intractable epistaxis saddam holy

8/12/2019 Intractable Epistaxis Saddam Holy

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JournaL:Management of

Intractable Spontaneous

Epistaxis

Oleh : Holy Fitria Ariani (FK UPH)

Saddam Sudarsono (FK UPN)


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Defined as acute hemorrhage from the nostril, nasalcavity, or nasopharynx.

The most common otolaryngology and accounts for~1 in 200 emergency room consultations.

The majority of cases are controlled with commonfirst-line interventions such as chemical or electrical

cautery, the application of hemostatic agents, orshort-term anterior nasal packs.

However, there is a subset of patients withintractable spontaneous epistaxis who continue tobleed and require more aggressive therapy.

Epistaxis are


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Most common causes of Epistaxis


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Intractable epistaxis is defined as recurrent or persistentbleeding after appropriate conservative treatment, ormultiple episodes of epistaxis over a short period of time,each requiring medical attention.

Intractable epistaxis usually arises from the posterior or

superior parts of the nasal cavity, and is therefore notreadily controllable by direct pressure, topical cauterisationor anterior nasal packing.

Interactable Epistaxis


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With improvements in both endoscopic and endovasculartechniques, transnasal endoscopic sphenopalatine artery

ligation (TESPAL) and arterial embolization have gainedpopularity over the traditional approach. Both techniques canbe successful in controlling intractable epistaxis but thedecision to use one versus the other can be challenging.

This article will focus on the management of intractablespontaneous epistaxis and discuss the role of TESPAL andembolization as it pertains to this challenging clinical scenario.


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Blood Supply of Nasal Cavity

Anatomy


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The vascular supply of the nasal cavity arises fromterminal branches derived from both the internalcarotid artery (ICA) and the external carotid artery

(ECA). The majority of epistaxis occurs on the anterior nasal

septum at a region called Littles area, which is sup-plied by Kiesselbachsplexus.

Because of inherent challenges with visualization andpoor treatment localization, the majority ofintractable epistaxis cases would be classified asposterior epistaxis.


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the most common artery involved in posteriorintractable epistaxis is the Sphenopalatine Artery(SPA).

The SPA is a terminal branch of the internal maxillaryartery (IMA) and enters the nasal cavity in the regionof the posterior attachment of the middle turbinatethrough the sphenopalatine foramen (SPF).

Epistaxis from the (Anterior Ethmoid Artery) AEA is

less common and is typically associated with midfacetrauma or iatrogenic injury during endoscopic sinussurgery.


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Before the definitive management of intractable

epistaxis, several important interventions should beused to optimize treatment success.

The first priority is to control or slow the activehemorrhage with some form of temporizing packing.

This can be achieved with commercially availableanteriorposterior balloon combo packs or a Foleycatheter combined with anterior packing.

General Management of Epistaxis


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Guideline of Epistaxis


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Anterior Nasal Packing


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Posterior Nasal Packing


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Antero-Posterior Nasal Packing


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The anticoagulated patient can pose a challengingproblem, because they tend to have more severe epistaxisand bleed from several sites.

Because of the risk for serious medical complications,reversal or discontinuation of the anticoagulationmedication should not be performed unless it is deemedsafe by the initiating medical specialty.

During warfarin-related epistaxis, ~80% of patients were

outside their disease-specific international normalized ratio(INR) range; therefore, in addition to a complete bloodcount, all patients should have an INR evaluated at thetime of presentation.


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Surgical intervention for intractable epistaxis provides

targeted therapy and can prevent prolonged posteriornasal packing with consequent hospital admission.

A randomized trial by Moshaver et al. evaluated patientswith intractable epistaxis and compared early surgicalintervention (using TESPAL) to posterior nasal packing.The results showed that TESPAL resulted in a significantlyshorter hospital stay and reduced health care costs.

SURGERY FOR INTRACTABLE

EPISTAXIS


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The following section will describe two endoscopicsurgical techniques used to manage intrac- tableepistaxis: (1) TESPAL and (2) transnasal endoscopic

anterior ethmoid artery ligation (TEAEAL).


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Transnasal Endoscopic

Sphenopalatine Artery Ligation

In 1992, Budrovich reported on the endoscopic

approach for SPA ligation, which has increased inpopularity because of improved visualization andreduced patient morbidity.


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Technique for TESPAL

After administration of a general anesthetic and airway

protection, TESPAL begins with thorough nasalpreparation to optimize visualization and improvetreatment success.

First, the temporizing nasal packing material is removedand the nasal cavity is cleaned of all blood clots.

A detailed endoscopic examination should be performedbefore decongesting the nose to clearly define the site ofbleeding.


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Next, decongesting the nose for 510 minutes (we use

pledgets soaked with 1:1000 epinephrine) will reduce activebleeding and significantly improve visualization during theprocedure.

To further optimize intraoperative hemostasis, the

sphenopalatine region or greater palatine canal may beinjected with local anesthetic containing epinephrine (weuse 1% Xylocaine with 1:100,000 epinephrine).


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Success Rate for TESPAL

The reported overall success rate is 85%.

In 2003, Kumar et al. reviewed the literature andreported a pooled success rate of 98% with meanhospital admission of 1.6 days after TESPAL.

Nouraei et al. defined surgical failure as recurrent

epistaxis occurring within 2 weeks after TESPAL.They reported a 12% failure rate


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Risk factors for early rebleeding requiring nasal

packing: (1) warfarin administration, (2) low plateletcount on admission, and (3) not using cauterizationfor SPA ligation.


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Complications in TESPAL

Minor rebleeding requiring nasal packing occurs in 15

20% of cases. Major rebleeding requiring a second surgical

procedure is rare and would be 1% of cases.

Other

include nasal crusting (34%),

palatal numbness (12%),

and acute sinusitis (3%).


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Transnasal Endoscopic Anterior

Ethmoid Artery Ligation

Two recent cadaver studies showed that TEAEAL may

be possible in 20% of patients, and all cases requiredthat the AEA run in a bony mesentery across theethmoid skull base.

Two small case series have reported success in

controlling intractable epistaxis, which localized tothe ethmoid region during the endoscopic exam.


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Technique of TEAEAL

Preoperative CT scan of the sinuses review the AEA

anatomy General anesthetic is typically required

Thorough nasal preparation


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Success Rate of TEAEAL

There is limited evidence for the success rate of

TEAEAL. AEA ligation is typically combined with SPA ligation


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Complications of TEAEAL

Potential serious complications include cerebral spinal

fluid leak, orbital injury, and failure to controlepistaxis.


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ARTERIAL EMBOLIZATION

Endovascular control of intractable epistaxis was first

described in 1974 and has since been evaluated inseveral large studies to become a well-acceptedtherapeutic option.


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Technique of Embolization

The first step involves a preembolization angiogram

of the ICA and ECA systems. The purpose of this angiogram is to evaluate for

contrast blush, which can localize the site of bleeding,and to identify rare etiologies of epistaxis, such astumors, vascular malformations, or pseudoaneurysm.

Additionally, it can identify dangerous anastomosesbetween the ECA and ICA that can predispose tostroke or blindness.


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Success of Embolization

Several recent studies have shown success rates

between 80 and 90%. A study by Christensen et al. pooled the results from 23

studies and indicated a mean success rate of 88%.


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Complications of Embolization

SURGERY VERSUS EMBOLIZATION


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SURGERY VERSUS EMBOLIZATION

FOR

INTRACTABLE EPISTAXIS

In cases of intractable epistaxis, the decision to

choose surgery or embolization is challengingbecause both modalities have similar high successrates.

Thus, therapeutic decision making is commonlyinfluenced by several factors, such as patient

comorbidity, presence of anticoagulation, institutionsurgical and endovascular expertise, patientpreference, and health care costs.


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THE ENDTHANK YOU~

intractable epistaxis saddam holy

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