隐蔽部位鼻出血点黏膜形态特征分析

隐蔽部位鼻出血是经鼻镜或内镜检查难以明确的反复、间隙性鼻腔大出血。隐蔽部位鼻出血止血的关键是查明出血灶。现对本科2006年2月至2008年5月116例内镜检查隐蔽部位鼻出血点形态特征分析如下。     

2150例鼻出血部位分析

结果：2?150例患者中1920例1次找到出血部位或原因（89.30%）,其中Little′s区1?284例（59.72%）,下鼻道151例（7.02%）,嗅裂前部107例（4.98%）,鼻中隔中部106例（4.93%）,下鼻甲59例（2.74%）,鼻底40例（1.86%）,部位不确定230例（10.74%）,其他173例（8.05%）。结论：Little′s区为鼻出血的第一高发部位,其次为下鼻道、嗅裂前部、鼻中隔中部。     

鼻出血部位的判断及治疗

鼻出血部位的判断对其治疗十分重要,随着鼻内镜的广泛应用,对鼻出血部位的判断及治疗有了飞跃性的发展,本文就此进行简要综述。     

鼻出血部位的判断及治疗

鼻出血部位的判断对其治疗十分重要，随着鼻内镜的广泛应用，对鼻出血部位的判断及治疗有了飞跃性的发展，本文就此进行简要综述。     

鼻内镜下动脉性鼻出血的综合治疗

目的 探讨鼻内镜下治疗鼻腔深、浅部动脉性出血的方法及特点.方法 以电热烧灼术、高频电凝术、微波凝固术及微创填塞法治疗深、浅部动脉性鼻出血.结果 487例患者中,电热烧灼术治疗327例浅部鼻出血患者,均治疗成功;微波烧灼术治疗135例浅部鼻出血患者,其中有40例患者在活动性出血状态下,治疗失败,改用电热烧灼法治疗均获成功;高频电凝术治疗鼻腔后部动脉性出血15例及嗅裂区微创填塞术治疗筛顶部动脉出血10例,均获成功.经随访治疗后4周以内,原部位均未再次出血.结论 ①隐蔽部位即中、下鼻道侧后部及嗅裂筛顶部等往往是顽固性鼻出血发生的常见区域;②动脉性鼻出血内镜下微创治疗是可靠、方便、有效的方法;③微波凝固术不适宜治疗活动性动脉出血点,这与微波不能有效加热凝固快速流动的血液有关;④对于静止的或活动性的动脉出血点电热烧灼术及电凝术均能施行有效热凝治疗,为最迅速和可靠的止血方法之一;⑤嗅裂筛顶部动脉出血点适宜用可吸收性止血材料微创填塞法治疗;⑥动脉性鼻出血好发于中老年人群,以男性为常见,常发生于鼻中隔前中部,即鼻腔动脉末梢部;⑦高血压病及动脉粥样硬化可能是动脉性鼻出血的主要原因,且与季节、吸烟和饮酒有一定关系.     

隐蔽部位鼻出血的再认识与治疗

大多数患者鼻出血发生在前鼻镜检查能够发现的部位，如鼻中隔前下部和下鼻甲前端，治疗较简单，而对于前鼻镜检查无法发现部位的出血，通常采用鼻腔填塞和血管结扎、栓塞，患者痛苦大，疗效差。我们从2003年开始采用鼻内镜下微波烧灼或选择性填塞治疗此类患者，报告如下。     

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。     

难治性鼻出血患者出血部位各年龄段间的差异与特点

目的　探讨难治性鼻出血位点与年龄相关的分布特点及规律。方法　回顾性分析住院治疗的149例难治性鼻出血患者的临床资料,按年龄分为青年组（≤39岁）、中年组（40～59岁）、老年组（≥60岁）,分析其出血部位的特点及规律。结果　149例患者中,男性110例,女性39例;年龄 18～87岁,平均（53±14）岁;青年组36例,中年组52例,老年组61例。149例患者均行鼻内镜下鼻腔探查止血术。其中明确出血部位后行电凝止血或微填塞145例,并记录出血部位;未明确出血部位患者4例。三组患者最常见出血部位依次为：青年组：下鼻道穹窿22例（61%）,中鼻甲后段13例（36.1%）,嗅裂区中隔面1例（2.7%）;中年组：下鼻道穹窿23例（44.2%）,中鼻甲后段10例（19.2%）,嗅裂区中隔面17例（32.7%）;老年组：嗅裂区中隔面37例（60.6%）,中鼻甲后段15例（24.6%）,下鼻道穹窿7例（11.5%）。结论  难治性鼻出血患者中,青、中年患者出血部位以蝶腭动脉分支出血居多;老年患者出血部位以筛前动脉、筛后动脉分支出血居多。随年龄增长蝶腭动脉分支出血比例减少,筛前动脉、筛后动脉分支出血机会增加。     

全身麻醉鼻内镜下隐蔽部位顽固性鼻出血的治疗

鼻腔嗅裂、中鼻道、下鼻道等狭窄隐蔽部位出血,局麻下止血治疗比较棘手。因出血点位于鼻腔中后段隐蔽部位且鼻出血较凶猛,或因患者精神紧张、鼻出血加重、疼痛及咽反射敏感等不能很好配合,难以找到出血点,以至于多次鼻腔填塞仍未能止血,给患者身心造成很大的痛苦,严重影响患者身体健康甚至危及生命。     

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。     

Identification of bleeding sites and microwave thermal ablation of posterior epistaxis

Background: Microwave ablation (MWA) is a relatively new technique which has been used to achieve hemostasis at surgical field. However, few publications have reported MWA for epistaxis.

Objectives: Our objectives were to identify the bleeding sites/points in instances of posterior epistaxis and to evaluate the efficacy of MWA for controlling bleeding.

Material and methods: Patients with posterior epistaxis who met the inclusion criteria were examined and treated endoscopically using MWA. Recurrent bleeding and complications were evaluated at 1 and 3 months after treatment.

Results: Of the 71 patients, the bleeding site/point was identified in 67 patients while 4 patients was unknown. Of the 67 patients with known bleeding sites, the olfactory cleft was in 44 patients, the middle meatus in 5 patients, and the inferior meatus in 18 patients. Only the bleeding point was coagulated in the 67 patients while prophylactic MWA in the 4 patients. No side effects or complications (including recurrent bleeding, crusting, nasal discomfort, and nasal septal perforation) were seen at 3-month follow-up.

Conclusions: MWA may effectively control posterior epistaxis with a low cost and without complications.     

隐蔽性鼻出血的临床分析

目的探讨隐蔽性鼻出血的出血部位及主要供应血管。方法对106例经前鼻镜未查明出血部位的隐蔽性鼻出血的患者经鼻内镜检查,明确出血部位并行止血治疗,对出血部位及疗效进行回顾性分析。结果出血部位依次为：下鼻道顶部占55.7%（59/106）、中鼻甲及中鼻道顶部占33.0%（35/106）、嗅裂及鼻中隔部占9.4%（10/106）及部位不明者占1.9%（2/106）。106例中,除2例反复前后鼻孔填塞鼻腔黏膜损伤较重无法判断出血部位外,其余104例均采用鼻内镜下射频止血,1次治愈102例（96.2%）,2次治愈2例（1.9%）,随访1个月无复发,治愈率为98.1%。结论①隐蔽性鼻出血绝大部分为蝶腭动脉供应;②鼻内镜下查找出血部位并射频治疗隐蔽性鼻出血疗效确切,患者痛苦少,值得临床推广应用。     

难治性鼻动脉出血的诊治

目的：探讨难治性鼻动脉出血的有效诊治途径。方法：用鼻内镜检查106例难治性鼻动脉出血,部位不明者配合鼻腔异常结构或鼻腔病变处理进一步寻找出血点,找到出血点后行选择性微创治疗。结果：内镜检查一次发现出血点93例（87.74%）,内镜下行鼻腔结构或病变处理再次发现出血点11例(10.37%),2例（1.89%）部位不明。106例中,1次治愈90例（84.91%）,2次治愈14例(13.20%),3次治愈2例(1.89%)。随访3个月无复发,鼻中隔穿孔1例。结论：难治性鼻动脉出血的诊治应施行个性化治疗,首先在内镜下明确出血点,明确出血点后,选择性微创治疗。     

Usefulness of computed tomography in predicting ethmoidal arterial bleeding in refractory epistaxis

European Archives of Oto-Rhino-Laryngology - Epistaxis that is refractory to conservative management can be treated with endoscopic sphenopalatine artery ligation (ESPAL). Although rare, ethmoidal...     

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。     

Fibrin glue treatment for epistaxis

Our study was made to prove the second-generation surgical fibrin sealant Quixil to be an effective substitute for nasal packing, chemical coagulation and cautery in management of patients with epistaxis. Our series includes 204 patients with anterior epistaxis (186), and with posterior epistaxis (18) as results of trauma, clotting disorders, chronic and/or atrophic rhinitis and upper respiratory infections, and hypertension. Patients were randomly divided into four groups: with fibrin glue (67) (Quixil), with electric cautery (61), with silver nitrate coagulation (60), and with foam nasal packing (16). For the fibrin glue group, hemostasis was achieved by spraying with 0.3 ml Quixil fibrin glue to each bleeding nostril. The results were excellent in all of the 62 (92.5%) patients of the fibrin glue group with complete and immediate hemostasis. We found good healing of bleeding sites, no swelling and secondary bleeding, no inflammation, no plaque or crists. Three months monitoring of atrophic changes of the nasal mucosa proved absence of atrophy of the nasal mucosa. In this group, the bleeding time averaged 2 min 30 sec since the moment of admittance. In the groups where cautery, coagulation, or nasal packing was used, we found local swelling, pain, and slow healing of the bleeding site with accidental atrophy of the nasal mucosa. The rates of these side effects were significantly higher in comparison with the fibrin glue group. The bleeding time was also longer. We found that the fibrin glue is more effective hemostatic in comparison with foam nasal packing, cautery and coagulation, and provides no complications usual for these types of treatment of epistaxis.     

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.     

Treatment of intractable epistaxis using arterial embolization

Arterial embolization has become the procedure of choice for managing intractable epistaxis in certain centres in North America and Europe, with arterial ligation reserved for those patients in which it fails. In Ireland, the role of this relatively new technique is poorly defined. The aim of this retrospective study was to investigate the outcome of all patients who underwent arterial embolization for intractable epistaxis in Dublin since it was introduced in 1998. Embolization resulted in complete and immediate resolution of epistaxis in 10 out of 12 patients (82%). Two patients required carotid ligation because of persistent epistaxis. One other patient had a further minor epistaxis 2 days following embolization, which was treated successfully with cautery. No major complications occurred in any of the patients. This study suggests that arterial embolization is an effective and safe method of managing patients with intractable epistaxis.     

Prevalence and characteristics of S-point bleeding compared to non S-point bleeding in severe epistaxis

IntroductionStamm's S-point is gaining importance as a bleeding focus in severe epistaxis. However, prevalence and features of S-point bleeding compared to non S-point bleeding have not been studied.ObjectiveTo investigate the characteristics of patients with S-point bleeding among those with severe epistaxis and to compare the factors involved in the treatment of epistaxis.MethodsWe retrospectively analyzed medical records of 268 patients admitted to the otorhinolaryngology department of Konkuk University Hospital and Chung-Ang University Hospital with epistaxis of which the bleeding focus clarified. Patients with anterior nasal bleeding (n = 129) were excluded. The study was conducted at the department of otorhinolaryngology from January 2008 to August 2019. Collected data included patients’ demographic information, bleeding focus, body mass index underlying medical and sinonasal diseases, laboratory test results (initial hemoglobin, platelet count, and triglyceride level), use of anticoagulants, direction of epistaxis, initial and final treatments, and need for blood transfusion.ResultsThe prevalence of S-point bleeding was 28.8% of non-anterior bleeding cases. Mean body mass index score was lower in the S-point group (23.41 ± 3.71) compared to the non S-point group (24.93 ± 3.97) (p = 0.039). Underweight patients tended to show a greater incidence of S-point bleeding (15.0%) than non S-point bleeding (2.0%) (p = 0.010). Incidence of anemia was higher in the S-point group (67.5%) than in the non S-point group (36.4%). Anemia (Odds ratio [OR]: 3.635; 95% confidence interval [CI]: 1.669-7.914, p = 0.001) and underweight (body mass index < 18.5, OR: 8.559, CI: 1.648-44.445, p = 0.011) were significantly associated with S-point bleeding.ConclusionPrevalence of S-point bleeding was significant, underlining the importance of examining the S-point in patients with severe epistaxis. Patients with S-point bleeding had lower body mass index scores and a higher incidence of anemia than those with non S-point bleeding.