PM Fri Apr 10 es <€ s3?bucket=uploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6m41m0395302%2F ks... Current Approaches to Epistaxis Treatment in Primary and Secondary Care Rafael Beck", Martin Sorge*, Antonius Schneider, Andreas Dietz Summary ‘Background: The lifetime prevalence of epistaxis is approximately 60%, and 610% othe affected persons need medical care In rare cases, severe bleeding cals for the rapid ination of effective treatment Methods: This review i based on pertinent articles that were retrieved by a selective search PubMed, and on the authors clinical experince, Results: There are no German guidelines forthe management of epistaxis. The avaiable evidence consists manly of retrospective analyses and exper opinions. 65-75% ofthe paints who requie treatment canbe adequately cared for by their primary care physician or by an emergency physician wih baseline measures. ther is persistent anterior epistaxis, an otolaryngologist can contol the bleeding saststactorl in 78-88% of cases with chemical or electrical cauterizaton. Nasal packing is used his treatment fa, of for poster epistaxis. na retrospective study, surgical treatment was found io be more efectve than nasal packing inte treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization isan atematve treatment for patients whom general anesthesia woud put at high isk. Conclusion: The treatment of severe or recurrent epistaxis raquies the iterdisciplinary calaboration of the primary care physician, the emergency Physician, the practce-based otolaryngologist, and the hospital otslaryngology service. Uniform guidelines and epidemiological studies on his topic ‘would be desirable. Cite this as: Beck R, Sorge M, Schneider A, Dietz A: Curent approaches to epstais treatment in primary and secondary cre Dtsch Art! nt 2018; 115: 12-22. DOK: 10.8286lartebl 2018 0012 “Bahar ild episodes of epistaxis stop spontaneously or Method shsec ony are treated, often succesfilly, by the primary This article is based on a selective literature search of cate physician or by the emergency physician. the PubMed database, searching forthe terms “cpi- aoe fe: Only when nosebleeds are reeurent or severe are stax,” “epistaxis anticoagulation,” “epistaxis the steely" patients refered to an otorhinolaryngologist or to an apy," “epistaxis packing,” and “epistaxis embolization” ce eHlentand emergency department for Father diagnostic inthe tile of atiles published between I Janvary 2000 Bepgt Som assessment and treatment, No guideline exists in and 1 February 2017. Some older standard public Bee’ Germany today onthe treatment of epistaxis. The aim of cations, textbooks, and our own clinical experience iti ofGonant__ the present article sto provide an up-todate overview — were als included Paice nium of knowledge reparding is epidemiology, anatomy, and sea re isk factors, Specific recommendations willbe given for Epidemiology Pel dened, the treatment of epistaxis atthe primary and secondary About 60% of the population experience a nosebleed at Semeur levels of eae. least once in ther life (1), Presse epidemiological data Leaming goals ‘After reading this article, the reader should! «© Have acquired a general understanding of the epi- demiology, anatomy, and causes of epistaxis. «© Know the most important basic elements of the treatment of epistaxis. © Be familiar with the diagnostic and therapeutic procedures performed by, respectively, general practitioners and emergency physicians, otorhino- laryngologists, and ear, nose, and throat (ENT) hospital departments on incidence are unavailable, because no epidemiolo cal studies have been performed and only about 6% to 10% of the persons affected seek medieal help (1,2). In Epidemiology “Thelfelie prevalence of epistaxis is 60%. Only about 6% to 10% of those affected seek medical help. Deutsches Arabia intraoral | Oisch Aran 2018; 15: 12-22cra i md s3?bucket=uploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6m41mM039530z%2F kB... 2 0f 15 ‘ova ot reid ary Posterior ethoial artery ane srry Excemal cxotd, ary arenes lateral ral ‘Arto suppy ofthe nasal avy (034) “The eon ators supped byte rtema cared atey (re) andthe extemal carat (low) are nats ina). The Kiesalbach area ue) snp by branches of bot the man ates (0) 8) Areres sipping the nsa septum and theta asf nal ay. Germany, the only accurate data are those collected by ‘emergency departments, One retrospective study re- ported an epistaxis incidence of 121 / 100 000 inhabi- fants treated in two emergency departments in East ‘Thuringia (3) According toa retrospective study from the United States, 1 t0 2 out of 200 visits to the emergeney de- partment were due fo epistaxis, and about 5% of the patients had to be admitted for inpatient care (4, 5). In Germany, a total of 19 841 patients (11733 male and 8108 female) received inpatient treatment for epistaxis in 2015. The average hospital stay was 3.6 days (6). OF those who received treatment as inpa- tients, 71% were aged 65 or over, 18% were between 45 and 65 years of age, 5% were aged from 15 t0 45, and 6% were under the age of 15 (6). No figures for ‘weatment of epistaxis by primary care physicians have been published. Anatomy ‘The arterial supply of the nasal cavity is shown in Figure 1. n 90% to 95% of eases, the bleed occurs anteriorly inthe area of the anterior part of the nasal septum, the Kessebach area (or Litle’s area) (7-10), Anatomy In 908 to 95% of cases of pitas, the source of the Beed is. inthe area ofthe anterior part of he nasal septum, the Kiesslbach aea (Lil's area), Deutsches Ariba iomatinal| Dish Art It 2018; 15: 12-22. and in 5% to 10% of cases it occurs posteriorly in the posterior region of the nasal cavity (7,10, 11) Causes/Etiology ‘The most frequent cause of epistaxis is trauma due to | manipulation (nose picking) (12). Other causes fare shown in Box J. In 2014, a systematic review re ported that most studies described raised blood pressure at the time the epistaxis occurred. However, these studies were unable to show hypertension to be an im mediate cause of epistaxis. Confounding stress and, possibly, “white coat syndrome” may have contributed to raised arterial blood pressure in the setting of ‘epistaxis (13). Several studies have shown a relative in- ‘reas in epistaxis episodes during col, dry weather or ‘during periods when there are marked variations in ait temperature and pressure (14-18). Ingestion of anticoagulant drugs inereases the risk of epistaxis (19). About 24% to 33% of all patents, hospitalized for epistaxis take anticoagulants andor antiplatelet drugs 20, 21) Ingestion of acetylsalicylic ‘acid increases the severity and number of recurrences ‘of epistaxis and the need for surgical intervention 22, 23). A. retrospective cohort study in Zurich, Causes, ‘The most frequent cause of epstai i trauma due to digital ‘manipuiaton,COLD a) i i Deutsches Arstebiatt International | Désch Arstebl Int 2048: 475: 12-22. s3?bucket=uploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6m41m039530z2%2F ks... MEDICINE 3 of 15 Treatment algorithm Lol By prevary careemer- Basie measures forall levels of restment: ‘ene pysian Generation ee remantol beating ad headers Level 2: yan sr cncwrmgeys | E88 }-———— Blonds nag ety en can ceria ‘ots Love: nthe ENT Compression ofthe nostri eparrent lee aplzaon othe neck rea Upright sing poston lod be spat out “Tate loo pressure: one poopie T Palins hemodjnamicaly Patient heanaicaly Patent harodyraicaly ‘Sal, loding stops sal, bleeding persists ‘raabe + ‘0 min oberon, anise nasal ceem Beoting Bosting does notresune SUES ty Discharge patent home Emergency rans fo an ENT dparnent Prevent recurence: nasal mucosal] | Eergnoy refer to "volume replacement re, nonosesiowing xo 10 | | Sofhndanradopst ays Source of eedng nat Source of een vile, aneor Saeande ene sceegialen 1 es crsiveriat | leedng ale, te — [esa pacing hemes gauze frequres ersts v Bldg stops Discharge patent hare Prevent recorene: nasal mucosal + t a, no nose owing fr Tio 10 cays Een ern ‘Bleding pests, patntBleting persis, pati ot t Bledng sons ‘tor sigery efor sugery No bleding win 24h 1 t TENET ont, Tan” | Sete Samat ier antioics [iter cin ite, |_sptanopsatin ton Bleeding persis Booting patent nt ip palette anPM Fri Apr 10 s3?bucket=uploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6m41mM039530z%2F kB... 4 of 15 Suatzrland, showed ingestion of vitamin K antago- nists to be an independent and significant risk factor for recurrent epistaxis with an odds ratio(OR) of 11.6 (23), Prescription of direct oral anticoagulants for patients is increasing (24). There is curently a paucity of data conceming this group of drugs in relation to epistaxis. One prospective observational study showed reduction in the number of eases of severe epistaxis in patients taking dabigatran versus vitamin K antago~ nists Hospital stay was longer for dabigatran patients, however, because the lack ofan easily available co- agulaton test and persistent oozing after removal of packing made it necessary to keep the patents undet continued observation (28). One retrospective study of epistaxis in patents taking rivaroxaban showed a lover percentage of inpatient admissions (10.4% ver= sus 180%, p= 0.033) and shorter hospital stay (0.7 = 2.2 versus 1.53.7 days, p= 0.011) in comparison to patents taking vitamin K antagonists (26). Another Fisk factor identified was alcohol (14-16). One ran- domized, controlled, double-blind study showed that Setoid nasal sprays increase the risk of epistaxis ‘within 12 months in comparison to placebo from 89% 10 20%, The nosebleeds that occurred were slight © moderate; only 1 of 605 patients suffered a severe nosebleed within 12 months (27) In a meta-analysis of randomized, controlled studies, epistaxis was re- ported to be the most frequent undesired effect of PDE-S inhibitors, with a relative risk of 4.701 (95% confidence interval [95% Cl}: (1.314; 16812], p = 0.017) 28). Treatment of epistaxis No uniform guidelines exist for diagnostic and thera- peutic procedures in patents with epistaxis. However, clinically tried and tested treatment paths do emerge in hospitals and doctors’ offices, based largely on retrospective analyses, case. series, and. expert opinion. Only few prospective oF randomized controlled studies are available for some discrete areas of epistaxis treatment Epistaxis ranges from light nosebleeds that are casy 10 manage using simple methods to life- threatening bleedings that require hospital admission and may even need surgical treatment. For a structured overview of the interdisciplinary management of epistaxis, in this article treatment recommendations are given separately for level 1 (primary cate physicianemergency physician), level 2 (otorhinolaryngologis!), and level 3 care (hospital Treatment The treatment of pitas requires a structured intisciplin- ‘ary approach by the primary cae physician, emergency physician, olorhinolaryngologist, and hospital ENT department. Deutsches Arta tational isch tb It 2018; 16: 12-22, ENT department). Figure 2 shows the treatment algo- rithm developed by ourselves, which includes treat- ment recommendations from the international literature as well as our department's own in-house standard operating procedures. Some steps are relevant at al three levels of eae. Contamination controt Measures to prevent contamination must always be ‘observed, It is recommended that all who have close ‘contact with patients, ein the course of rhinoscopy ‘or endoscopy, should wear protective eye gear, lab coal, loves, and a face mask (12) Initial assessment of breathing and hemodynamics Especially in cases of severe bleeding, following the ABC approach, security of the airway, breathing, and ‘cardiovascular stability should be assessed (29-31). If symptoms of hypovolemia are found, a peripheral ve- nous access should be placed and volume replacement therapy started. Early blood pressure measurement is ‘an essential part of the diagnostic process. History taking ‘The most important parts of the history are first ofall the intensity and course overtime of the bleed, which allow a judgment to be made about the urgency of treat ment (29). The patient should be asked about factors that would predispose to epistaxis (Boxes 1,2) (12,29) ‘An important element ofthe history is what medication the patient ison, especially any anticoagulants or an platelet drugs (Box 2) 29). Blood tosts In many cases of uncomplicated epistaxis, no blood tests are required. Ifthe patient is on anticoagulation therapy, owever, coagulation testing with Inter- national Normalized Ratio (INR) measurement should be carried out. Imaging Imaging is not usually necessary. However, in patients ‘with recurrent epistaxis of unknown cause, imaging should be carried out 10 investigate the possibility of neoplastic disease such as juvenile nasopharyngeal an- iofibroma (32), Management of patients on anticoagulants In France, guidelines on the management of epistaxis in patients taking anticoagulants have existed since 2016 (33), In acute epistaxis, these recommend sereening for ‘Contamination control Its recommended that ll who have cose contact wih pa- tients, in the course of hinoscopy or endoscopy, should wear protective eye gear, a lab coal, gloves, anda face mask.cra i md s3?bucket=uploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6m41mM039530z%2F kB... MEDICINE 5 of 15 Causes of epistaxis* © Traunatc ~ Digital manipulation = Nasal racturelcentusion ~ Foreign body in the nose = latogeic (eg. nasogastc ube, sual iervetions) © Neoplaste = Juvenile nasopharyngeal angiofiroma ~ Tumors of the nasal cay and paranasal sinuses, © Hematological ~ Thrombocytopenia = Hemophilia A and B ~ Von Wilebrand disease = Liver fare © Stucurl = Mucosal dryness ~ Septal perforation ~ Osle-Neber-Rendu disease (hereditary hemorrhagic telangiectasia) © Drugrelated ~ Anticoagulants and antiplatelet drugs ~ Glucocorticoid nasal sprays = Nasal consumption of rugs © Inflammatory = Allergic hints ~ Aut infectious seases ‘eto en) ‘overdose and assessment of the risk of thrombosis, Anticoagulation therapy should always be continued so long as the bleeding can be stopped or contolled. Only if bleeding is massive and unstoppable, or ifan antico- agulation overdose is found, should adjustment of the ‘anticoagulation therapy be considered in consultation ‘with a hematologist and cardiologist. ‘Antiplatelet drugs Because it takes up to 10 days for hemostasis to be re- stored alter cessation of antiplatelet therapy, stopping antiplatelet drugs in a patient with acute epistaxis isnot useful, Ifthe bleeding eannot be halted, stopping anti= platelet therapy while atthe same time giving platelet transfusions is an option (33) Patients on anticoagulants Ifthe bleding can be stopped or controled, anticoaguaton ‘therapy should be continued. Onli bleding is massive and unstoppable, e.g, de o anticoagulation overdose, should ‘adjustment ofthe anticoagulation therapy be considered. Medical drugs associated with epistaxis’ «© Phenprocouon abigatran © Rivaroxban «© Fondaparinux © Clopidogrel © Acoysalic acd ‘Guucocortsid nasal sprays «© Phosphodiesterase'S inhibi (lative rsk: 4.701) Wo om 2 25,26, 28, 2, 8) Vitamin K antagonists For a patients taking a vitamin K antagonist, the drug should be stopped and an antidote given only if the bleeding is uncontrollable. If the vitamin K antagonist has been overdosed and the bleeding can be controlled, the dosage should be altered (33). Direct oral anticoagulants Stopping medication with direct oral anticoagulants is recommended only afler consultation with a eardiolo- gist Ifbleeding is uncontrolled, dabigatran is the only drug for which an antidote (idarueizumab 5 mg in two consecutive Sto 10-min intravenous infusions) is cur- rently available (33). Anticoagulation treatment should not be altered in «patient about to undergo endovascular embolization (expert opinion) (33) Preventing recurrence ‘To prevent recurrences, intensive care of the nasal mu cosa using an antiseptic nasal cream is recommended. A prospective, randomized, controled study in the United Kingdom in children with recurrent epistaxis compared treatment with an antiseptic cream for 4 weeks versus a waitand-sce policy. A significantly lower recurrence rate was seen in the treatment group (45% versus 71% recurrence rate, relative risk redue~ tion 47% with 95% Cl [9%; 69%)) (34). In addition, energetic nose blowing should be avoided for 7 to 10 days (29), Bed rest is not necessary. According 10 a Danish prospective, randomized study, mobilizing the patient does not increase recurrence in comparison to bed rest 35). Direct oral anticoagulants ‘Stopping medicaton with these drugs is recommended only ater consultation witha cardiologist. If bleeng is uncon- ‘toed, dabigatran is the only drug for which an ano is ‘curently avaiable Deutsches Arzteblatt International | Dtsch Arztebl int 2018: 115: 12-22PM Fri Apr 10 ete 6 of 15 ‘Treatment by the primary care physician andlor emergency physician ‘The first step isto compress both sides of the nose eon- tinuously for 15 4 20 min, using two fingers or a nose clip (29, 36,37). The patient should sit upright and lean slightly forward to prevent the blood from running down the pharynx (12). Local application of ice, eat the back ofthe neck, i intended to encourage vasocon- striction ofthe blood vessels ofthe nose. Its therapeutic value is a matter of debate and has been challenged in the literature (19, 38). No final conclusion can be drawn on the basis of existing publications. Inpatients with raised blood pressure that i not eausing symptoms (180/120 mmtlg, measured several times), the Euro- pean Society of Hypertension and the European Society of Cardiology recommend oral medication to reduce the blood pressure. The aim is to slowly reduce the blood pressure over a period of 24 to 48 hours (39, 40). In around 65% to 75% of cases, these steps combined with application of a decongestant, oxymetazoline- ‘based nasal spray will sueeed in topping the bleeding (el, €2). I bleeding does not restart during @ 30-min ‘observation period and the patient is hemodynamically stable, emergency specialist ENT treatment is not required In the presence of any ofthe following, we recom- ‘mend consultation with an otorhinolaryngologist: © Epistaxis uncontrollable by the measures described above ‘© Recurrent epistaxis «© Suspected neoplasm as the source ofthe bleed Treatment by an otorhinolaryngologist Anterior rhinoscopy ‘To locate the source of the bleeding, the first investi- zation is anterior rhinoscopy with a nasal speculum and headlight (29). Once any clots have been removed by suetion or with pincers, the nasal cavity can be ine spected, including the Kiesselbach area, where the bleeding often originates. Application of « vasocon- siritor and local anesthetic, ein the form of an im pregnated cotton tut will enable a better view. Owing to the local anesthetic effect, this ste has therapeutic as well as diagnostic value (12,30, 36). Endoscopy Especially in cases where the bleeding is from the posterior nasal cavity, locating the source of the bleed- ing by anterior rhinoscopy is difficult. In such eases, the French guidelines on treating epistaxis recommend a a supplementary procedure rigid endoscopy of the Treatment bythe primary care physician andlor emergency physician Important basic measures are compression ofthe nostri, ora ‘medication to reduc blood pressure if appropiate, and use of ‘an oxymetazoline nasal spay ‘Deutsches Arteblat Intemational | Dich Arie nt 2018; 116: 12-22 nasal cavity by a physician experienced in endoscopy (G0, 36). Two prospective studies have shown that 80% 10 94% of bleed sources can be identified by endoscopy (le), ‘Cauterization Most cases of epistaxis ffom an easily visible anterior source can be effectively treated by cateiztion with silver nitrate or electrocoagulaton. Before starting the procedure, a. vasoconstrictor and local anesthetic should be applied (30). Figure 3 shows a bleeding from the Kiesselbach area before and after bipolar coagu- lation. A Swiss retrospective study showed that in terms ‘of therapeutic success, electrocoagulation was superior to chemical coagulation (88% versus 78%) (uur rate 12% with 95% CI [0.09; 016] versus 22% with 95% CL {0.14; 0.33) (evidence level 26) (e4).A US study of children treated intraoperatively by these same two methods for recurrent anterior epistaxis also found @ lower recurrence rate for electrocoagulation than for chemical cauterization during the 2-year period ater the procedure (recurrence events 2% versus 18%) (5). ‘Chemical cautery is described as simpler to use, cheaper, and more widely available (e6). Compl cations of cauteizaton include septal perforation, infection, thinorthea, and inereased bleeding (12). Bilateral cautery inthe area ofthe nasal septum should bbe avoided if possible, as this risks septal perforation {€1). There are no published studies onthe incidence of seplal perforation after cautery (€8 9. Hemostatic gauze As a supplement to cautery, local application of gauze made of oxidized regenerated cellulose can be used. AS ‘a resorbable hemostyptic, it supports physiological he- rmostasis, Diffuse mucosal bleedings in particular can foflen be adequately managed by the application of a thin layer ofthis gauze (c10). Nasal packing [If cauterization is unsuccessful, the next step in manag- ing epistaxis is nasal packing. Packing takes different forms for anterior and posterior bleeding. Bilateral nasal packing produces a higher intranasal. pressure ‘than unilateral packing and its practice is therefore ‘widespread, although there is little evidence to support this (ell) Comprehensive overviews of the features and mechanism of action of the most common forms of nasal packing are presented by Beule et al. in theit 2004 publication (e12) and by Weber in his 2009 ‘Treatment by an otorhinolaryngologist For anterior epistaxis, the treatment of choice is biplar coagulation Wher bleeding is persistent or ftom & posterior soutoe the fist stp is nasal packinga md ete MEDICINE 7 of 15 ploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6mM41mM039530z%2F kB... Figure : Bleeding in the Kiesebach area (ght se) Before and ster bipalar cautery review article (¢ 10). The eFigure shows a selection of items in common use for nasal packing. The main nasal packing products used in Germany are rubber- coated sponge packs or tampons (Cummifingerlings ‘tamponaden), expandable sponge packs, and ribbon gauze impregnated with a medical cream (e12) (for more details sce eBox 1) Complications of nasal_packi serious complication of nasal packing is posterior dislocation, Reports have been published of fatal as- piration of nasal packs (e13). Rubber-coated sponge tampons and cotton ribbon gauze packs are Hable to dislocate (€10). To prevent this, all nasal packs must be strongly fixed to the patient’ face, e.g, with stick- ing plaster on the bridge of the nose or the cheek (€7 12). Additionally, the threads attached to some packs The most Other reported complications include allergic reac~ tion, mucosal necrosis, foreign body reaction, tube dysfunction, paraffinoma, and decompensation of pre-existing sleep apnea (c7, €10, ¢12). Nasal packing can also cause discomfort for the patient in the form of pain, obstructed breathing, and a reduced sense of smell (¢10). In addition, bilateral nasal packing ean result in impaired pressure equalization via the auditory (Eustachian) tube, leading to the patient’s Nasal packing “The main nasal packing products used in Germany are rubber- ‘coated sponge packs, expandable sponge packs, and ribbon gauze impregnated with a medical cream, discomfort due to ne the middle ear ive pressure (€10). There have been case reports of staphylococcal toxic shock syndrome as a serious complication (c14-€16). The release of toxic shock syndrome toxin 1 (TSSTI) causes symptoms such as. vomi diarrhea, fever, myalgia, diffuse erythema, and even septic shock. Treatment consists of immediate re moval of the packing, transfer of the patient to an intensive care ward (e10). Prophylactic antibioties—The role of prophylac- tic administration of antibiotics with nasal packing has not been adequately studied. Wide variation in practice has been described in England (e17), e. prophylactic antibiotics in patients with cardiac anomalies, especially prosthetic heart valves (30). Like some other authors, with anterior nasal packing. ‘we recommend prophylactic antibioties only after the packing has been in place for more than 48 hours, but with posterior packing we recommend it in al eases, ith the aim of preventing migration of infection into the sinuses and middle ear and toxie shock syndrome (e18). Preferred amibiotics are amoxicillin-clavu- lanie acid, amoxicillin alone, and cephalosporins (el?) Removal of packing—When to remove the packing is variously defined in the intravenous antibiotis, and ure, ranging Complications of nasal packing Posterior dislocation, aleric reaction, mucosal necrosis, {foreign body reaction, tbe dystuncton,parafinome, decom. pensation of pre-existing sleep apnea and staphylococcal toxic shock syndrome, Deutsches Arztebiatt International | Dtsch Arztebl int 2018; 115: 12-22PM Fri Apr 10 ete from 12 or 24 hours to 3 to 5 days after placement (12, 29, 30). For anterior packing alone, we recom- ‘mend removal after 48 hours, Where @ nasopharyn- ‘geal balloon has also been placed, this should be at Teast partially deflated after 24 hours at the latest. If clinically significant bleeding starts again after pack ing removal, we advise surgical teatment where possible Treatment in the ENT department From the point of view of the ENT department, for both ‘unilateral and bilateral packing, inpatient admission for ‘observation and packing removal are recommended be- ceause of the risk of posterior dislocation, Other indications for inpatient admission are shown in Figure 2 Surgical treatment ‘When conservative treatment fails, surgical hemostasis is generally required. A Swiss retrospective cohort study showed surgical intervention to be markedly supetior to packing in the management of posterior epistaxis (treatment failure rate 3% [0.00; 0.14] versus 38% (0.30; 0.67) (e4). The method of choice is endoscopic clipping or co- agulation ofthe sphenopalatine artery (e19).A British study reviewed the evidence for endoscopic spheno- palatine artery ligation and compared it to alternate ‘methods. The former proved to be superior 10 the ‘other treatment methods (monopolar cautery, embol- ization, etc.) controlling the bleeding in 98% of cases (€20). In retrospective cohort studies, recurrence of bleeding, intranasal dryness with erust formation, sinusitis, impaired nasal and palatal sensitivity, formation of intranasal synechiae, unilateral chronic epiphora, and septal perforation have all been re- ported as complications. One Brazilian retrospective longitudinal study reported a case of amaurosis after the intervention (¢21), Taken together, these studies show endoscopic sphenopalatine artery ligation to have few complications (e21-e25). Clinically signif cant hypoxia of the territory supplied by this artery hhas not been described and is not anticipated, given the multiplicity of anastomoses between the spheno- palatine and ethmoidal arteries (9). For this reason, the criteria for surgical treatment can be quite wide recurrence of bleeding afler one attempt at packing and where the source of the bleeding is not evident (€19). Surgical hemostasis (eBox 2) should also be considered carly on in. patients with persistent bleeding despite packing. Endoscopic ligation of the Treatment in an ENT department For posterior epistaxis, surgical intervention is markedly su- perorto packing, The method of choice is endoscopic clipping ‘0 coaguaton ofthe sphenopaltine artery, which conto the bleeding in 96% of cases. Deutsches Arcteblatt Intemational | Disch Arrtebt Int 2018: 118: 12-22 ‘anterior ethmoidal artery is indicated mostly in the context of revision surgery. In four retrospective studies, approximately 2.9% to 8.6% of all patients undergoing surgery for severe epistaxis had anterior ‘ethmoidal artery ligation (¢21-e23, €26). Embolization Another possible method in patients with epistaxis that is dificult to conteol is percutaneous embolization, This technique has a reported success rate of 87% 10 93% (€27-<29). The target vessel is imaged angio traphically and then an occluding agent is injected via «8 percutancous transrteral catheter (e30). The embol- ization should be carried out by an experienced interventional neuroradiotogist (e31). Because of the potential for complications such as cerebrovascular ischemia, facial nerve paralysis, and soft tissue necro~ sis, some authors recommend using this technique only in patients who have an inereased anesthetic risk be- ‘cause of other comorbidities, oF in whom attempted sungical treatment has failed (30). One retrospective ‘eross-sectional study in the US eompared embolization ‘with surgical vascular occlusion in terms of morbidity, hospital mortality, and duration of hospital stay. No sig nificant differences were found in relation to blood transfusions (22.8% versus 24.3%), stroke (0.5% ver~ sus 0.3%), amaurosis (0.4% versus 0.5%), and hospital morality. However, surgery is associated with lower hospital costs and a shorter hospital stay (¢32) ‘Treatment of epistaxis in children ‘An overview of recommended treatment strategies in ‘epistaxis in children is given in a French systematic review by Béquignon et al. (e33) In addition to removal of clots, bidigital compression, and (permissible from the age of 6 onwards) application of a local anesthetic and decongestant, the use of an antiseptic ‘cream is recommended (33). If bleeding persists, chemical cautery (silver nitrate stick) should be preferred to electrical eautery, as electrical cautery is ‘more painful and would therefore require a general anesthetic (€33). Conclusions for clinical practice In 65% to 70% of cases of epistaxis, simple frst aid measures provided by the primary care physician or ‘emergency physician stop the bleeding. IF bleeding persists, specialist ENT expertise should be urgently consulted. So long as the source of the bleeding is visible, most cases of epistaxis can be successfully treated using electrical or chemical cautery. In cases Embolization ‘Where surgical treatment fal rth patient has a high ‘anesthetic sk, percutaneous embolization isa reasonable alternative, ploads&prefix=attach%2Fk360nmh6oej3mc%2Fj6mM41mM039530z%2F kB... MEDICINEOd i s3?bucket attach%2Fk360nmh6oej3mc%2Fj6m41m039530z2%2F k8.. MEDICINE 9 of 15 ‘where the bleeding source is posterior, or where the bleeding remains refractory to packing, surgery should ‘be considered early on and liberally. Because of its high sucess rate and comparatively low complication rate, endoscopic ligation or coagulation of the sphenopalatine artery is the method of choice. In eases ‘of severe epistaxis, where surgical treatment fails or the patient has a high anesthetic risk, percutaneous embol- ization isa reasonable alternative. confit of inerast statement ‘Te uot delet mo coffee st, Manus recived on 15 May 2017, sed verso econ ‘7 Oaober 217, “Tears a toga Geman ty Ket Wp, MA References 1. Parson B, usin The faquecy of epistaxis ina mae popua- ton sample Rhicogy 1075, 1: 129-33. 2 Sal Muay JA Maran AG: A ty of patents ih pitas requrrg action hospital Meath Bul 182; 40: 20-9. 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