Severe epistaxis: protocol to diagnosis and endoscopic surgery treatment in 59 patients

INTRODUCTION
The epistaxis is defined as any bleeding of nasal mucosa and is the most common otolaryngology emergency, with a prevalence between 10 and 12%
Santos, RP et al. Ligadura endoscpica endonasal da artria esfenopalatina para epistaxe severa. Rev. Bras. Otorrinolaringol. 2002; 68(4): 511-514 Voegels RL et al. Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis. Otolaryngol Head Neck Surg 2001;124:464-467 Snyderman, CH et al. Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis. Am J Rhinol 1999;13:137-140

INTRODUCTION
SUPERIOR EPISTAXIS: Internal Carotid Artery => Oftalmic Artery Anterior Ethmoidal Artery Posterior Ethmoidal Artery POSTERIOR EPISTAXIS: External Carotid Artery => Internal Maxilar artery: Sphenopalatine Artery Nasoseptal Artery Nasal Lateral Posterior Artery
Andrade GS, Felippu Neto A. Epistaxe grave. In: Campos CAH, Olival HO. Tratado de Otorrinolaringologia, 1 Ed. So Paulo: Roca; 2002. p.209-15

ANTERIOR OR SEPTAL EPISTAXIS:

Kiesselbach Plexus or Little`s

INTRODUCTION
Local Disturbance
Trauma Surgical Procedures

Hematologic Disturbance
Coagulation disorders Use of aspirin or anticoagulants

Neoplasic Disturbance
Juvenile nasopharyngeal angiofibroma Benign/Malignant Tumors

Genetic Disturbance
Osler-Weber-Rendu Syndrome

Systemic Disturbance
Arteriosclerotic disease Hypertension

Others
Barotrauma Hemodialisis

RESEARCH QUESTION
The objective of the present study is to describe and discuss an emergency care protocol for topographic diagnosis and endoscopic surgical treatment performed on patients with severe epistaxis

MATERIAL AND METHODS

From March 2004 to February 2012 a total of 185 patients complaining of epistaxis were treated at the Otolaryngologic specialist service in Blumenau /SC and of these 59 patients of both genders were selected with severe epistaxis requiring endoscopic treatment.

MATERIAL AND METHODS

Were considered for surgical decision: (1) control of the companions, (2) the clinical conditions of the patient and requested laboratory tests, (3) the presence of comorbidities and medication use, (4) history of previous surgery, (5) the habits of life, including narcotics, (6) the topographic diagnosis

MATERIAL AND METHODS

ENDOSCOPIC EXAMINATION

TOPOGRAPHIC DIAGNOSIS

COMPUTADORIZED TOMOGRAPHY

MATERIAL AND METHODS:

S

According to the topographic diagnosis cases were classified as anterior (A), posterior (P) and superior (S)

Anterior epistaxis (plexus Kiesselbach) were not included

MATERIAL AND METHODS

Were considered cases of POSTERIOR EPISTAXIS the ones related with the sphenopalatin artery and its branches, including the posterior portion of the nasal septum, the body or tail of the inferior turbinate

MATERIAL AND METHODS

Were considered cases of SUPERIOR EPISTAXIS the ones related to the anterior or posterior ethmoidal arteries.

MATERIAL AND METHODS

NOT LOCALIZED TOPOGRAPHY

TABLE 1. Protocol to endoscopic surgical treatment on cases of severe epistaxis

MATERIAL AND METHODS

For the ligadure of sphenopalatin and its branches an incision was performed aproximately 1cm anterior to the medium nasal CONCHA or the maxilar sinusectomy was used for the unsticking of a mucosal shred.

MATERIAL AND METHODS

For the ligadure of the anterior ethmoidal artery was realized a trasethmoidal technique or supra-bulbar depending of the case.

MATERIAL AND METHODS

- General anesthesia or sedation, - Endoscopic technique with optical lenses of 30 and 45 degrees, - Adequate material for dissecation and arterial ligadure.
Patients without clinical conditions/ up to the chirurgic procedure: - Temporary (between 1hour to 72 hours) anterior/posterior nasal tampon was introduced

RESULTS
LIFE HABITS
25,4

GENDER

MALE 44%

13,5

FEMALE 56%

SMOKERS

ALCOHOLIC

RESULT
CAUTERIZATION OR LIGADURE

19% 44% RIGHT SIDE 37%

LEFT SIDE
BILATERAL

RESULT
Principals etiologic factors related with severe epistaxis
Chronic inhalation of narcotic Nasal trauma Tracheal intubation or nasogastric tube Nasal lymphoma Nasal hemangioma Nasal melanoma Radiotherapy Diabetes mellitus Chronic renal failure

Hypertension
Sinusitis chronic/nasosinusal polyposis Medicamental (anticoagulant) Idiopatic spontaneous Iatrogenic Post-operatory complication 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00%

RESULT

Tabela 3. Principais achados topogrficos dos focos de epistaxe severa

RESULT

Endoscopic-video showing the topographic diagnosis of post-operatory epistaxis from left sphenopalatine artery with posterior arterial ligadure

RESULT

Sinus paranasals TC (coronal cut) and video-endoscopy showing the right sphenopalatin artery ligadure on a patient with rinusinutis chronic

RESULT

Tabela 3. Principais achados topogrficos dos focos de epistaxe severa

RESULT

TC de seios paranasais (corte coronal) e vdeo-endoscopia demonstrando ligadura da artria etmoidal anterior direita por via transetmoidal em paciente com tumor nasossinusal

RESULT

Tabela 3. Principais achados topogrficos dos focos de epistaxe severa

RESULT

No patient presented new epistaxis episode in the immediate or late post-operatory No trans or post operatory complications were presented

All patients were discharge between 8 to 48 hours of post-operatory according to their clinical conditions

CONCLUSION:

The use of the endoscope has proved to be a useful tool to aid in the topographic diagnosis and endoscopic surgical techniques were safe and effective in the treatment of severe epistaxis.