严重鼻衄治疗的相关问题研究

鼻衄是耳鼻咽喉科的常见疾病，治疗方法多样。报告６３例严重鼻衄患者，引起贫血的４８例（７６．２％），鼻腔填塞２次以上的５５例（８７．３％），前后鼻孔填塞的３４例（５４．０％），全部２元首行鼻内窥镜检查。在窥镜下重新止血的１９例，行血管栓塞的２例。本文着重分析研究实际临床工作中鼻衄填塞治疗存在的问题，指出医源性同血是严重鼻衄的原因之一，探讨鼻腔填塞、鼻内窥镜、血管栓塞及全身综合治疗在鼻衄中应用价值。     

鼻内窥镜下电凝术治疗顽固性鼻出血

顽固性鼻出血其治疗以鼻腔填塞为主，对无效者常需住院进行全身治疗，甚至行血管结扎术或血管造影栓塞术。我们从1995年3月利用内窥镜配合具有绝缘性能的吸引管和单极电凝，治疗66例顽固性鼻出血病人，取得了满意效果。现介绍如下。1材料和方法1．五一般资料住院病人66例，男40例，女26例，年龄42～78岁，平均56．1岁。左侧34例，右侧32例。全部病人入院前均作过2～4次前后鼻孔填塞术，治疗时间为5～15天。人院时病人都处于前后鼻孔填塞状态，仍有间歇的鼻腔、口咽部渗血。重者来院前已输血1200毫升。2手术器械2．1鼻内窥镜：直径4mm，2．7m…     

数字减影血管造影在严重鼻衄中的应用

本文对我院1994年来,采用DSA血管栓塞治疗的13例严重鼻衄进行了分析。其中11例栓塞颌内动脉后止血;1例去除前、后鼻孔填塞物仍出血,再次栓塞面动脉后止血;仅1例插管失败。栓塞止血有效率为92．3％。无严重并发症发生。DSA具有实时显像、轨迹减影透视等功能。在严重鼻衄治疗中,有简单、有效、安全等优点。文章讨论了DSA的操作要点、并发症预防措施。认为DSA血管栓塞可作为治疗严重鼻衄常现方法。     

难治性鼻后部出血的上颌内动脉(IMA)结扎与栓塞的比较

鼻出血大多来自鼻腔前部，易控制，少数鼻后部出血虽后孔填塞亦难止住，过去用颈外动脉结扎，现除ＩＭＡ结扎外还有经股动脉穿刺插管行ＩＭＡ栓塞，鼻内窥镜下结扎蝶腭动脉，内窥镜下烧灼止血等方法可供选用。作者为比较ＩＭＡ结扎和栓塞两种方法在处理难治性鼻后部出血患者的优缺点，并进行了１９７３～１９９５年间文献复习及１９８７～１９９４年间３９例患者４４次手术的回顾。１９７９～１９９５年共有１０篇（２６４例）ＩＭＡ栓塞报道，失败（处理后仍有鼻出血）率为２０％，并发症发生率１４％（轻者１０％，严重并发症州）；１９７…     

鼻内窥镜引导下鼻咽血管纤维瘤切除术

目的鼻咽血管纤维瘤是一种较少见的难治性良性肿瘤，为避免常规手术的并发症，采用鼻内窥镜技术辅以动脉血管栓塞、控制性低血压麻醉等治疗８例。方法８例均为男性，平均年龄１６．６岁。全部患者术前均接受了ＣＴ和鼻内窥镜检查；６例在数字减影血管造影下进行了肿瘤供血动脉栓塞；７例全身麻醉术中采用了控制性低血压技术。结果全部患者无并发症；术中平均出血９００ｍｌ；８例平均随访８个月（１～２０个月），１例（１２．５％）术中未能完全切除。结论使用鼻内窥镜技术治疗鼻咽血管纤维瘤，并配合其他一些相关技术，对肿瘤局限在鼻腔、鼻咽腔、筛蝶窦和部分侵及翼腭窝的患者是适宜的。     

选择性血管内栓塞治疗难治性鼻出血的临床分析

目的：了解选择性血管内栓塞治疗难治性鼻出血的疗效及影响疗效的因素。方法：23例难治性鼻出血患者在颈动脉数字减影血管造影(DSA)的基础上行选择性颌内动脉末梢病变血管内栓塞，其中5例同时栓塞面动脉。结果：DSA证实23例患者均存在颌内动脉末梢发育不良或畸形，15例伴有出血征象，6例并面动脉形态异常。治愈22例，其中l例24h内复发鼻出血者证实有新侧支供血，经补加栓塞后出血停止，治愈率为95．6％。l例治疗失败，与栓塞前去除鼻腔填塞物有关，且不能除外有面动脉出血。结论：难治性鼻出血与颌内动脉发育不良及畸形有关，选择性血管内栓塞治疗能收到迅速而满意的疗效。治疗失败与潜在侧支开放或面动脉出血有关，过早去除鼻腔填塞物也是影响栓塞疗效的因素。     

血管造影栓塞术治疗鼻衄108例次复习

虽大多数鼻衄来自鼻腔前部,易控制,但来自后和上份的出血仍难处理,后孔填塞失败率约26％～52％,对老年患者尤难耐受。已知并发症有:鼻翼及中隔坏死,低氧血症,心肌梗死,中风,猝死,输血并发症也 增多,故极需寻找控制严重鼻衄的方法。经上颌窦结扎颌内动脉(IMA)虽疗效高,但并发症率约13％～47％。1974年Sokoloff等首述用选择性血管造影行同侧IMA栓塞治疗严重鼻衄成功以来,几经多人改进,强调行栓塞前必先行双侧颈内(ICA)及颈外动脉(ECA)造     

鼻内窥镜下上颌动脉结扎术

介绍鼻内窥镜引导下经上颌窦行上颌动脉结扎治疗严重鼻出血患者４例。一、临床资料４例鼻出血患者年龄２６～６７岁，男３例，女１例。均有反复鼻出血史，病程１～６ｄ，常规处理（鼻腔填塞和应用止血药物）不能控制，其中２例在转入我院前已做后鼻孔栓塞术，鼻出血仍不能...     

翼腭管内阻滞麻醉在鼻后部止血中的应用

鼻后部出血是耳鼻咽喉科常见急症，一般都需鼻腔填塞压迫止血。为减轻患者在填塞时的痛苦，查清出血部位，我们在行鼻腔填塞前，先经口腔翼腭管内阻滞麻醉及药物压迫阻断供血血管，收到满意效果。报告如下。1临床资料本组41例，男24例，女17例；年龄45～69岁。均排除血管瘤、恶性肿瘤所致鼻出血。其中有高血压病史者35例。本次鼻出血发作行1次填塞压迫止血者33例（80．5％），2次者8例（19．5％）。2操作方法患者头后仰，大张口，注射针（5号牙科针头）从对侧尖牙与第一双尖牙之间往上、后、外方向，在腭大孔标志前方刺入腭粘膜进入孔口，然…     

住院医师培训中内窥镜鼻窦手术并发症分析

回顾分析了在美国西维吉尼亚大学耳鼻咽喉-头颈外科住院医师培训中，内窥镜鼻窦手术（ESS）并发症的发生情况。共337例手术，209例由住院医师在培训教员指导下施行，128例由培训教员施行。根据是否会对患者造成严重损害这一标准，将并发症分为严重和非严重并发症。337例中有5例（1．5％）患者出现严重并发症：3例（0．9％）为脑脊液鼻漏，均在术中发现并采用游离粘膜瓣修补成功；2例（0．6％）为鼻泪管损伤，其中1例需行泪囊鼻腔造孔术。非严重并发症发生51例（15.1％），最常见是中鼻甲与鼻腔侧壁粘连，共有21例（6．2％），其中16例在局…     

难治性鼻出血的出血部位及治疗

目的探讨难治性鼻出血常见的出血部位及治疗方法。方法对92例常规鼻内镜检查未发现出血点，并经规范的鼻腔填塞未能控制的鼻出血患者的出血部位、与年龄的关系及疗效进行回顾性分析。结果出血部位依次为：下鼻道顶部56．5％(52／92)、嗅裂鼻中隔部27．2％(25／92)、中鼻道后上部8．7％(8／92)及部位不明者7．6％(7／92)。出血部位与年龄有一定的相关关系，49岁以下年龄组以下鼻道顶部出血最为常见(67．3％，37／55)，50～59岁年龄组下鼻道顶部与嗅裂鼻中隔区出血分别为46．4％(13／28)及35．7％(10／28)；而在60岁以上则以嗅裂鼻中隔区出血比例最高(77．8％，7／9)。92例中，除8例嗅裂鼻中隔部出血行明胶海绵填塞及1例中鼻道出血因电凝止血失败而施行血管造影颌内动脉栓塞外，其余83例均采用电凝止血。全部病例1次治愈82例(89．1％)，2次9例(9．8％)，4次1例(1．1％)，随访l～3个月无复发。结论鼻内镜技术结合中、下鼻甲骨折移位对探查鼻腔深部的出血点具有重要意义，对出血部位进行准确电凝或填塞，是止血成功的关键。     

头面部外伤性假性动脉瘤致鼻出血的诊治

目的 探讨外伤性假性动脉瘤引起顽固性鼻出血的临床诊断思路.方法 选择16例外伤后假性动脉瘤病例,男性12例,女性4例,年龄16～41岁,平均25.4岁,回顾性分析该组病例鼻出血的临床特点.结果 该组病例1例死亡,其他患者行血管造影栓塞治疗后均痊愈出院.患者自入院到通过行数字减影血管造影(digital subtraction angiography,DSA)检查明确诊断为假性动脉瘤相隔时间最短为3天,最长为15天,平均为4.5天,患者均有多次行前后鼻孔填塞病史,填塞的次数最少1次,最多达5次,平均2.5次.结论 外伤后反复大量鼻腔出血患者如行前后鼻孔填塞止血效果差,应尽早行DSA检查,明确有无假性动脉瘤存在,诊断明确后行血管造影栓塞治疗.尽可能避免盲目多次的前后鼻孔填塞给患者带来的痛苦,同时也可有效避免因延误诊断造成假性动脉瘤破裂致患者出血死亡的可能.     

Is Nasal Packing Necessary Following Endoscopic Sinus Surgery?

OBJECTIVES/HYPOTHESIS: To determine the necessity of nasal packing or hemostatic agents or both following endoscopic sinus surgery. STUDY DESIGN: Retrospective review of cases in a tertiary care sinus practice at an academic medical center. METHODS: Records of 165 patients undergoing 169 endoscopic sinus surgeries were reviewed to determine the presence of adjunctive nasal procedures, the use of nasal packing or hemostatic agents or both, blood loss during surgery, and the incidence of bleeding complications following surgery. RESULTS: The median estimated blood loss during surgery was 50.0 mL (range, 5-1000 mL). In four surgeries (2.4%) hemostatic agents were placed in the nose at the conclusion of surgery, 19 (11.2%) had packing, and 147 (87.0%) had no material left in the nose. No patients had bleeding complications postoperatively. There was a significant decrease in the use of packing or hemostatic agents or both over time. CONCLUSION: Placement of nasal packing or other hemostatic agents or both within the nasal cavity is not necessary in the majority of endoscopic sinus surgeries. The risks, costs, and discomforts associated with these interventions can often be avoided.     

Endoscopic intraoperative control of epistaxis in nasal surgery

Objective

: Epistaxis represents a dangerous post-operative complication of nasal surgery. The advances of endoscopic procedures have also brought along the possibility of a surgical solution of nasal bleeding. These procedures include endoscopic cautery of the bleeding points, and more difficult techniques of endoscopic ligation of the sphenopalatine artery or the anterior ethmoidal artery. These surgical methods permit avoiding nasal packing, a very annoying procedure for the patient. This study aims to evaluate the advantages of this approach at the end of a nasal surgery to prevent routine nasal packing.

Method

: 133 subjects were operated on by the same surgeon in the Otorhinolaringology Department of University of Foggia (Italy) from March 2006 to March 2007. 17 (12.8%) patients were submitted to septoplasty, 42 (31.5%) to turbinoplasty (in 22 accompanied by septoplasty) and 74 (55.6%) to endoscopic sinus surgery (ESS) for nasal polyposis or nasal tumors.

Results

: Only 16 cases (12%) underwent nasal packing, while in the remaining 117 (88%) endoscopic control of bleeding permitted avoiding packing. In 53 (39.8%) patients only an endoscopic cauterization of bleeding points was performed; in 29 (21.8%) cases a sphenopalatine artery ligation was necessary. Only 2 subjects (1.5%) underwent anterior ethmoidal artery ligation. In the remaining 34 (25.5%) patients no procedure was necessary, due to the apparently scarce bleeding in the endoscopic vision at the end of surgery. In this group of non-packed patients, only 8 (6.8%) needed a post-operative tamponade while in the group of packed patients, 2 (12.5%) cases had a re-bleeding and a revisional surgery was necessary.

Conclusion

: Intra-operative precautional packing is therefore not justified during nasal surgery because of the small percentage of post-operative epistaxis. Intra-operative control of bleeding allowed nasal packing to be avoided in a large percentage of cases.     

Nasal packing and transseptal suturing techniques: surgical and anaesthetic perspectives

The objective of this study is to compare the nasal packing and the transseptal suturing techniques regarding the extubation difficulty evaluation scores, follow-up times in post-anaesthesia care unit (PACU), pain scores, and postoperative complications. Two hundred patients who underwent septoplasty from January 2009 to October 2009 were randomly assigned either to have nasal packs (n: 100) or transeptal sutures (n: 100). In the transseptal suture group, extubation was easier and PACU follow-up times were shorter, when compared to the nasal packing group (p < 0.001). Patients with nasal packing had significantly higher pain scores (p < 0.001). Minor bleeding was significantly higher in the transseptal group with seven cases, compared to the nasal packing group without any bleeding cases (p = 0.014). There were two patients who had postoperative major bleeding, and two patients who had septal hematoma in the transseptal suture group. One patient with nasal packing had postoperative infection. Septal perforation was not seen in any of the cases. While patients in both groups experienced postoperative crusting, patients in the transseptal suture group also complained about foreign body sensation. Extubation was more comfortable; post-anaesthesia monitorization duration was shorter, and postoperative pain was less, but minor bleeding was seen more with transseptal sutures. There was no significant difference in terms of major bleeding, hematoma, infection or perforation. Foreign body sensation was the main cause of postoperative discomfort in the transseptal suture group. Transseptal suturing might be a significantly comfortable, cost-effective and reliable alternative to nasal packing.     

功能性内窥镜鼻窦手术出血的预防

目的探讨功能性内窥镜鼻窦手术(FESS)出血的相关因素及预防措施。方法对144例实施 FESS,对患者术中出血量及相关因素进行统计学分析。结果144例中出血量为20～700ml,其中20m1～2例 (14.6％),50ml～47例(32.6％),100ml～54例(37.5％)200ml～18例(12.5％),500ml～4例(2.8％)。术中易 损伤的血管是筛前动脉及筛后动脉,蝶腭动脉和鼻后中隔动脉,颈内动脉。多次手术的患者因瘢痕组织中血 管失去弹性和病变处血管异常增生是术中出血的重要因素。手术全麻和手术时间长可增加出血。结论为 减少FESS术中出血,术者须熟悉鼻窦解剂学,术前仔细阅读CT片,了解病变范周及解剖学变异。术中要清 楚每一步操作处的解剖位置,仔细辩认术区的重要血管并加以保护,术前常规使用1％肾上腺素收敛鼻黏膜 血管可减少术中出血。     

Endoscopic management of posterior epistaxis

The traditional method of management of posterior epistaxis has been with anteroposterior nasal packing. Apart from the high failure rate of 26-50% reported in various series, nasal packing is associated with marked discomfort and several complications. In order to avoid nasal packing, we started doing endoscopic cauterization in cases of posterior epistaxis. A total of 23 patients with posterior epistaxis were subjected to nasal endoscopy with the intent to stop bleeding by cauterization of the bleeding vessel. Of these, in four cases unsuspected diagnosis was made. Of the remaining 19, in three patients, the bleeding point could not be localized accurately and these patients were managed by anteroposterior packing. The rest of the 16 patients were managed by endoscopic cauterization. In four patients, there was recurrence of bleeding within 24?h. In one of these, cauterization controlled the bleeding while in the rest nasal packing had to be resorted to. Thus, of the 23 patients of posterior epistaxis subjected to nasal endoscopy, we could avoid nasal packing in 17 (74%). To conclude, endoscopic nasal cauterization is recommended as the first line to treatment in all cases of posterior epistaxis. This will not only prevent the uncomfortable and potentially dangerous nasal packing but also help in finding the underlying pathology.     

Management pitfalls in the use of embolization for the treatment of severe epistaxis

Angiographic embolization for the treatment of severe recurrent epistaxis was added to the traditional treatment options--nasal packing, cauterization, and surgical vessel ligation--in 1974. Since then, clinical experience has shown that this procedure is safe and effective. When epistaxis cannot be controlled with cautery, nasal packing is the most common next step. As such, it is often performed by emergency physicians and other clinicians who are not otolaryngologists. We report two cases in which intranasal neoplasms were obscured as a result of a significant distortion of the normal anatomy. This distortion was secondary to emergency-room treatment of severe epistaxis by repeated nasal packing followed by angiographic embolization. Pre-embolization angiographic studies and subsequent postembolization endoscopic evaluations did not reveal the presence of the occult neoplasms because of the presence of inflammation and edema after treatment. Clinicians should be aware that nasal packing and embolization can obscure the underlying source of epistaxis, and follow-up radiologic studies and endoscopic evaluations are essential to avoid delays in diagnosis.     

Transarterial embolization to control posterior epistaxis

Posterior nasal epistaxis is a challenging problem for the oto-laryngologist, particularly when patients are critically ill after significant blood loss. The purpose of this paper is to describe a new radiologic technique designed to enhance the treatment of acute nasal hemorrhage. Seven patients with posterior nasal epistaxis underwent portable, computerized, digital subtraction angiography before embolization. Results are presented, and the advantages and limitations of this approach are compared and contrasted with those of nasal packing and arterial ligation. We conclude that this new procedure permits rapid location of the bleeding source and safe, rapid placement of a maxillary arterial catheter for hemostasis by embolization.     

凡士林纱带包裹膨胀海绵用于鼻出血84例的疗效观察

目的探讨凡士林纱带包裹膨胀海绵用于鼻出血的疗效。方法对84例鼻出血患者应用凡士林纱带包裹膨胀海绵填塞止血。结果3例填塞凡士林纱带包裹膨胀海绵后当时少量渗血（3．57％）,2例48h抽出后凡士林纱带包裹膨胀海绵再发出血（2．38％）,1例填塞凡士林纱带包裹膨胀海绵后失败。83例治愈（94．04％）。结论凡士林纱带包裹膨胀海绵是一种有效的鼻腔填塞材料,值得应用和推广。