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.     

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。     

Clinical analysis of delayed epistaxis following endoscopic sinus surgery

ObjectiveTo investigate the clinical characteristics and treatment methods associated with delayed epistaxis following endoscopic sinus surgery.MethodsThe clinical data of 46 patients with delayed epistaxis following endoscopic sinus surgery were retrospectively analyzed. To explore the clinical features, pathogenesis, and treatment plan for delayed epistaxis, the postoperative bleeding time, bleeding inducements, systemic complications, surgical approach, the hemorrhage locations and responsible vessels, and treatment methods were analyzed.ResultsThe average bleeding time was 16.34 ± 9.05 days after the operation, and 76.6% of the cases occurred 6–20 days after the operation. Sphenopalatal artery hemorrhage accounted for 69.6% (32/46), the most common of which was a posterior nasal septal artery hemorrhage (17/32). A total of 45 patients received endoscopic low-temperature plasma hemostasis following ineffective nasal packing, and no rebleeding in the ipsilateral nasal cavity was observed during the postoperative follow-up for 3 to 6 months.ConclusionsThe peak of hemorrhaging in delayed epistaxis following endoscopic sinus surgery occurred at 6–20 days post-operatively. Bleeding of the posterior nasal septal artery from the sphenopalatine artery was the most common. Surgical methods were closely related to delayed postoperative hemorrhage. Treatment with low temperature plasma hemostasis under nasal endoscope was found to be effective.     

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entively satisfactory because of morbidity, high failure rates, and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior existaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior & posterior nasal packing.     

鼻内窥镜下微波治疗在后段鼻腔出血中的应用

目的 探讨后段鼻腔出血的治疗方法。方法 54例后段鼻出血的病人中，26例仅行前后鼻孔填塞，28例病人在抽除填塞纱条后再在鼻内窥镜下进行微波热凝治疗。结果 两组病人的治愈率分别为65．4％和89．3％，其差异具有显著性的意义（P＜0．05）。结论 对前后鼻孔填塞的病人配合鼻内窥镜下微波热凝可以减少后段鼻出血的复发率。     

A new approach to the management of acute epistaxis

A new approach to the management of acute epistaxis is described using suction with the operating microscope to define the bleeding point prior to the application of hot wire cautery. This technique was shown to be completely successful in stopping haemorrhage in 82% of acute referrals in a prospective series of 33 patients. It resulted in a significant reduction both in the use of nasal packing and in the length of hospital stay compared with a group of controls treated by traditional means. It is proposed that in most cases of acute epistaxis the bleeding point is accessible to cautery and nasal packing should be reserved for a minority of refractory cases. This avoids unnecessary patient discomfort and the complications of prolonged nasal packing and hospitalization.     

顽固性鼻出血的治疗

目的 探讨不同治疗方法对顽固性鼻出血的意义。方法 224例顽固性鼻出血病例中,50例行颈外动脉结扎,35例行筛动脉结扎,鼻内镜下治疗139例,鼻咽填塞3例。结果 224例中,随访3个月,颈外动脉结扎者复发率22.00%,筛动脉结扎者复发率17.14%,鼻内镜下治疗者复发率4.32%。结论 应用鼻内镜辅助检查明确出血灶后局部止血效果明显,且复发率低。     

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（7．2％），鼻腔填塞2次以上的55例（873％），前后鼻孔填塞的34例（54．0％）。全部患者均行异内窥镜检查。其中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，指出医源性鼻出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治疗中的应用价值。     

Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis

Intractable posterior epistaxis remains a challenging problem for our specialty. Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entirely satisfactory because of morbidity, high failure rates and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior epistaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior and posterior nasal packing.     

鼻内镜下双极射频联合鼻腔微型填塞治疗鼻腔深部出血

目的分析鼻内镜下双极射频联合鼻腔微型填塞治疗鼻腔深部出血的疗效及优越性,探讨治疗鼻腔深部出血更为完善的治疗方法。方法 2004年6月～2010年6月利用鼻内镜下双极射频联合鼻腔微型填塞治疗出血部位明确的鼻腔深部出血79例,观察治疗效果。结果 79例鼻腔深部出血,一次性治愈76例,术后患者痛苦小,随访1个月未再次出血。结论鼻内镜下双极射频联合鼻腔微型填塞治疗鼻腔深部出血,视野清晰、定位准确、止血可靠、患者术后痛苦少,是治疗鼻腔深部出血的有效方法。     

Merocel高膨胀海绵用于鼻出血

目的：探索更好的鼻腔填塞物。方法：比较传统的凡士林纱条与高膨胀海绵做为鼻腔填塞物的应用效果。结果：比较两组病人鼻腔填塞后24小时出血量，两者之间出血量无统计学差异（P＞0．05）。填塞时及取出时疼痛的程度，应用Merocel者明显较填塞凡士林纱条者轻，填塞期间的主要症状也较凡士林沙条组的病人轻。结论：Merocel高膨胀海绵是理想的鼻出血鼻腔填塞物。     

Persistent epistaxis: what is the best practice?

Epistaxis is the commonest otolaryngological emergency, which is often managed by a nasal pack. A significant number of cases fail to respond to nasal packing and various surgical measures are available to control the nosebleed in these cases. However evidence is sparse regarding the best available surgical option for the management of persistent epistaxis. We designed a retrospective cohort study comparing endoscopic ligation of sphenopalatine artery (ELSA) and all other surgical options (non-ELSA) in the management of persistent epistaxis. All consecutive cases of persistent epistaxis between 1997-2004 (Feb) requiring operative intervention were included in the study and divided in two groups according to the surgical intervention. Postoperative epistaxis was excluded. Non-ELSA group consisted of various procedures including nasal cautery and packing, submucous resection, anterior ethmoid artery ligation, external carotid artery ligation, internal maxillary artery ligation. Both groups were matched for age, sex, risk factors, other medical conditions and medications. The main outcome measures evaluated were immediate success in arresting the bleeding and the mean hospital stay. Recurrence and patient acceptability of the procedure were the secondary variables investigated. We found that ELSA proved to be the best practice to manage persistent epistaxis on all measures of immediate success rate, shorter hospital stay, recurrence rate, and patient satisfaction.     

Posterior epistaxis: identification of common bleeding sites

OBJECTIVE: The objective of this study was to determine common bleeding sites in the nasal cavity of patients with posterior epistaxis and thus review our management protocol. STUDY DESIGN: A prospective study was carried out from 1989 to November 2003 in the otolaryngology-head and neck surgery department of a tertiary referral center. This study included patients who presented with posterior epistaxis uncontrolled with standard nasal packing and with no identifiable bleeding point on examination under local anesthesia. METHOD: All patients underwent a formal examination under general anesthesia by the senior author of this article. Findings at examination were documented along with subsequent management and its outcome. RESULTS: Forty-three patients were included in this study. Bleeding points were identified in 36 cases. Seven patients had septal bleeding points (20%). The rest were located on the lateral nasal wall (81%). Of these, 4 were on the lateral wall of inferior meatus, 7 on the lateral surface of inferior turbinate, 8 on the lateral wall of middle meatus, and 10 on the lateral surface of middle turbinate. All were located posteriorly. CONCLUSIONS: We recommend examination under general anesthesia when conservative measures fail to control bleeding, concentrating on the posterior aspect of the lateral nasal wall. In addition, the lateral aspect of the middle and inferior turbinates may contain a groove within which bleeding points may be concealed. The lateral position of most bleeding sites indicates that use of nasal packing can only attempt to indirectly tamponade blood flow and is rarely justified bilaterally. Electrothermocautery can achieve excellent results with minimal complications. Failure to identify a bleeding point, after thorough examination under general anesthesia, does not require further intervention unless complicated by further bleeding.     

难治性鼻出血隐匿出血部位的分布和治疗

目的　通过大数据分析并绘制隐匿部位鼻出血分布“地图”以及精准优化诊疗模式。方法　检索近10年鼻内镜下诊治“顽固性/难治性/隐匿性”鼻出血的中文文献117篇,患者11 708例,结合我院患者总共纳入患者11 860例,分析出血部位和责任血管,绘制成隐匿部位鼻出血分布“地图”。总结我院鼻内镜下精准搜寻出血部位、射频微创止血和无填塞的优化诊疗模式。结果　我们发现责任血管主要是蝶腭动脉和筛前动脉、筛后动脉;出血部位的频率依次是下鼻道穹窿区域31.90%（3783例）、中鼻甲嗅裂区域29.70%（3522例）、中鼻道后端区域11.37%（1349例）、鼻中隔偏曲区域8.98%（1065例）、鼻腔最前上区域6.22%（738例）、其他/不明区域11.83%（1403例）,将隐匿出血部位和责任血管绘制成简明的鼻出血分布“地图”。152例患者按照我院的优化诊疗模式,99.34%（151例）患者能够精准微创止血。结论　我们绘制出了隐匿部位鼻出血分布“地图”以便指引出血部位的搜寻;鼻内镜下针对隐匿出血部位的精准搜寻和微创止血是优化的诊疗方案。     

Complications resulting from treatment of severe posterior epistaxis.

Recent advances in nasal endoscopy and arterial embolization have improved the treatment of severe posterior epistaxis. This report reviews the therapeutic options, including a case of epistaxis that did not respond to nasal packing but was successfully controlled with superselective arterial embolization. The discussion includes an outline of potential complications of epistaxis treatment, including a case of nasal septal perforation.     

鼻内镜下成人严重鼻出血处理

目的：探寻成人严重鼻出血位置分布规律及有效微创处理方法。方法：通过鼻内镜观察成人严重鼻出血位置,并以微创手段进行止血。结果：129例成人严重鼻出血患者出血部位：鼻中隔嗅裂区及鼻顶前端68例(52.7%);下鼻道后端穹隆部37例(28.7%);蝶筛隐窝下方10例(7.8%);利特尔氏区8例(6.2%);中隔后上端5例(3.9%);部位不明1例(0.8%)。查明出血部位的128例患者为动脉出血,均予电凝止血。结论：绝大多数患者出血部位在鼻中隔嗅裂区、鼻顶前端和下鼻道后端穹隆部;鼻内镜下绝大多数出血部位均可发现;鼻内镜下电凝止血创伤微小,效果确切。     

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.     

鼻内窥镜下诊治难治性鼻出血68例分析

目的：探讨难治性鼻出血常见的出血部位及治疗方法。方法:回顾分析经内窥镜诊治的难治性鼻出血68例的临床资料，分析其出血部位及治疗效果。结果:出血部位在下鼻道顶部占27.9%(19/68)、嗅裂鼻中隔占20.7%(14/68)、中鼻道后上部占16.1%(11/68)、中鼻甲后端蝶腭动脉区和鼻中隔后端均为10.3%（7/68）、鼻咽顶占5.9%（4/68）、Woodruff静脉丛和部位不明均为4.4%(3/68)。1次治愈59例(86.7%)，2次9例(13.3%)，随访1～3个月均无复发。结论:应用鼻内窥镜检查鼻腔深部的出血并在镜下电凝或填塞止血安全有效。     

Effect of total nasal obstruction on nocturnal oxygen saturation

BACKGROUND: Nasal obstruction is considered a risk factor for sleep-disordered breathing (SDB), although the relationship has not been established clearly. This study explores the repercussion of total nasal packing on arterial oxygen saturation during the nocturnal resting hours and its implication in SDB. METHODS: Forty patients were subjected to total nasal packing after nasal surgery or epistaxis. In all cases the oxygen desaturation index (ODI) was monitored with and without nasal packs, and the results were compared. RESULTS: Thirty-seven patients (92.5%) showed poorer oxygen saturation after nasal occlusion. Of these, 19 patients (47.5%) reached pathological desaturation (ODI > or = 12). Desaturation was greater among obese subjects. CONCLUSION: Total nasal packing causes significant nocturnal oxygen desaturation. This must be taken into account in the postoperative nasal packing of patients with respiratory failure, obesity, or SDB.     

Internal maxillary artery ligation for idiopathic intractable epistaxis

Epistaxis though common, is rarely life threatening. Routinely nose pinching, anterior find posterior nasal packing and endoscopic cauterization of bleeding points is sufficient to control epistaxis in 99% of the cases. It is mandatory to rule out local and systemic causes before labeling a case as idiopathic by using a battery of investigative modalities. Here are two interesting cases of epistaxis which did not respond to conventional therapeutic modalities in which transantral internal maxillary artery ligation was attempted leading to complete cure.