Breaking paradigms in severe epistaxis: the importance of looking for the S-point

Introduction

Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point.

The pathology of visible blood vessels on the nasal septum in children with epistaxis

Objective

Epistaxis is common in children, but its cause remains unknown. About half the children who present with epistaxis have prominent vessels on the nasal septum. The aim of this study was to determine the pathological nature of the prominent septal vessels in children with recurrent epistaxis.

Methods

4 mm punch biopsies of the nasal septal mucosa were taken from 5 children undergoing nasal cautery under general anaesthesia.

Results

Histology showed that the prominent vessels were thin-walled arterioles and capillaries with a surrounding inflammatory infiltrate. There was no evidence of venous varicosities or arterial microaneurysms.

Conclusion

We postulate a mechanism for septal neovascularisation due to chronic low-grade inflammation as a cause for recurrent epistaxis in children.     

重组人表皮细胞生长因子凝胶治疗鼻中隔黏膜糜烂性鼻出血

目的 观察重组人表皮细胞生长因子凝胶治疗鼻中隔黏膜糜烂性鼻出血的疗效。方法 将患者随机分为治疗和对照组各52例,治疗组用重组人表皮细胞生长因子凝胶涂在鼻中隔的糜烂面上, 2次/d,7d为1个疗程。对照组用红霉素软膏涂抹, 2次/d,7d为1疗程。结果 治疗组治愈率86.5％, 对照组治愈率44.2％（P＜0.01）,未见不良反应发生。结论 重组人表皮细胞生长因子凝胶治疗鼻中隔黏膜糜烂性鼻出血方便,疗效显著。     

鼻窦内窥镜下探明鼻出血部位及其临床应用价值(附226例报告)

目的 :探讨鼻窦内窥镜下诊治鼻出血的应用价值及其适应证。方法 :回顾分析 2 2 6例非外伤鼻出血患者经鼻窦内窥镜检查的临床资料。结果 :出血部位 :中鼻道 5 2例 ,中鼻甲 6例 ,鼻中隔后段 4 4例 ,下鼻甲后端 5 7例 ,鼻底部 6例 ,鼻中隔前上端 2 8例 ,部位不明确 3 3例。鼻窦内窥镜下鼻腔填塞 12 6例 ,微波、激光、烧灼 78例 ,手术 4 2例。患者均获得满意的止血效果。结论 :鼻窦内窥镜检查鼻出血 ,诊断准确 ,治疗方便 ,效果好。     

下鼻道后穹窿部鼻出血特点及内镜治疗分析

目的探讨下鼻道后穹窿部鼻出血的临床特点及治疗方法。方法回顾性分析2017年1月~2017年6月收治的5例下鼻道后穹窿部鼻出血患者的临床资料,5例患者均为反复、频发、动脉性出血,出血位置隐蔽,常规行前后鼻孔填塞后仍反复间断出血,所有患者均在全麻鼻内镜下行鼻腔探查及电凝止血术。结果5例患者均在术中探及出血点位于下鼻道后穹隆部,通过电凝止血术一次止血成功,随访1~3个月均未复发。结论临床中反复顽固性鼻出血、前后鼻孔填塞无效时,需考虑下鼻道后穹隆部出血,鼻内镜下单极电凝止血疗效肯定。     

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。     

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。     

Rapid hemostasis: a novel and effective outpatient procedure using microwave ablation to control epistaxis of isolated mucosal bulge lesions

IntroductionRecurrent epistaxis is commonly encountered in the rhinology outpatient clinic. Under endoscopic guidance, both bipolar cautery and monopolar forceps (combined with suction) have been employed to control the bleeding. However, the use of monopolar forceps requires the placement of grounding pads. Most procedures are currently performed in operating rooms.ObjectiveWe investigated outcomes after the use of Microwave Ablation (MWA) to control epistaxis in adults with isolated mucosal bulge lesions. All procedures were performed with patients under local anesthesia in our outpatient clinic.MethodsThis is a retrospective cohort study. We included 83 adults with epistaxis of isolated mucosal bulge lesions. Microwave ablation was performed in the outpatient clinic to control bleeding, after induction of local anesthesia. The primary outcome was successful hemostasis. The secondary outcomes were the rebleeding rates at weeks 1 and 4 and month 6, and complications (crust or synechiae formation, septal perforation, and/or orbit or brain complications).ResultsAll bleeding points were successfully ablated; hemostasis was achieved within 1–2 min. The mean pain score was 1.83 intra-operatively and 0.95 1 h postoperatively. No patient re-bled, and no severe MWA-related complication (septal perforation, synechiae formation, or orbit or brain complication) was recorded to 6 months of follow-up.ConclusionsEndoscopic microwave ablation with patients under local anesthesia is a novel, safe, effective, rapid, well-tolerated, outpatient treatment for adults with epistaxis of isolated mucosal bulge lesions, especially those for whom general anesthesia might be risky, those with electrical implants, and those exhibiting contraindications for arterial embolization.     

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.     

Pediatric epistaxis: Epidemiology,management & impact on quality of life

Objective

Epistaxis in the pediatric population is a common problem for both primary care physicians (PCPs) and otolaryngologists. Although a frequent reason for referral to ENT clinics, data is lacking regarding causes, effects on quality of life and common treatment modalities.

Methods

Prospective, clinical and questionnaire based study, with ethical approval. We identified 50 cases of pediatric epistaxis (<16 years old) over a 6-month period. A thorough clinical history was taken, first aid measures and management outcome was recorded. The impact of recurring epistaxis on parental quality of life was assessed using the Parental Stress Index Short Form (PSISF).

Results

Thirty-three males and 17 females (2:1) were included. Mean age at presentation was 8.8 years. Initial management was inadequate, with only 30% of carers applying appropriate first aid measures. Quality of life was significantly affected in 10% of cases with primary parental concerns being fear of excessive blood loss and the stress of soiled bedclothes and night wear. Children were most affected by the negative impact on sporting activity. Otolaryngology consultation found the common causes to be iatrogenic trauma and rhinitis affecting “Littles” area. Of which 78% required silver nitrate cautery, and 22% just required reassurance and advice

Conclusions

Recurrent minor nosebleeds in children can be troublesome and alarming for parents and children. We found the PSISF an easy and reliable method of assessing patient and parental stress in dealing with this problem. Raising awareness of simple management strategies among parents and PCPs could significantly reduce associated quality of life issues. Mucosal hydration, cautery and first aid advice are the fundamentals of management.     

A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis

A prospective study was performed to compare the efficacy and patient tolerance of Merocel^® and Rapid Rhino^® nasal tampons in the treatment of epistaxis. A total of 42 patients were studied. There was no significant difference between the two types of pack in efficacy or patient discomfort with pack in situ. Rapid Rhino^® produced significantly lower scores for subjective patient discomfort during insertion and removal of pack.     

Guidelines of the French Society of Otorhinolaryngology (SFORL) (short version). Specific treatment of epistaxis in Rendu-Osler-Weber disease

Objectives

The authors present the guidelines of the French Oto-Rhino-Laryngology – Head and Neck Surgery Society (Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou: SFORL) concerning specific treatment of epistaxis in Rendu-Osler-Weber disease.

鼻内镜下下鼻甲骨部分切除术治疗下鼻道出血

目的:探讨鼻内镜下下鼻甲骨部分切除术治疗下鼻道出血的有效性。方法:对21例下鼻道出血患者行鼻内镜下下鼻甲黏骨膜分离、下鼻甲骨骨折后部分切除,局部填塞。术后鼻腔粘连者,分离后放置薄荷石蜡油浸后的明胶海绵,观察疗效。结果:全部患者经过手术填塞后止血满意,3~7 d治愈出院,随访2个月~3年,无复发。结论:鼻内镜下黏骨膜分离及下鼻甲骨部分切除术治疗下鼻道鼻出血是一种有效、可靠的方法。用薄荷石蜡油浸润后的明胶海绵放置隔离预防粘连,简单易耐受,效果好。     

Effect of single-dose intravenous tranexamic acid on postoperative nasal bleed in septoplasty

ObjectivePostoperative nasal bleeding is a common complication of septoplasty and may lead to painful procedure of nasal packing to stop bleeding. Since Tranexamic acid (TXA) has been reported to reduce bleeding, the purpose of this study is to investigate the effect of single dose of intravenous TXA on postoperative nasal bleed associated with septoplasty.Materials and methodsThis prospective randomized, double-blinded clinical trial consisted of 176 patients aged 18–55 years who underwent septoplasty for symptomatic deviated nasal septum. These participants were randomly divided into 2 groups; 88 patients were given normal saline (Control group) and 88 patients were administered a single shot of intravenous TXA 10 mg/kg (TXA group). Operative technique applied was same in all cases. At the end of surgery nasal packs, nasal splints or trans-septal suturing were not done. Nasal bleeding was monitored after surgery and up to 2 weeks postoperatively.ResultsPatients receiving TXA showed significantly less postoperative nasal bleeding compared with controls. Extensive bleeding in terms of number of gauze pads used and duration was also higher in placebo with a statistically significant difference (all P = < 0.05). Seven patients required nasal packing in control group to stop bleeding as compared to one patient in TXA group. Adverse reactions to TXA were minimal, and these were easily managed conservatively.ConclusionSingle intravenous dose of TXA is shown to be effective and safe agent in preventing postoperative nasal bleeding after septoplasty therefore avoiding additional techniques of nasal packing, intranasal splint or trans-septal suturing during surgery.     

顽固性鼻出血发病特征及临床分析

目的探讨顽固性鼻出血的临床特征。方法分析1998年1月～2004年12月期间收治的289份鼻出血病例资料,统计年龄、性别、发病季节、伴随疾病,记录出血部位和治疗方法。结果顽固性鼻出血男女发病比例约为2．9：1,高发年龄在40～69岁之间,高发季节为每年10月至次年3月,81．31%患者合并一种或多种全身疾病,33．91%患者合并高血压。出血部位以鼻中隔居多为118例,出血部位不明116例。结论顽固性鼻出血是自身和环境因素综合作用的结果,治疗时应结合其临床特征,充分考虑各种相关因素。     

2015年北京市空气质量指数及PM2.5浓度对鼻出血发病率的影响

摘要：目的探讨鼻出血的发病率与PM2.5浓度之间的关系,分析除自身因素以外,环境因素特别是空气质量以及大气中PM2.5浓度对鼻出血发病率的影响。方法收集2015年北京同仁医院急诊就诊鼻出血患者数量,北京市空气质量指数（air quality index, AQI）和大气中细颗粒污染物PM2.5浓度,统计鼻出血数量与PM2.5浓度之间的关系;按空气质量指数将全部数据进行分组,统计各组之间鼻出血发病率之间的差异。结果鼻出血的发病率与PM2.5之间呈正相关(r=0.261);当空气质量达到重度污染时,鼻出血的发病率比空气质量为优良时明显增加,差异具有统计学意义（P<0.05）。结论PM2.5浓度的增加可能是鼻出血发病的一个健康风险因素。     

鼻内镜下蝶腭动脉阻断术治疗老年难治性鼻出血

探讨鼻内镜下蝶腭动脉阻断术治疗老年难治性鼻出血的疗效。