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Endoscopic Control of Endoscopic Control of EpistaxisEpistaxis

Steven D. Pletcher MDSteven D. Pletcher MDAssistant Professor Assistant Professor

Department of Otolaryngology Department of Otolaryngology ––Head and Neck SurgeryHead and Neck Surgery

University of California, San FranciscoUniversity of California, San Francisco

EpidemiologyEpidemiology

60% of the population will develop 60% of the population will develop nosebleeds during their lifetimenosebleeds during their lifetime6% of these will seek medical care for 6% of these will seek medical care for their symptomstheir symptoms

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AnatomyAnatomy

Primary blood supply to the Primary blood supply to the sinosino--nasal nasal cavity is via the cavity is via the sphenopalatinesphenopalatine and and anterior ethmoid arteriesanterior ethmoid arteries

SPA branch of the internal maxillary artery SPA branch of the internal maxillary artery from the external carotid systemfrom the external carotid systemAnterior ethmoid artery is a branch of the Anterior ethmoid artery is a branch of the ophthalmic artery, originating from the ophthalmic artery, originating from the internal carotid systeminternal carotid system

AnatomyAnatomy

Levine & Clemente. Sinus Surgery: Endoscopic and Microscopic Approaches

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How Do Endoscopes Help in How Do Endoscopes Help in the Management of the Management of EpistaxisEpistaxis??

How Do Endoscopes Help in the How Do Endoscopes Help in the Management of Management of EpistaxisEpistaxis??

Identification of bleeding siteIdentification of bleeding siteDirect Direct cauterycauteryDirected packingDirected packing

Identification and Ligation of Feeding Identification and Ligation of Feeding VesselsVessels

SphenopalatineSphenopalatine ArteryArteryAnterior Ethmoid Artery Anterior Ethmoid Artery

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Identification of Bleeding SiteIdentification of Bleeding Site

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IndicationsIndications

IntraoperativeIntraoperative BleedingBleedingRefractory Refractory EpistaxisEpistaxis

Epistaxis Refractory to Packing

EmbolizationOperative Control

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Posterior PackingPosterior Packing

5050--80% efficacy in 80% efficacy in controlling controlling epistaxisepistaxisDoes not require Does not require General Anesthesia or General Anesthesia or SedationSedation

ComplicationsComplicationsMinor: Minor: AlarAlar soft tissue soft tissue injury, sinusitis, injury, sinusitis, septalseptalperforationperforationMajor: Hypoxia, Major: Hypoxia, Arrhythmia, Arrhythmia, SepticemiaSepticemia

Uncomfortable/Poor Uncomfortable/Poor patient satisfactionpatient satisfaction

Schaitkin et al, Laryngoscope ’87; Pollice et al, OTO/HNS ‘97

Klotz et al, Laryngoscope ’02; Cannon et al, OTO/HNS ‘93

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EmbolizationEmbolization8080--90% efficacy in 90% efficacy in controlling controlling epistaxisepistaxisCan be performed Can be performed under sedationunder sedation

Does not address Does not address anterior ethmoid anterior ethmoid artery bleedsartery bleedsComplicationsComplications

Minor: facial pain, Minor: facial pain, temporary temporary paresthesiasparesthesiasMajor: CVA (1%), Soft Major: CVA (1%), Soft tissue necrosis, CN tissue necrosis, CN PalsyPalsy

AvailabilityAvailability

Tseng et al, Laryngoscope ’98; Christensen et al, OTO/HNS ‘05

Gurney et al, AJR ’04

Endoscopic SurgeryEndoscopic Surgery

90% success rate90% success rateSurgical access to all Surgical access to all major feeding vesselsmajor feeding vesselsCombine with Combine with cauterizationcauterizationIncludes thorough Includes thorough examination of the examination of the nasal cavitynasal cavity

Requires general Requires general anesthesiaanesthesiaComplications: Complications: crusting, palatal crusting, palatal paresthesiasparesthesiasPublished experience Published experience limited to several limited to several small seriessmall series

Snyderman et al, AJR ’99; Voegels et al OTO/HNS ‘01Wormald et al AJR ‘00

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Epistaxis Requiring Posterior Packing

EmbolizationOperative Control

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Endoscopic Control of Endoscopic Control of EpistaxisEpistaxis

Wait to remove packing until all Wait to remove packing until all instruments are available and patient is instruments are available and patient is anesthetizedanesthetizedInspectionInspectionCauterizationCauterizationArtery ligationArtery ligationDirected packingDirected packing

CauterizationCauterization

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SphenopalatineSphenopalatine Artery LigationArtery Ligation

Identification Identification IsolationIsolationClippingClipping

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IdentificationIdentification

IdentificationIdentification

Posterior Maxillary WallPosterior Maxillary WallCristaCrista EthmoidalisEthmoidalisMiddle TurbinateMiddle Turbinate

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Endoscopic Endoscopic SphenopalatineSphenopalatineArtery LigationArtery Ligation

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SphenopalatineSphenopalatine Artery LigationArtery Ligation

Wide maxillary Wide maxillary antrostomyantrostomyLook for the impression of the artery on Look for the impression of the artery on the posterior maxillary wallthe posterior maxillary wallOpen the foramen laterally, removing a Open the foramen laterally, removing a portion of the posterior wall of the portion of the posterior wall of the maxillary sinusmaxillary sinusLook for multiple foraminaLook for multiple foraminaPlace clips proximal on the arteryPlace clips proximal on the artery

Anterior Ethmoid ArteryAnterior Ethmoid Artery

IdentificationIdentificationTransTrans--facialfacialEthmoid roofEthmoid roof

CauteryCautery or clippingor clipping

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TransTrans--Facial LigationFacial Ligation

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TransTrans--nasal Anterior Ethmoid nasal Anterior Ethmoid Artery LigationArtery Ligation

CauteryCauteryClippingClipping

Identification Identification –– Ethmoid RoofEthmoid Roof

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Low Anterior Ethmoid ArteryLow Anterior Ethmoid Artery

Anterior Ethmoid Artery

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TransnasalTransnasal Ligation (Identification)Ligation (Identification)

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TransnasalTransnasal Ligation (Isolation)Ligation (Isolation)

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TransnasalTransnasal Ligation (Clipping)Ligation (Clipping)

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SummarySummary

EpistaxisEpistaxis is a common disorder that is is a common disorder that is typically treated with conservative typically treated with conservative measuresmeasuresIn severe, refractory cases endoscopic In severe, refractory cases endoscopic surgery is an effective treatment with surgery is an effective treatment with minimal morbidityminimal morbidity

SummarySummary

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