Endovascular intervention for the treatment of epistaxis: cone beam CT review of anatomy, collateral, and treatment implications/efficacy.

Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase in frequency significantly over the next two decades. Sphenopalatine artery embolization is rapidly becoming the most common type of procedural intervention. The efficacy of endovascular embolization is dependent on a refined understanding of the anatomy and collateral physiology of this circulation as well as the impact of temporizing measures such as nasal packing and inflation of a nasal balloon. Likewise, safety is dependent on a detailed appreciation of collateralization with the internal carotid artery and ophthalmic artery. Cone beam CT imaging has the resolution to enable a clear visualization of the anatomy and collateral circulation associated with the arterial supply to the nasal cavity, in addition to assisting with hemorrhage localization. We present a review of epistaxis treatment, a detailed description of anatomic and physiologic considerations informed by cone beam CT imaging, and a proposed protocol for sphenopalatine embolization for which there is currently no standard.

[Deforming endonasal mass during pregnancy]. / Deformierende endonasale Raumforderung während der Schwangerschaft.

This article presents the case of a 33-year-old woman who consulted the authors' ENT clinic in the 39th week of pregnancy with recurrent epistaxis. A livid endonasal mass was found on the left side, subtotally displacing the nose and leading to deformation of the external nose. External biopsy provided no indications of malignancy. Postpartum CT of the paranasal sinuses revealed a mass destroying the cartilaginous nasal septum. Endoscopic resection of the finding was performed with preservation of the clinically sound nasal septal cartilage. Histopathological examination revealed a capillary hemangioma, which was classified as granuloma gravidarum due to its occurrence during pregnancy.

Cavernous Hemangioma of the Maxillary Sinus Masquerading Recurrent Hemorrhagic Mass: Histological-Radiological Correlation and a Literature Review.

BACKGROUND: Sinonasal cavernous hemangioma is rare. To date, fewer than 20 cases have been reported in the literature; however, they may be a source of recurrent epistaxis and masquerade of a hemorrhagic mass on CT and MRI. CASE REPORT: A 68-year-old woman was presented with recurrent epistaxis and progressive right malar fullness. On rhinoscopy, a bulge lesion was observed with multifocal hemorrhagic and friable surfaces in the right nasal cavity. CT and MRI demonstrated a well-defined mass in the right maxillary sinus with inhomogenous T2 hyperintensity, hypointense septa, peripheral rim, and multiple papillary enhancement, suggesting a recurrent hemorrhagic mass. The mass was excised endoscopically, and the histologic diagnosis was cavernous hemangioma. CONCLUSION: Imaging studies, such as CT and MRI, are essential in making an accurate diagnosis of cavernous hemangioma of the maxillary sinus. Endoscopic excision of the lesion can be curative.

An image-guided (CT) assessment of a new asymmetric balloon for the treatment of epistaxis.

PURPOSE: The main objective was to perform an image-guided (CT) assessment of the efficacy of the CAVI-T™ balloon to compress the sphenopalatine artery (SPA) on cadaver heads, for the management of epistaxis. The secondary objectives were to analyse the deployment and stability of this balloon according to the volume injected into the nasal cavity, to optimise its use. METHODS: A descriptive anatomical study was performed. The catheterization of the SPA was performed on four fresh-frozen heads with a SPA approach through the maxillary sinus, leaving the nasal cavity unscathed. Computed Tomography images were acquired without and with the balloon, inflated by injections of progressive volumes of diluted iodine, for optimal contrast with the surrounding tissues. We evaluated the positioning of the balloon according to two predetermined markers on the device. RESULTS: Out of 68 image-guided acquisitions, the CAVI-T™ balloon compressed the SPA in 88% of cases. The other nasal cavity structures were compressed in 86% to 100% of the cases, depending on the positioning of the CAVI-T™ balloon, therefore allowing a complete obstruction of the nasal cavity. The device remained stable upon inflation and did not obstruct the nasopharynx. CONCLUSION: The CAVI-T™ balloon provided effective compression of the SPA and the different structures of the nasal cavity.

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck.

OBJECTIVES: Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain. METHODS: We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization. RESULTS: Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%. CONCLUSIONS: CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Nasal Packing Causing Occlusion of Contralateral Internal Carotid Artery During Control of Pseudoaneurysm Bleed.

BACKGROUND: Carotid pseudoaneurysm is a rare complication of pituitary surgery and can present with epistaxis. Nasal packing is considered first-line treatment for the control of carotid bleeding. We describe a case of complete occlusion of the contralateral cavernous carotid artery because of nasal packing placed to control hemorrhage from a cavernous carotid pseudoaneurysm. CASE DESCRIPTION: A 55-year-old man presented with a history of recurrent epistaxis requiring multiple hospital visits and nasal packing over a 9-month period. Nasal endoscopies failed to show a source of bleeding; therefore, the patient underwent bilateral sphenopalatine artery ligations. Postoperative computed tomography angiogram showed no evidence of aneurysm, but did report indistinctness of the lateral sphenoid walls. Symptoms remained controlled for 4 months, but ultimately, he presented to the emergency department with massive epistaxis. A magnetic resonance angiogram noted a 2- to 3-mm left cavernous carotid pseudoaneurysm, and the patient underwent endovascular embolization of bilateral internal maxillary arteries. Significant epistaxis was noted immediately thereafter and he was taken to the operating room to control bleeding. A 4-cm absorbable nasal packing was placed into each sphenoid cavity after profuse bleeding from the left sphenoid sinus was noted. After control of bleeding, cerebral angiogram showed complete occlusion of bilateral internal carotid arteries (ICAs). The right-sided packing was adjusted, and the ICA profusion improved. CONCLUSIONS: To our knowledge, this is the only report that describes complete occlusion of the contralateral cavernous carotid artery because of extrinsic compression of the lateral sphenoid wall, in the setting of a symptomatic pseudoaneurysm.

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

PURPOSE: Epistaxis that is refractory to conservative management can be treated with endoscopic sphenopalatine artery ligation (ESPAL). Although rare, ethmoidal artery (EA) bleeding can be a cause of rebleeding after successful ESPAL. EA bleeding is diagnosed by angiography and can also be identified during surgical exploration. However, since the angiographic embolization of the EA is contraindicated, surgical hemostasis is mandatory. This study investigated whether paranasal sinus (PNS) CT could provide information for predicting EA bleeding without angiography in patients with refractory epistaxis requiring ESPAL. METHODS: Forty-seven patients, who were surgically treated [with ESPAL or EA ligation (EAL)] for refractory epistaxis from March 2010 to June 2019, were retrospectively analyzed. A positive PNS CT finding for EA bleeding was defined as the presence of soft tissue densities having continuity with the EA pathway, accompanied by a partially deficient surrounding bony canal. These findings as well as soft tissue densities in each paranasal sinus were compared between the ESPAL and EAL groups. RESULTS: All patients in the EAL group had positive CT findings of EA bleeding, compared to only 12.2% in the ESPAL group (P < 0.001). The rate of soft tissue densities within the frontal and sphenoid sinuses were noted in 26.8% and 17.1% of patients in the ESPAL group, compared to 83.3% and 83.3% of patients in the EAL group (P = 0.013 and P = 0.003, respectively). CONCLUSION: PNS CT might be useful for predicting EA bleeding in patients with refractory epistaxis requiring surgical hemostasis.

Pseudoaneurysm of the basilar artery presenting with epistaxis.

The internal carotid artery is the most commonly affected artery in pseudoaneurysm presenting with epistaxis. Basilar arterial pseudoaneurysm is usually associated with intracranial haemorrhage. We report a basilar artery pseudoaneurysm after endoscopic surgery for clival chordoma, leading to epistaxis. The mechanism of epistaxis and strategy of embolisation are discussed.

Sinonasal organising haematoma - a little known entity / Hematoma nasossinusal em organização - uma entidade pouco conhecida

Abstract Introduction: Sinonasal organising haematoma is a recently described, rare, benign inflammatory condition, which closely resembles malignancy in its clinical presentation. Objective: To describe the clinical features of organising haematoma and to review the evolution of surgical options successfully used. Methods: A retrospective review of charts of all patients with a histopathological diagnosis of sinonasal organising haematoma was performed. Results: Six (60%) of the 10 patients were male with a mean age of 47.4 years. All patients had unilateral disease with recurrent epistaxis as the presenting symptom. Maxillary sinus was the most commonly involved sinus. There was no history of trauma in any of the patients. Hypertension (80%) was the most commonly associated comorbidity. Contrast-enhanced CT scan of the paranasal sinuses showed heterogeneous sinus opacification with/without bone erosion. Histopathological examination was diagnostic. Complete endoscopic excision was done in all patients resulting in resolution of the disease. Conclusion: Awareness of this relatively new clinical entity and its evaluation and treatment is important for otolaryngologists, maxillofacial surgeons and pathologists alike. Despite the clinical picture of malignancy, histopathological features of benign disease can safely dispel such a diagnosis.

Resumo Introdução: Hematoma nasossinusal em organização é uma condição inflamatória benigna rara, recentemente descrita, que se assemelha a lesões malignas em sua apresentação clínica. Objetivo: Descrever as características clínicas do hematoma em organização e analisar a evolução das opções cirúrgicas usadas com sucesso. Método: Foi feita a revisão retrospectiva dos prontuários de todos os pacientes com diagnóstico histopatológico de hematoma nasossinusal em organização. Resultados: Seis (60%) dos 10 pacientes eram do sexo masculino, com média de 47,4 anos. Todos os pacientes apresentavam doença unilateral com epistaxe recorrente como sintoma de apresentação. O seio maxilar era o mais comumente afetado. Não havia histórico de trauma em qualquer dos pacientes. Hipertensão (80%) foi a comorbidade mais comumente associada. A tomografia computadorizada dos seios paranasais com contraste mostrou opacificação heterogênea do seio com/sem erosão óssea. O exame histopatológico foi diagnóstico. A excisão endoscópica completa foi feita em todos os pacientes, resultou na resolução da doença. Conclusão: A conscientização a respeito dessa entidade clínica relativamente nova e sua avaliação e tratamento são importantes para os otorrinolaringologistas, cirurgiões buco-maxilo-faciais e patologistas. Apesar do quadro clínico de malignidade, as características histopatológicas da doença benigna podem descartar com segurança esse diagnóstico.

Computed tomography findings in patients with primarily unknown causes of severe or recurrent epistaxis.

OBJECTIVE: In addition to rhinoscopy, computed tomography of paranasal sinuses (CT) may be performed on patients with primary unknown cause of severe epistaxis (SE) or recurrent epistaxis (RE) to further assess the potential cause of bleeding. The aim of this study was to evaluate CT findings during the work-up of intractable epistaxis patients. METHODS: 6937 patients were treated in our emergency department with acute epistaxis between 2009-2018. 304/6937 patients underwent CT and rhinoscopy due to intractable SE or RE. 33 patients presented with head trauma prior to epistaxis and were excluded from the final analysis. In 271 cases the primary causes of SE (n = 252) or RE (n = 19) remained unknown. Two observers retrospectively evaluated CT scans for potential sources of epistaxis. Disagreement was settled by consensus. CT and rhinoscopy findings were compared. RESULTS: In 247/271 (91.1%) SE patients no related pathology was found on CT. A possible cause for epistaxis was found in all RE patients, but only in 5/252 (1.9%) patients with SE. Most tumours (10/11) and inflammatory conditions (9/10) were found in patients with RE. In three SE cases, a tumour was suspected on CT, from which two suspicions were refuted during rhinoscopy. CT revealed 10 cases of inflammatory conditions of the sinus and anatomical variant as potential cause of bleeding. CONCLUSION: For patients with unknown causes of epistaxis, supplementary CT imaging may be a useful diagnostic add-on to rhinoscopy in the event of RE, tumour suspicion or inflammation of the paranasal sinuses. However, in most cases of first-time SE, CT does not necessarily add to the diagnosis. In these cases, the marginal benefit of CT needs to be weighed carefully against its risks.

Delayed Pipeline Embolization of a Ruptured True Internal Carotid Artery Aneurysm Presenting with Epistaxis: Case Report and Review of the Literature.

BACKGROUND: Massive epistaxis from rupture of an intracavernous internal carotid artery aneurysm is a potentially fatal event. Although rare, this presentation is seen most often in patients after trauma or iatrogenic injury secondary to transsphenoidal surgery or radiation therapy. CASE DESCRIPTION: We present our unusual case of a patient with no significant risk factors who had recurrent epistaxis owing to a ruptured true cavernous internal carotid artery aneurysm. The patient was treated initially with coil embolization followed by placement of a Pipeline embolization device. The patient had complete resolution of her bleeding events. A follow-up arteriogram performed 14 months later confirmed aneurysm obliteration, with parent artery preservation and no evidence of in-stent stenosis. CONCLUSIONS: Our case highlights the importance of evaluating for intracranial pathological conditions in patients who present with refractory epistaxis. In selected patients, the use of flow-diversion technology as an adjunct or alternative to primary coil embolization for treatment should be considered.

Clinical characteristics of internal carotid artery pseudoaneurysms in the sphenoid sinus.

BACKGROUND: Internal carotid artery (ICA) pseudoaneurysms are associated with high mortality if lack of proper management. Patients with ICA pseudoaneurysms in the sphenoid sinus often visit a hospital's ear, nose and throat (ENT) department due to nasal bleeding. In such cases, simple examination and therapy will lead to misdiagnosis. OBJECTIVE: This study sought to investigate the clinical characteristics, diagnostic methods and treatment of ICA pseudoaneurysms in the sphenoid sinus. METHODS: Various data, including clinical features, imaging examination results, and treatment and prognosis information, were collected and analyzed for 8 patients who visited the Department of Otolaryngology, Head & Neck Surgery of West China Hospital from March 2008 to January 2017. RESULTS: The patients included 6 males and 2 females (ages 16 to 56 years). Repeated epistaxis was a common symptom in six of the eight patients (6/8), whereas monocular blindness and binocular blindness were observed in the other two patients. Head trauma was found to play a role in the induction of ICA pseudoaneurysms, given that five patients (5/8) exhibited a specific history of head injury. CT examination tended to result in misdiagnosis, whereas MRI and digital subtraction angiography (DSA) were helpful for obtaining a definite diagnosis with all diagnoses were confirmed via DSA. Coated stent intervention was performed in five patients, while carotid artery ligation was performed in two patients in emergency situations: one of whom exhibited paraplegia, but recovery was ultimately observed after rehabilitation. Moreover, failure of coated stent intervention in one patient was resolved via additional unilateral common carotid artery ligation. Furthermore, one patient with vision loss experienced vision restoration. One patient discontinued treatment for personal reasons and was lost to follow-up. No recurrence was observed in the other 7 patients. CONCLUSION: ICA pseudoaneurysms in the sphenoid sinus are uncommon. To accurately identify ICA pseudoaneurysms, collaboration between otolaryngologists and imaging specialists is essential. On the other hand, both surgical and interventional treatments can achieve good results; therefore, otolaryngologists should enhance their cooperation with neurosurgery and intervention departments. Accurate diagnosis and rapid treatment are keys to managing ICA pseudoaneurysms.

Sinonasal organising haematoma - a little known entity.

INTRODUCTION: Sinonasal organising haematoma is a recently described, rare, benign inflammatory condition, which closely resembles malignancy in its clinical presentation. OBJECTIVE: To describe the clinical features of organising haematoma and to review the evolution of surgical options successfully used. METHODS: A retrospective review of charts of all patients with a histopathological diagnosis of sinonasal organising haematoma was performed. RESULTS: Six (60%) of the 10 patients were male with a mean age of 47.4 years. All patients had unilateral disease with recurrent epistaxis as the presenting symptom. Maxillary sinus was the most commonly involved sinus. There was no history of trauma in any of the patients. Hypertension (80%) was the most commonly associated comorbidity. Contrast-enhanced CT scan of the paranasal sinuses showed heterogeneous sinus opacification with/without bone erosion. Histopathological examination was diagnostic. Complete endoscopic excision was done in all patients resulting in resolution of the disease. CONCLUSION: Awareness of this relatively new clinical entity and its evaluation and treatment is important for otolaryngologists, maxillofacial surgeons and pathologists alike. Despite the clinical picture of malignancy, histopathological features of benign disease can safely dispel such a diagnosis.

Transarterial Embolization in Maxillofacial Intractable Potentially Life-Threatening Hemorrhage.

PURPOSE: Although transarterial embolization (TAE) of vascular lesions with embolizing agents through angiographic catheters has been used for more than 45 years, reports of life-threatening maxillofacial bleeding are relatively rare and have not been updated. The authors review treatment modalities, present their experience of the past 21 years, and suggest a comprehensive algorithm and guidelines for the use of TAE in the treatment of intractable life-threatening maxillofacial hemorrhage. MATERIALS AND METHODS: This article describes 28 patients treated with TAE for severe bleeding that did not respond to conservative therapies. Of these, 13 had uncontrolled epistaxis, 9 were oncologic patients, 4 were postsurgical patients, and 2 were trauma patients. RESULTS: Details of patients' medical history, failed conservative therapy administered before TAE, imaging results, and blood vessels involved are presented, as are the TAE procedures and materials used, outcome, and complications. All these are discussed in relation to the available updated literature. All 9 oncologic patients (100%) had been treated with chemotherapy before the uncontrolled bleeding, and 7 also had radiotherapy administered to the maxillofacial region. Continuous anticoagulant therapy also seemed to predict such bleeding episodes. TAE resolved the bleeding in all 28 cases and rapidly in 90% of cases. Only in 3 oncologic cases did continued bleeding require 3 to 4 consecutive TAE sessions and combinations of embolizing agents. CONCLUSIONS: The reported high rate of success could be the result of careful techniques, appropriate preoperative imaging, highly professional personnel, and intraoperative and perioperative treatments.

Traumatic Anterior Cerebral Artery Pseudoaneurysmal Epistaxis.

BACKGROUND: Pseudoaneurysmal epistaxis is a rare but emergent condition. We report a case of traumatic anterior cerebral artery pseudoaneurysmal epistaxis and review the published literature. CASE DESCRIPTION: A 49-year-old man sustained severe head trauma. He was diagnosed with multiple skull bone fractures, left subdural hematoma, subarachnoid hemorrhage, pneumocephalus, and right frontal hematoma. Subdural hematoma evacuation was done at a local hospital. In the following months, he experienced repeated epistaxis that required nasal packing to stop the bleeding. Digital subtraction angiography showed an anterior cerebral artery pseudoaneurysm protruding into the posterior ethmoid sinus. Embolization of the aneurysm was performed with microcoils, and the parent artery was occluded by thrombosis. The patient presented 1 month later with another epistaxis episode. Digital subtraction angiography showed recanalization of the parent artery and recurrence of the aneurysm. The parent artery was occluded for the second time with coils and Onyx embolic agent. CONCLUSIONS: Pseudoaneurysmal epistaxis is rare, and this is the first report of an anterior cerebral artery pseudoaneurysm that manifested with epistaxis. Endovascular intervention has become the first choice of treatment for this disease. The high recurrence rate is the main disadvantage of endovascular intervention. Aneurysm trapping with bypass surgery is another treatment option.

Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies.

CONCLUSIONS: Transarterial embolization (TAE) appears to be a safe and effective treatment for patients with intractable epistaxis, despite different etiologies or angiography findings. Idiopathic epistaxis is prone to present with negative angiographic findings. OBJECTIVE: To retrospectively evaluate the safety and effectiveness of TAE for intractable epistaxis, and focus on the factors of etiology and angiographic findings. MATERIALS AND METHODS: From March 2008 to December 2014, the data of 43 patients with intractable bleeding undergoing TAE were reviewed. The outcomes of interventional therapy were assessed according to different etiology (malignant or benign disease) and angiographic finding (positive or negative angiogram). RESULTS: Positive angiographic findings were found in 11 of 12 cases with malignant diseases and 22 of 31 cases with benign diseases, respectively (p = 0.237). Among the 10 cases with negative angiographic findings, the negative angiography rate of idiopathic epistaxis was higher than that of epistaxis with definite etiology (p = 0.003). Bleeding was controlled successfully in all of the 43 patients after embolization. During the mean follow-up period of 24.0 ± 16.7 months, five patients relapsed. No significant difference was found in recurrence rates between malignant and benign diseases or between positive and negative angiography (p = 0.241, p = 0.704, respectively).

The Potential Significance of Concha Bullosa During Nasotracheal Intubation.

The authors experienced a case of severe epistaxis caused by accidental partial middle turbinectomy during nasotracheal intubation, which the patient had bilateral concha bullosa narrowing the nasal airway. Although anesthesiologist checked nasal airway through subjective symptoms and the size of both nostrils, they tend to overlook common anatomic variation, concha bullosa, and can injure turbinate structures. Therefore, preoperative computed tomography images should be carefully evaluated for the possibility of concha bullosa, which narrows nasal airway and induces the traumatic injury or epistaxis during nasotracheal intubation.