Standards
Conflict of interest
The authors declared that they have no conflict of interest.
Ethical Approval
Ethical approval was obtained from the Institutional Ethics Committee.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
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Contributor Information
Sajilal Manonmony, Email: drsajim@rediffmail.com.
Sreelakshmi Balakrishnan, Email: srkbalak@gmail.com.
Rejee Ebenezer Renjit, Email: rejee72@gmail.com.
Avinash Mohan, Email: avinashmohan88@gmail.com.
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