Journal Information
Vol. 71. Issue 2.
Pages 146-148 (March - April 2005)
Share
Share
Download PDF
More article options
Visits
5473
Vol. 71. Issue 2.
Pages 146-148 (March - April 2005)
Original Article
Open Access
Nasal endoscopy and localization of the bleeding source in epistaxis: last decade's revolution
Visits
5473
Glauco Soares de Almeida1,
Corresponding author
glaucosoaresalmeida@ig.com.br

Address correspondence to: Dr. Glauco Soares de Almeida - Rua José Vilar 2720 ap. 402 Dionísio Tôrres 60125-001 Fortaleza CE
, Camilo A. Diógenes2, Sebastião D. Pinheiro3
1 Specialist in Otorhinolaryngology, Physician with Hospital Otoclínica
2 Generalist (Emergency physician)
3 Joint Professor, Medical School, Federal University of Ceará, Head of the Service of Otorhinolaryngology. Hospital Otoclínica - Fortaleza, Ceará
This item has received

Under a Creative Commons license
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Summary

Epistaxis remains one of the most common otolaryngology emergencies. Despite considerable interest in the subject, there is still no consensus on the most appropriate primary therapeutic modality.

Aim

The purpose of this study was to evaluate the bleeding source of acute or recurrent epistaxis in adults.

Study design

Clinical prospective.

Material and Method

Thirty adults patients with acute or recurrent epistaxis were evaluated through the use of frontal light and endoscope for identification of the bleeding source in the nasal cavity.

Results

Use of the nasal endoscope allowed diagnosis of the bleeding site in all patients.

Conclusion

A careful examination of the posterior nasal cavity allows identification of the bleeding source in most patients and should be a routine procedure.

Key words:
epistaxis
nasal bleeding
treatment
Full Text
INTRODUCTION

Not so many issues in Otolaryngology have so deeply shifted their paradigms in the last decades as the treatment of epistaxis. Terms like “untreatable epistaxis” and “conservative treatment” should be revised. The main reason for this paradigm shift was the advent of nasal endoscopy. If epistaxis was previously labeled as an “untreatable” condition and managed with multiple nasal packing, ligature of the carotid and/or maxillary arteries1,2, or even vessel embolization3, now they have shown to be easily diagnosed and treated through nasosinusal endoscopic surgery. Treatments previously considered “conservative”, such as nasal packing seem much more traumatic, uncomfortable and, in some cases, with higher risks4 than simple endoscopic procedures, such as local cauterization or ligature of the sphenopalatine artery.

For effective therapeutic approach, it is crucial that nasal vascularization and prevalent bleeding sources are better understood. Ligature of the external carotid conducted by Hyde2 in 1935 was the first vascular procedure for epistaxis control. Chandler1, in 1965 was the first to perform a ligature of the maxillary artery transantrally in an attempt to intervene next to an intranasal bleeding site. Intranasal approaches for epistaxis control were established after the first ligature of the sphenopalatine artery using a microscope (Stamm, 1985)5 and an endoscope (Budrovich and Saette, 1992)6. Since then, treatment of epistaxis under microscopic or endoscopic magnification of the nasal cavity posterior segment became popular, less threatening and reduced distress.

OBJECTIVE

This study aims at identifying the nasal cavity's bleeding source of patients with active or recurrent epistaxis by means of nasal videoendoscopy.

MATERIAL AND METHOD

A prospective study was conducted with 30 patients with epistaxis who were assisted at the emergency otolaryngology service (Otoclinica - Fortaleza, CE), in the period of January 2002 to August 2004. Ages ranged from 32 to 68 years, with mean age of 52. The group of patients comprised 17 men (56.6%) and 13 women (43.3%). After clinical assessment, all patients were initially examined by classical anterior rhinoscopy with frontal illumination, while those whose bleeding sources were not identified were submitted to nasal endoscopic evaluation. Bleeding sources were classified as: anterior or posterior; from the lateral nasal wall or nasal septum.

RESULTS

Out of 30 patients assessed, 19 (63.2%) presented bleeding in the posterior segment of the nasal cavity – 14 (46.6%) in the nasal septum and 5 (16.6%) in the lateral nasal wall. Out of 11 patients (36.6%) with bleeding at the anterior segment of the nasal cavity, all bleedings were found in the anterior nasal septum. No patients presented bleeding in the anterior region of the lateral nasal wall or bilateral bleeding.

DISCUSSION

W. Messerklinger7 was the first to adopt nasal and paranasal endoscopic surgery, rendering further contributions to otolaryngologists. Since 1985, this approach started to be broadly practiced by Kennedy8 in the United States, and worldwide in the 90's.

In 1992, when Budrovich6 reported the treatment of epistaxis by nasal endoscopy, several other studies were published. The first articles on this technique for the control of epistaxis described comprehensive maxillary antrostomy followed by removal of the posterior wall of the maxillary sinus and ligature of pterygomaxillary fossa vessels (White, 1996). The improved approach was very radical concerning nasal vascularization, although it did not play a direct effect over the intranasal bleeding source. After various studies on anatomy micro-dissections of cadavers, ligatures of sphenopalatine vessels to reach the nasal cavity9–13 were the following step. The concept that vascular ligature is more effective when performed the nearest possible to the bleeding source led nasal endoscopy to become the gold standard approach for patients with epistaxis.

Regular use of clinical endoscopy during the last decade amplified the knowledge on the etiology and treatment of epistaxis. The bleeding source inside the nasal cavity could be more easily and accurately identified. Moreover, other less invasive procedures, such as cauterization of the bleeding source, could be done presenting high efficacy rates14. Local cauterization of the bleeding spot, which was previously limited to anterior portions of the nasal cavity, could be amplified to posterior regions, with the advent of endoscopic visualization.

Clinical use of endoscopy showed that, except for the anterior nasal septum as a bleeding source, the most frequent site of epistaxis was the posterior portion and not the lateral wall of the nasal septum, which is contrary to what was previously believed, but corroborates our casuistic and the data in the literature available14,15. The literature also emphasizes the importance of Woodruff's venous plexus, which corresponds to less than 10% of the cases with posterior epistaxis.

These clinical observations corroborate reports of highly effective cauterization of the sphenopalatine artery (and/or its branches: posterior lateral and septum nasal artery) in the control of posterior epistaxis, although it opens new possibilities for less invasive approaches by local cauterization of the bleeding spot in the posterior nasal septum through endoscopic visualization, which also presents high efficacy rates16,17.

CLOSING REMARKS

The nasal septum is the most frequent site for posterior nasal bleeding. If the bleeding source is not identified by anterior rhinoscopy, a nasal endoscopy is mandatory. Identification and cauterization of the bleeding point under endoscopic magnification of the posterior nasal septum becomes an effective and less invasive procedure, avoiding unnecessary cauterization of the sphenopalatine artery.

REFERENCES
[1]
Chandler JR , Serrin AJ. .
Transantral ligation of the maxillary artery for epistaxis..
Laryngoscope, 75 (1965), pp. 1151-1159
[2]
Hyde FT. .
Ligation of the external carotid artery for control of idiopathic nasal haemorrage..
Laryngoscope, 35 (1925), pp. 899
[3]
Vokes DE , Mcivor NP , Wattie WJ , Morton RP. .
Endovascular Treatment of epistaxis..
ANZ J Surg, 74 (2004), pp. 751-753
[4]
Jensen PF , Kristensen S , Juul A , et al.
Episodic noturnal hypoxia and nasal packs..
Clin Otolaryngol, 16 (1991), pp. 433-435
[5]
Stamm AC , Pinto JA , Neto AF , et al.
Microsurgery in severe posterior epistaxis..
Rhinology, 23 (1985), pp. 321-325
[6]
Budrovich R , Saetti R. .
Microscopic and endoscopic ligature of the sphenopalatine artery..
Laryngoscope, 102 (1992), pp. 1391-1394
[7]
Messerklinger W. .
Uber die Dranage der menschlichen NNH unter normalen und pathologischen bedingungen..
Mitteclung Monatsschr Ohrenheick, 100 (1966), pp. 56-68
[8]
Kennedy DW , Zinreich SJ , Rosenbaum A , Jonhs ME. .
Functional endoscopic sinus surgery: theory and diagnostic evaluation..
Arch Otolaryngol, 111 (1985), pp. 576-578
[9]
White PS. .
Endoscopic ligation of the sphenopalatine artery: a preliminary description..
J Laryngol Oto, 110 (1996), pp. 27-30
[10]
Sharp HR , Rowe-Jones JM , Biring GS , et al.
Endoscopic ligation or diathermy of the sphenopalatine artery in persistent epistaxis..
J Laryngol Oto, 111 (1997), pp. 1047-1050
[11]
Snyderman CH , Goldman SA , Carru RL , et al.
Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis..
Am J Rhinol, 13 (1999), pp. 137-140
[12]
Almeida GS , Pinheiro SD , Neto CPD. .
Cauterizaçã o endoscópica da artéria esfenopalatina em epistaxe posterior..
Arq Fund Otorrinolaringol, 5 (2001), pp. 99-101
[13]
Voegel RL , Thome DC , Iturralde PP , et al.
Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis..
Oto Head Neck Surg, 124 (2001), pp. 464-467
[14]
O'dnnell M , Robertson G , Mcgarry GW. .
A new bipolar diathermy probe for the outpatient management of adult acute epistaxis..
Clin Otolaryngol, 24 (1999), pp. 537-541
[15]
Chiu TW , Shaw-Dunn J , Mcgarry GW. .
Woodruff's nasonasopharyngeal plexus: How important is it in posterior epistaxis.
Clin Otolaryngol, 23 (1988), pp. 279
[16]
Babin E , et al.
Anatomic variations of the arteries of the nasal fossa..
Otol Head Neck Surg, 128 (2003), pp. 236-239
[17]
Batra P , et al.
Surgical anatomy of the distal maxillary artery..
Otol Head Neck Surg, 131 (2004), pp. 186-187

Article submited on March 14, 2005. Article accepted on March 30, 2005.

Copyright © 2005. Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial
Idiomas
Brazilian Journal of Otorhinolaryngology (English Edition)
Article options
Tools
en pt
Announcement Nota importante
Articles submitted as of May 1, 2022, which are accepted for publication will be subject to a fee (Article Publishing Charge, APC) payment by the author or research funder to cover the costs associated with publication. By submitting the manuscript to this journal, the authors agree to these terms. All manuscripts must be submitted in English.. Os artigos submetidos a partir de 1º de maio de 2022, que forem aceitos para publicação estarão sujeitos a uma taxa (Article Publishing Charge, APC) a ser paga pelo autor para cobrir os custos associados à publicação. Ao submeterem o manuscrito a esta revista, os autores concordam com esses termos. Todos os manuscritos devem ser submetidos em inglês.