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Endoscopic management of anterior and posterior epistaxis

  • Kent Lam
    Correspondence
    Address reprint requests and correspondence: Kent Lam, MD, Department of Otolaryngology—Head and Neck Surgery, Eastern Virginia Medical School, 600 Gresham Drive, Suite 1100, Norfolk, Virginia 23507.
    Affiliations
    Department of Otolaryngology—Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, Virginia
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  • Amber Luong
    Affiliations
    Department of Otorhinolaryngology—Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
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  • William C. Yao
    Affiliations
    Department of Otorhinolaryngology—Head and Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
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Published:August 22, 2017DOI:https://doi.org/10.1016/j.otot.2017.08.002
      The current management for epistaxis encompasses a wide variety of options that include pressure and intranasal decongestants, nasal packing, chemical and electrical cauterization, endovascular embolization, and surgical ligation of offending vessels. For episodes of epistaxis refractory to the more conservative measures, the use of the rigid endoscope has significantly increased the efficacy of therapeutic techniques by improving visualization of and access to intranasal bleeding sites. This review highlights the endoscopic approach to manage cases of severe epistaxis through direct cauterization, ligation of the sphenopalatine artery, and ligation of the anterior ethmoid artery.

      Keywords

      Introduction

      Epistaxis is a common rhinologic event that affects an estimated 60% of the population.
      • Viehweg T.L.
      • Roberson J.B.
      • Hudson J.W.
      Epistaxis: Diagnosis and treatment.
      Although most episodes of epistaxis are idiopathic and self-limited, about 6% of nosebleeds are regarded as severe and require medical evaluation for some form of intervention.
      • Viehweg T.L.
      • Roberson J.B.
      • Hudson J.W.
      Epistaxis: Diagnosis and treatment.
      The etiologies of epistaxis are attributed to various local and systemic factors. Local variables may include facial trauma, desiccation of the nasal lining, concomitant inflammatory disorders of the sinonasal cavities, and intranasal tumors of benign and malignant origin. Systemic comorbidities, including hypertension, liver and renal dysfunction, and congenital and acquired coagulopathies, may also predispose individuals to increased incidences of severe epistaxis.
      The management of all episodes of epistaxis varies according to the severity, location, and etiology of intranasal bleeding. Initial considerations should focus on the stability of the airway and hemodynamics, both of which may be compromised in individuals with prolonged hemorrhaging. Special attention should be brought to normalize the patient’s blood pressure. Following acute assessment and stabilization, most cases of epistaxis may then be effectively treated with the application of pressure to the external nose, use of intranasal decongestants, and/or either chemical or electrical cauterization. In most cases, cauterization may be performed through direct visualization with anterior rhinoscopy. Various resorbable and nonabsorbable nasal packing materials, which are increasingly coated with various hemostatic agents, may be selected to tamponade bleeding sites.
      • Nikoyan L.
      • Matthews S.
      Epistaxis and hemostatic devices.
      The authors’ recommend the use of resorbable packing to minimize the trauma that can be encountered with the removal of nonabsorbable packing materials. Reversal of both local and systemic factors contributing to the onset of epistaxis is another important step in managing and preventing the recurrence of epistaxis.
      When epistaxis persists despite the use of conservative measures, endovascular embolization and surgical procedures through the endoscopic endonasal approach have become important treatment options.
      • Soyka M.B.
      • Nikolaou G.
      • Rufibach K.
      • et al.
      On the effectiveness of treatment options in epistaxis: An analysis of 678 interventions.
      The increasing use of the rigid endoscope in surgical interventions allows for improved visualization of intranasal sites of bleeding and targeted application of treatment techniques. Endoscopic interventions for epistaxis control are also associated with decreased morbidity when compared to open approaches. The common endoscopic interventions available for management of severe epistaxis include endoscopic nasal cauterization, sphenopalatine artery ligation, and anterior ethmoid artery ligation. This review highlights the operative techniques of these various endoscopic procedures.

      Differences between anterior and posterior epistaxis

      The mucosal lining of the nasal cavity provides a rich vascular network of arterial vessels derived from both internal and external carotid systems. The internal carotid artery provides the ophthalmic artery, which branches into the anterior ethmoid and posterior ethmoid arteries to supply the superior aspects of the nasal cavity. Of the external carotid artery, the main intranasal vessels derive from the internal maxillary artery, which provides the sphenopalatine and greater palatine arteries; and the facial artery, which supplies the superior labial artery. The sphenopalatine artery contributes to blood supply of the posteroinferior aspects of the lateral nasal wall and posterior nasal septum through the lateral nasal artery and the posterior septal nasal artery, respectively. The anastomoses of these various distal arterial vessels identifies common areas at which epistaxis occurs.
      Nosebleeds are characterized as either anterior or posterior according to the vascular sources of intranasal bleeding. In about 90%-95% of cases, epistaxis occurs along the anterior nasal septum at Little’s area, where the anterior ethmoid artery, superior labial artery, sphenopalatine artery, and greater palatine artery form a confluence of vessels known as Kiesselbach’s plexus.
      • Schlosser R.J.
      Clinical practice. Epistaxis.
      • Douglas R.
      • Wormald P.J.
      Update on epistaxis.
      (Figure 1—diagram of Kisselbach’s plexus) The caudal location of this vascular plexus predisposes the septal mucosa to minor trauma and irritation from environmental factors. Epistaxis in young children and healthy adults commonly occur from this anterior site. Due to favorable access to Kiesselbach’s plexus and generally more benign etiologies, anterior nosebleeds usually respond well to conservative management techniques.
      Figure 1
      Figure 1The triangle depicts the Little’s area, where there is a confluence of several vessels. Injury to this area commonly leads to anterior epistaxis.
      In contrast, posterior nosebleeds account for 5%-10% of episodes and involve the Woodruff’s plexus, which is composed of the terminal branches of the sphenopalatine artery.
      • Schlosser R.J.
      Clinical practice. Epistaxis.
      • Douglas R.
      • Wormald P.J.
      Update on epistaxis.
      Common intranasal sites for posterior epistaxis include the posterior nasal septum and the lateral aspects of the middle or inferior turbinates. Because of the more distal location of these sites, posterior nosebleeds are more difficult than anterior nosebleeds to access and ultimately control. Additionally, posterior nosebleeds are more common in the geriatric populations and in patients with comorbid systemic conditions. In some instances, bleeding may occur directly from sinonasal tumors. For these reasons, individuals with posterior nosebleeds are more likely to require more aggressive interventions and inpatient hospitalizations.
      • Supriya M.
      • Shakeel M.
      • Veitch D.
      • Ah-See K.W.
      Epistaxis: Prospective evaluation of bleeding site and its impact on patient outcome.

      Operative technique

      Endoscopic cauterization of intranasal sites of bleeding

      In patients who are awake and cooperative, nasal endoscopy with a rigid endoscope may enhance visualization of intranasal bleeding and allow for attempts to remedy focal areas of bleeding. Endoscopic maneuvers are generally used in conjunction with the application of topical decongestants and suctioning of blood clots to aid with a thorough evaluation. Patients who are awake should also sit in an upright position to decrease venous hydrostatic pressure and reduce drainage into the oropharynx. If the source of bleeding is localized and can be adequately accessed, chemical and electrical cauterization may be attempted. Oftentimes, focal sites of bleeding along the nasal septum, inferior turbinate, or middle turbinate may be addressed with gentle cauterization. Endoscopic cauterization of bleeding sites, however, is usually more easily accomplished for sites of anterior epistaxis, as opposed to posterior epistaxis.
      In cases with profuse epistaxis, endoscopic visualization and cauterization of bleeding sites may be best performed under general anesthesia. The use of general anesthesia ensures that the patient’s airway is protected, thereby affording a controlled environment to manipulate the intranasal tissue. Patient comfort is also assured during the procedures. From a therapeutic standpoint, general anesthesia offers the options of anesthesia-induced hypotension, elevation of the head of bed, and use of warm saline irrigations, all of which may optimize conditions to reduce the rate of hemorrhaging and identify bleeding sources. If focal sources are found, monopolar or bipolar electrocautery may then be used to halt further bleeding. Additional procedures, including the ligation of the sphenopalatine artery and anterior ethmoid artery, may be valuable options if initial cauterization is insufficient.

      Endoscopic ligation of the sphenopalatine artery

      Surgical intervention for epistaxis has increasingly been tailored by otolaryngologists to involve the ligation of the sphenopalatine artery. Because it provides vascular supply to the lateral nasal wall, rostrum of the sphenoid sinus, and posterior nasal septum, the sphenopalatine artery is a common culprit vessel for posterior epistaxis. The ligation of the sphenopalatine artery may thus be pursued in cases of posterior epistaxis that do not demonstrate a clear bleeding source on nasal endoscopy. While the transantral ligation of the internal maxillary artery branches has traditionally provided a means to truncate the primary vascular supply to the posterior nasal cavity, the endoscopic approach is increasingly utilized due to its improved visualization and decreased morbidity.
      The endoscopic ligation of the sphenopalatine artery addresses the vessel at the sphenopalatine foramen, where the artery transitions from the pterygopalatine fossa into the nasal cavity. Located at the junction between the palatine and sphenoid bones of the lateral nasal wall, the foramen can be found just posterior to the posterior wall of the maxillary antrum. Additionally, the intersection of the inferior portion of the basal lamella and the medial orbital wall may serve as a landmark for the sphenopalatine foramen (Figure 2). The crista ethmoidalis, which is a small bony crest along the palatine bone just anterior or antero-inferior to the sphenopalatine foramen, can furthermore be used as a consistent guide for identification of the sphenopalatine foramen and vessel.
      Figure 2
      Figure 2Endoscopic view of the right cristae ethmoidalis, which is the shaded area. The cristae ethmoidalis serves as an anatomic landmark to help identify the sphenopalatine artery. CE, crista ethmoidalis; MT, middle turbinate; IT, inferior turbinate.
      The procedure, which may utilize a 0° or 30° rigid endoscope, is highlighted:
      • (1)
        The middle turbinate is gently medialized to provide access to the posterior middle meatus. Cottonoids soaked with 0.05% oxymetazoline or a similar vasoconstrictive agent into the middle meatus may improve visualization of the surgical field.
      • (2)
        To provide local anesthesia into the pytergopalatine fossa, about 1-2 mL of 1% lidocaine with 1:100,000 epinephrine may be injected transorally into the ipsilateral greater palatine canal. This injection may be facilitated with a 90° bend about 2 cm from the tip of a 25-gauge spinal needle. Additional local anesthetic may be infiltrated under endoscopic guidance into the mucosa along the tail of the ipsilateral middle turbinate.
      • (3)
        A vertical mucosa incision is first created along the ascending process of the palatine bone approximately 1 cm anterior to its intersection with the basal lamella. A preceding ipsilateral uncinectomy and maxillary antrostomy may be performed to facilitate identification of the posterior wall of the maxillary antrum, although this is not always necessary. If a maxillary antrostomy is performed, the posterior wall of the maxillary antrum may serve as the anterior boundary for dissection toward the sphenopalatine foramen.
      • (4)
        From either the mucosal incision created in the posterior middle meatus or the mucosal edge of the posterior maxillary ostia, a subperiosteal flap is widely elevated off the lateral nasal wall with a Freer or Cottle periosteal elevator. Flap elevation is continued in the anterior to posterior direction broadly to identify the crista ethmoidalis and then the sphenopalatine foramen with its accompanying neurovascular bundle (Figure 3—figure representing the release of mucosa and exposure of the SPA/PSA).
        Figure 3
        Figure 3Cottle elevator is raising the mucosa along the left lateral nasal wall to expose the sphenopalatine artery and posterior nasal artery.
      • (5)
        Visualization of the sphenopalatine foramen may be improved by removing the crista ethmoidalis and anterior lip of the sphenopalatine foramen with a Kerrison rongeur.
      • (6)
        The sphenopalatine artery and its distal arterial branches are then gently dissected with a ball-tip probe to provide 360° of access around the vessels.
      • (7)
        After adequate skeletonization of the sphenopalatine artery and its associated distal branches, the sphenopalatine artery can be ligated with hemostatic clips or bipolar electrocautery. We recommend placing a miniature titanium clip proximally followed by bipolar electrocautery distally in case the clip falls (Figure 4—illustration representing clips on the SPA/PSA).
        Figure 4
        Figure 4(A) The image shows the sphenopalatine artery (SPA) with clip a clip applier engaging the artery. (B) The image shows the branches of the sphenopalatine artery (SPA) ligated with clips as it exits the lateral nasal wall.
      • (8)
        The elevated mucosa over the palatine bone can be repositioned over the palatine bone, followed by placement of hemostatic agents such as Surgicel to complete the procedure.
      Awareness of the anatomic variability improves the surgical success of endoscopic sphenopalatine artery ligation. The sphenopalatine artery demonstrates variable branching patterns at the sphenopalatine foramen before it diverges into its terminal vessels within the posterior nasal cavity. The sphenopalatine artery, for example, emerges from the sphenopalatine foramen as a single vessel in 60%-75% of cases, but may also be found as 2 separate branches in 20%-30% of cases and at least 3 branches in about 10%.
      • Lin G.
      • Bleier B.
      Surgical management of severe epistaxis.
      There is also variability in the location and number of sphenopalatine foramina: approximately 10% of patients may have an accessory foramen, from which a distal branch of the sphenopalatine artery may exit.
      • Midilli R.
      • Orhan M.
      • Saylam C.Y.
      • Akyildiz S.
      • Gode S.
      • Karci B.
      Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure.
      The endoscopic ligation of the sphenopalatine artery successfully controls epistaxis at a rate of 87%-100% and has also been determined to be a cost-effective method for managing severe epistaxis.
      • Gifford T.O.
      • Orlandi R.R.
      Epistaxis.
      • Dedhia R.C.
      • Desai S.S.
      • Smith K.J.
      • et al.
      Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis.
      Complications reported from endoscopic ligation are minimal, but may include rebleeding due to unidentified terminal branches of the sphenopalatine artery, numbness of the palate and nasal cavity, and sinusitis.

      Endoscopic ligation of the anterior ethmoid artery

      In cases of severe epistaxis, the ligation of the anterior ethmoid artery is generally performed in conjunction with the ligation of the sphenopalatine artery. The adjunctive role of the ligation of the anterior ethmoid artery is due to the lower incidence of injury to the anterior ethmoid artery when compared to the sphenopalatine artery. Epistaxis resulting from the anterior ethmoid artery typically occurs following midface trauma or iatrogenic injury during endoscopic sinus surgery.
      • Rudmik L.
      • Smith T.L.
      Management of intractable spontaneous epistaxis.
      While ligation of the anterior ethmoid artery has traditionally been performed through an open approach, the endoscopic approach avoids the need for an external incision. The endoscopic ligation of the anterior ethmoid artery, however, is best performed with the assistance of a preoperative computed tomography (CT) scan, which may clarify the location of the anterior ethmoid artery along the fovea ethmoidalis (Figure 5—CT image of anterior ethmoid artery).
      Figure 5
      Figure 5CT image of anterior ethmoid artery. Arrow signifies the area of the left anterior ethmoid artery traversing through the mesentery. (Color version of figure is available online.)
      As a distal branch from the ophthalmic artery, the anterior ethmoid artery traverses the ethmoid skull base in an anteromedial direction, starting from the ipsilateral orbital compartment and concluding at the cribiform plate. Within the orbital cavity, the anterior ethmoid artery is found between the orbital periosteum and lamina papyracea about 24 mm posterior to the lacrimal crest. Intranasally, the anterior ethmoid artery is generally located at the attachment site of the ethmoid bulla lamella to the ethmoid skull base, which is immediately posterior to the frontal recess. In a cadaveric study, about 36% of the anterior ethmoid artery was detected within a bony mesentery that is a few millimeters below the level of the ethmoid roof. The presence of a bony mesentery off the ethmoid skull base, which may be delineated on CT imaging, represents favorable anatomy for endoscopic intranasal ligation of the anterior ethmoid artery.
      The procedure, which utilizes both 0° and 30° rigid endoscopes, is highlighted:
      • (1)
        The middle turbinate is gently medialized to provide access to the posterior middle meatus. Cottonoids soaked with a vasoconstrictive agent into the middle meatus may improve visualization of the surgical field.
      • (2)
        Approximately 1-2 mL of 1% lidocaine with 1:100,000 epinephrine is injected into the mucosa of the axilla and tail of the ipsilateral middle turbinate.
      • (3)
        A standard uncinectomy, maxillary antrostomy, and anterior ethmoidectomy are all performed to expose the lamina papyracea and ethmoid skull base. Identification of the frontal recess following completion of the anterior ethmoidectomy can assist in localizing the more posteriorly based anterior ethmoid artery (Figure 6—illustration of the anterior skull base).
        Figure 6
        Figure 6Diagram of anterior and posterior ethmoid arteries following a maxillary antrostomy and total ethmoidectomy. Middle turbinate removed in this figure as a purpose for illustration.
      • (4)
        If the anterior ethmoid artery is located within the bony mesentery of the ethmoid roof, the vessel may then be ligated with hemostatic clips or bipolar electrocautery. The site of ligation should ideally be in the mid-nasal portion of the vessel, as this will prevent retraction of vessel into the orbital cavity and thus prevent formation of an orbital hematoma.
      • (5)
        If the anterior ethmoid artery is not easily accessible within the bony mesentery of the ethmoid skull base, partial removal of the lamina papyracea with a small curette provides a window to locate the anterior ethmoid artery within the orbital cavity. Gentle retraction of the orbital contents will better expose the anterior ethmoid artery.
      • (6)
        The anterior ethmoid artery, which is found between the lamina papyracea and the periorbita can be gently ligated endoscopically with hemostatic clips or bipolar electrocautery. The artery should not be ligated at a point too close to the periorbita in order to prevent formation of an orbital hematoma (Figure 7—illustration of Figure 6 with the area of ligation marked).
        Figure 7
        Figure 7Anterior and posterior ethmoid arteries visualized. The instrument is grasping the anterior ethmoid artery at its midpoint to minimize the risk of retraction of the proximal end into the orbit. AEA, anterior ethmoidal artery; PEA, posterior ethmoidal artery; FS, frontal sinus.
      • (7)
        The window through the lamina papyracea, if created, does not require additional repair once the anterior ethmoid artery has been ligated.
      The evidence regarding the success rates of an isolated endoscopic ligation of the anterior ethmoid artery for the control of severe epistaxis is limited because the procedure is typically combined with an endoscopic sphenopalatine artery ligation. Potential complications reported from endoscopic anterior ethmoid artery ligation include rebleeding, orbital injury (described in the Retrobulbar hematoma chapter), and cerebrospinal fluid leak.

      Postoperative care

      After endoscopic control of epistaxis is achieved with cauterization or vessel ligation, resorbable packing and hemostatic agents such as Surgicel may be placed along the mucosal edges created by prior trauma. The use of resorbable packing minimizes the risk of bleeding following surgical intervention and also helps to prevent adhesion formation in the nasal cavity. If the episode of epistaxis is the main reason for inpatient admission, most individuals may be discharged after 4-24 hours of observation. The postoperative course should involve maintaining good nasal hygiene with nasal saline sprays and saline irrigations. Saline irrigations are usually held by the authors for the first 2 weeks of recovery to prevent recurrence of the bleeding and dislodging of the clips and hemostatic products. The patient should follow-up in the outpatient clinic 5-7 days after surgical intervention to reassess for any recurrence of epistaxis.

      Conclusion

      Severe epistaxis is increasingly managed with endoscopic surgical techniques, such as endoscopic cauterization of focal bleeding sites, endoscopic ligation of the sphenopalatine artery, and endoscopic ligation of the anterior ethmoid artery. The merits of endoscopic interventions for severe epistaxis include the improved visualization of the sinonasal anatomy and direct access to posterior aspects of the nasal cavity. Endoscopic control of anterior and posterior epistaxis is additionally regarded as a cost-effective therapeutic option that is well tolerated by patients.

      Disclosures

      The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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