Cost-effectiveness of trans-nasal endoscopic sphenopalatine artery ligation vs arterial embolisation for intractable epistaxis: Long-term analyses.

OBJECTIVES: Trans-nasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolisation both provide excellent success rates for intractable epistaxis. Recent economic models suggest that TESPAL could be a cost-saving strategy. Our main aim was to perform cost-effectiveness analyses on TESPAL compared with embolisation to treat patients with epistaxis. DESIGN: We performed retrospective, monocentric, comparative analyses on patients referred to our centre and treated with embolisation or TESPAL. SETTING: This economic evaluation was carried out from a payer's perspective (ie French National Health Insurance) within a time horizon of 12 months. PARTICIPANTS: Thirty-seven TESPAL procedures and thirty-nine embolisation procedures to treat intractable epistaxis were used in the analyses. MAIN OUTCOME MEASURES: The primary outcome is presented as the cost per 1% of non-recurrence. Effectiveness was defined as avoiding recurrence of epistaxis during the 1-year follow-up. Cost estimates were performed from the payer's perspective. RESULTS: Hospitalisation costs were higher for embolisation compared with TESPAL (5972 vs 3769 euros). On average, hospitalisation costs decreased by 41% when a patient was treated by TESPAL compared with an embolisation strategy (P = 0.06). The presence of comorbidities increased hospitalisation costs by 79% (P = 0.04). TESPAL enabled 1867€ to be gained in intractable epistaxis. CONCLUSIONS: The outcomes from our decision model confirm that TESPAL is more cost-effective for patients with intractable epistaxis.

Inpatient Pediatric Epistaxis: Management and Resource Utilization.

OBJECTIVES: Epistaxis is a common condition that rarely warrants hospital admission in the pediatric population, making its inpatient management difficult to study. This study aims to use a nationwide database to analyze trends in the treatment of pediatric patients admitted with epistaxis and determine factors impacting total charges. METHODS: The latest (2012) version of the Kids' Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality was used to identify weighted discharges with the primary diagnosis of epistaxis. Information regarding demographics, comorbidities, treatment, hospital burden, and other admission details were obtained. Linear regression was used to analyze factors suspected to increase cost. RESULTS: Among 372 weighted discharges, the mean age was 9.68 years (SD = 5.79), and 60.0% were male. The most common comorbidities were thrombocytopenia, von Willebrand disease, and chronic sinusitis. The majority of admissions with epistaxis (56.7%) did not undergo any procedure to control epistaxis. Mean total charges was $30 208 (SD = $62 683) with a mean length of stay of 2.46 days (SD = 3.31). Independent predictors of increased charges included longer length of stay, admission from the emergency department, and median household income within the third quartile for patients' ZIP codes. Midwest hospital region independently predicted decreased charges. Having a procedure to control epistaxis did not significantly impact cost. CONCLUSIONS: Pediatric epistaxis admissions often do not require long hospital stays or procedural control of the bleed. However, significant charges are incurred treating epistaxis. Awareness of factors impacting these charges can potentially improve resource utilization.

Epidemiology of epistaxis in the emergency department of a southern European tertiary care hospital.

OBJECTIVE: Epistaxis is the most common rhinological emergency seen in the emergency department. The purpose of this study was to evaluate epidemiological data of epistaxis in a southern European tertiary care hospital. METHODS: A retrospective study was conducted during the period between January 2009 and December 2015. We analyzed the distribution by cross-referencing the demographic variables, destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding localization and treatment) and health-care costs with the disease. RESULTS: Epistaxis accounted for approximately 1 in 30 visits to the ED and 77 out of a population of 100,000 was served by that ED. Overall, 71,624 patients were treated and 2371 patients presented with epistaxis (3.31%). One-thousand three-hundred and twenty-seven cases were male and 1044 female (p <.001). The mean age was 56 years (±26). Age distribution was bimodal, with peaks among those <10 years and >70 (p <.001). Epistaxis was more common in the winter months (p < 0.001). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient (1.9%) services. Hospitalization was more frequent between the ages of 60 and 80 years (p =.029), and the major comorbidity was hypertension (47.8%). Medication interfering with haemostasis was documented in 30.4%. Most inpatient epistaxis was managed in a non-interventional manner and only. 5% of patients needed surgery. The mean total health-care cost was 69.8 € per episode. CONCLUSION: Emergency epistaxis was more frequent in men, the elderly, patients with underlying comorbidities, during the winter months, and showed a higher risk of referral and hospitalization with increasing age (as a result of an aging population in western countries). The main hospital expenses for epistaxis are related to hospitalization and health care costs.

Economic evaluation of floseal compared to nasal packing for the management of anterior epistaxis.

OBJECTIVES/HYPOTHESIS: To evaluate the cost-effectiveness of Floseal, a topically applied hemostatic agent, and nasal packing for the management of epistaxis in Canada. STUDY DESIGN: Outcomes research, a cost-utility analysis. METHODS: We developed a Markov model to compare the costs and health outcomes of Floseal with nasal packing over a lifetime horizon from the perspective of a publicly funded healthcare system. A cycle length of 1 year was used. Efficacy of Floseal and packing was sought from the published literature. Unit costs were gathered from a hospital case costing system, whereas physician fees were extracted from the Ontario Schedule of Benefits for Physician Services. Results were expressed as an incremental cost per quality-adjusted life year (QALY) gained. A series of one-way sensitivity and probabilistic sensitivity analyses were performed. RESULTS: From the perspective of a publicly funded health are system, the Floseal treatment strategy was associated with higher costs ($2,067) and greater QALYs (0.27) than nasal packing. Our findings were highly sensitive to discount rates, the cost of Floseal, and the cost of nasal packing. The probabilistic sensitivity analysis suggested that the probability that Floseal treatment is cost-effective reached 99% if the willingness-to-pay threshold was greater than $120,000 per QALY gained. CONCLUSIONS: Prior studies have demonstrated Floseal to be an effective treatment for anterior epistaxis. In the Canadian healthcare system, Floseal treatment appears to be a cost-effective treatment option compared to nasal packing for anterior epistaxis. LEVEL OF EVIDENCE: 2c Laryngoscope, 1778-1782, 2018.

Intranasal cautery for the management of adult epistaxis: systematic review.

BACKGROUND: Cauterisation techniques are commonly used and widely accepted for the management of epistaxis. This review assesses which methods of intranasal cautery should be endorsed as optimum treatment on the basis of benefits, risks, patient tolerance and economic assessment. METHOD: A systematic review of the literature was performed using a standardised methodology and search strategy. RESULTS: Eight studies were identified: seven prospective controlled trials and one randomised controlled trial. Pooling of data was possible from 3 studies, yielding a total of 830 patients. Significantly lower re-bleed rates were identified (p < 0.01) using electrocautery (14.5 per cent) when compared to chemical cautery (35.1 per cent). No evidence suggested that electrocautery was associated with more adverse events or discomfort. Limited evidence supported the use of a vasoconstrictor agent and operating microscope during the procedure. The included studies had considerable heterogeneity in terms of design and outcome measures. CONCLUSION: Consistent evidence suggests that electrocautery has higher success rates than chemical cautery, and is not associated with increased complications or patient discomfort. Lower quality evidence suggests that electrocautery reduces costs and duration of hospital stay.

Management of Epistaxis - A Single Centre Experience and Economic Considerations.

Epistaxis represents the most common ENT emergency and its management has been a focus of audit recently, with consideration given to the associated economic burden. The aim of our study is to evaluate the management of epistaxis in terms of treatments used, duration of stay, recurrence and cost. A retrospective review of hospital inpatient enquiry (HIPE) data from a single secondary referral centre was undertaken during a four year period. Four hundrefd and thirty-four patients were identified. The majority (n= 262, 60.3%) were male and the average age was 64.2 years. The vast majority (n=362, 83.4%) were managed non-operatively. Only 15 patients (3.4%) were managed surgically. The average length of stay was 2.5 days and did not vary greatly between the treatment groups. The recurrence rate was 8.2% (n=36). Approximate costs of packing vs EUA and cautery suggest that packing alone is more economical but more data is needed to fully compare the options.

Successful Implementation of a Clinical Care Pathway for Management of Epistaxis at a Tertiary Care Center.

OBJECTIVE: We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost. STUDY DESIGN: Single prospective analysis with historical control. SETTING: Tertiary academic hospital. SUBJECTS AND METHODS: Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing. RESULTS: Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented. CONCLUSIONS: Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures.

Cost of management in epistaxis admission: Impact of patient and hospital characteristics.

OBJECTIVES/HYPOTHESIS: To investigate patient and hospital characteristics associated with increased cost and length of stay in the inpatient management of epistaxis. STUDY DESIGN: Retrospective cross-sectional study of the 2008 to 2012 National (Nationwide) Inpatient Sample. METHODS: Patient and hospital characteristics of epistaxis admissions were analyzed. Multiple linear regression analysis was used to ascertain variables associated with increased cost and length of hospital stay. Variables significantly associated with high cost were further analyzed to determine the contribution of operative intervention and total procedures to cost. RESULTS: A total of 16,828 patients with an admitting diagnosis of epistaxis were identified. The average age was 67.5; 52.3% of the patients were male; 73.3% of the patients were Caucasian; and 70.7% of the hospital stays were government funded. The average length of stay was 3.24 days, and average hospitalization cost was $6,925. Longer length of stay was associated with black race, alcohol abuse, sinonasal disease, renal disease, Medicaid, and care at a northeastern U.S. hospital. Increased hospitalization costs of > $1,000 were associated with Asian/Pacific Islander race; sinonasal disease; renal disease; top income quartile; and care at urban teaching, northeastern, and western hospitals in the United States. High costs were predicted by procedural intervention in patients with comorbid alcohol abuse, sinonasal disease, renal disease, patients with private insurance, and patients managed at large hospitals. CONCLUSION: Although hospitalization costs are complex and multifactorial, we were able to identify patient and hospital characteristics associated with high costs in the management of epistaxis. Early identification and intervention, combined with implementation of targeted hospital management protocols, may improve outcomes and reduce financial burden. LEVEL OF EVIDENCE: 2C.

Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis.

IMPORTANCE: For patients with epistaxis in whom initial interventions, such as anterior packing and cauterization, had failed, options including prolonged posterior packing, transnasal endoscopic sphenopalatine artery ligation (TESPAL), and embolization are available. However, it is unclear which interventions should be attempted and in which order. While cost-effectiveness analyses have suggested that TESPAL is the most responsible use of health care resources, physicians must also consider patient risk to maintain a patient-centered decision-making process. OBJECTIVE: To quantify the risk associated with the management of intractable epistaxis. DESIGN AND SETTING: A risk analysis was performed using literature-reported probabilities of treatment failure and adverse event likelihoods in an emergency department and otolaryngology hospital admissions setting. The literature search included articles from 1980 to May 2014. The analysis was modeled for a 50-year-old man with no other medical comorbidities. Severities of complications were modeled based on Environmental Protection Agency recommendations, and health state utilities were monetized based on a willingness to pay $22 500 per quality-adjusted life-year. Six management strategies were developed using posterior packing, TESPAL, and embolization in various sequences (P, T, and E, respectively). MAIN OUTCOMES AND MEASURES: Total risk associated with each algorithm quantified in US dollars. RESULTS: Algorithms involving posterior packing and TESPAL as first-line interventions were found to be similarly low risk. The lowest-risk approaches were P-T-E ($2437.99 [range, $1482.83-$6976.40]), T-P-E ($2840.65 [range, $1136.89-$8604.97]), and T-E-P ($2867.82 [range, $1141.05-$9833.96]). Embolization as a first-line treatment raised the total risk significantly owing to the risk of cerebrovascular events (E-T-P, $11 945.42 [range, $3911.43-$31 847.00]; and E-P-T, $11 945.71 [range, $3919.91-$31 767.66]). CONCLUSIONS AND RELEVANCE: Laddered approaches using TESPAL and posterior packing appear to provide the lowest risk. Combining risk and cost-effectiveness perspectives, we recommend a laddered approach to intractable epistaxis with TESPAL first, followed by either embolization or posterior packing.

Cost-effectiveness analysis of endoscopic sphenopalatine artery ligation vs arterial embolization for intractable epistaxis.

IMPORTANCE: Intractable epistaxis is a common otolaryngology emergency. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular arterial embolization both provide excellent success rates, and therefore the decision to choose one over the other can be challenging. OBJECTIVE: To aid in decision making by evaluating the cost-effectiveness of TESPAL vs endovascular arterial embolization for intractable epistaxis. DESIGN, SETTING, AND PARTICIPANTS: Economic evaluation using a decision tree model with a 14-day time horizon for emergency department consultations for patients with intractable epistaxis defined as persistent bleeding despite bilateral anterior nasal packing. The economic perspective was the health care third-party payer. Effectiveness and probability data were obtained from the published medical literature. Costs were obtained from the published literature, the Centers for Medicare & Medicaid Services database, and the Healthcare Cost and Utilization Project database. Multiple sensitivity analyses were performed, including a probabilistic sensitivity analysis. Comparative treatment groups were (1) TESPAL and (2) embolization. INTERVENTIONS: TESPAL and endovascular arterial embolization. MAIN OUTCOME AND MEASURES: The primary outcome was the incremental cost-effectiveness ratio (ICER) for successful control of epistaxis. RESULTS: The reference case demonstrated that the embolization strategy was more effective but more costly compared with the TESPAL strategy: $22,324.70 per 0.70 effectiveness compared with $12,484.14 per 0.68 of effectiveness, respectively. The embolization vs TESPAL ICER was $492,028, which is higher than any willingness to pay (WTP), suggesting that TESPAL is the cost-effective decision. The sensitivity analysis demonstrated a 77.6% and 73.7% certainty that the TESPAL strategy is cost-effective at WTP thresholds of $10,000 and $50,000, respectively. CONCLUSIONS AND RELEVANCE: Results from this economic evaluation suggest that when both TESPAL and arterial embolization are viable options (based on patient and institutional factors), TESPAL is the more cost-effective treatment strategy for patients with intractable epistaxis.

[Epistaxis and anticoagulation - a medical and economic challenge?]. / Epistaxis bei Antikoagulation - eine klinische und ökonomische Herausforderung?

BACKGROUND: According to recent statistics more and more elderly patients are hospitalized due to epistaxis and need anticoagulation. Aim of the present study was to investigate if it was more complex to treat anticoagulated patients than non-anticoagulated patients, if these patients needed a longer hospital stay and to characterize the study population in terms of the various applied therapeutic methods. METHODS: Retrospective study, collecting clinical data of all in-patients treated between 1.1.2007 to 1.8.2011 at an ENT-Department of an University Clinic due to epistaxis. RESULTS: Of 656 patients 265 were not anticoagulated, 391 were anticoagulated. The mean patients' age increased statistically significant. Patients without anticoagulation were significantly younger than patients with anticoagulation. The duration of the hospitalization differed significantly between the groups, with the longest for patients treated with warfarin (5.4 days). 71 patients underwent surgical treatment of epistaxis (cautery of the sphenopalatine artery or anterior ethmoid artery). CONCLUSION: During the study period an increasing number of more elderly patients needed hospitalization due to epistaxis. The duration of hospitalization differed significantly between the groups, with longer stays for the anticoagulated patients. Currently, treatment of epistaxis patients however is reimbursed independently of the presence of comorbidities or anticoagulation therapy. For the further development of the German DRG System a new split of the epistaxis DRG should be considered.

Early versus delayed treatment of primary epistaxis in the United States.

BACKGROUND: Epistaxis treatment is variable. This study sought to determine demographic, management, and outcome differences in patients treated with early (<24 hours) vs late ligation or embolization. METHODS: This study was a retrospective review of the 2008 to 2010 Nationwide Inpatient Sample (NIS) for patients admitted with epistaxis. Hospital and patient demographics and outcomes were compared between early vs late surgical intervention. Multivariate models analyzed the economic measures (length of stay and hospital charges) between early and late treatment. RESULTS: Of 57,039 cases of primary epistaxis identified in the NIS database, 4662 (8.2%) received ligation or embolization. There was no significant influence of early treatment on the odds of mortality, stroke, blindness, or blood transfusion. The total charges and length of stay were significantly reduced for early surgical intervention using embolization or ligation. Two predictors of early intervention were common to both ligation and embolization: (1) weekday admission (p < 0.001; odds ratio [OR], 1.856), and (2) admission to a non-Midwest hospital (p < 0.001; OR, 3.276). Additional predictors of early intervention with ligation included: (1) admission to an urban hospital; (2) admission to a nonteaching hospital; (3) black race; and (4) income >$39,000. The odds of embolization within the first 24 hours were lowered with each additional chronic condition (p = 0.017; OR, 0.912). CONCLUSION: Efficient and effective healthcare delivery is paramount given the potentially life-threatening nature of epistaxis and the current economic environment. Delayed intervention significantly increased hospital charges and length of stay. Rapid identification and treatment may prove to be a cost-saving measure.

Discomfort and costs in epistaxis treatment.

Epistaxis is a very common ENT event. Apart from the effectiveness of the different treatment options, the discomfort and the financial burden are of great importance. It has been the aim of this study to obtain data regarding the discomfort/pain of the epistaxis treatments and to calculate the financial burden. During the period between April 2010 and July 2011 epistaxis patients at our hospital had the opportunity to rate the discomfort/pain they experienced during their treatment on a 0-10 VAS scale. The costs of epistaxis treatments were calculated in an extended cohort. 84 VAS scores in 61 patients were acquired and the costs of treatment were calculated in 96 patients. The lowest VAS scores were found in chemical and electric coagulation with 1.5 and 2.0, respectively, followed by surgery (3.0), Rapid Rhino packing (6.0) and balloon pack (7.5). The costs of treatments depended on whether the treatment was in an out- or inpatient setting. Surgery was not significantly more expensive than packing methods in the inpatient setting. Anterior epistaxis could be managed by local coagulation with an acceptable impact/cost ratio. At our institution, surgery was the most cost effective and the least troublesome procedure in posterior bleedings, preceded by Rapid Rhino packing if required.

Cost-effectiveness of endoscopic sphenopalatine artery ligation versus nasal packing as first-line treatment for posterior epistaxis.

BACKGROUND: The advent of endoscopic sphenopalatine artery ligation (ESPAL) for the control of posterior epistaxis provides an effective, low-morbidity treatment option. In the current practice algorithm, ESPAL is pursued after failure of posterior packing. Given the morbidity and limited effectiveness of posterior packing, we sought to determine the cost-effectiveness of first-line ESPAL compared to the current practice model. METHODS: A standard decision analysis model was constructed comparing first-line ESPAL and current practice algorithms. A literature search was performed to determine event probabilities and published Medicare data largely provided cost parameters. The primary outcomes were cost of treatment and resolution of epistaxis. One-way sensitivity analysis was performed for key parameters. RESULTS: Costs for the first-line ESPAL arm and the current practice arm were $6450 and $8246, respectively. One-way sensitivity analyses were performed for key variables including duration of packing. The baseline difference of $1796 in favor of the first-line ESPAL arm was increased to $6263 when the duration of nasal packing was increased from 3 to 5 days. Current practice was favored (cost savings of $437 per patient) if posterior packing duration was decreased from 3 to 2 days. CONCLUSION: This study demonstrates that ESPAL is cost-saving as first-line therapy for posterior epistaxis. Given the improved effectiveness and patient comfort of ESPAL compared to posterior packing, ESPAL should be offered as an initial treatment option for medically stable patients with posterior epistaxis.

Epistaxis simulator: an innovative design.

INTRODUCTION: This article provides directions for creating a cost-effective epistaxis simulator using an existing CPR Trainer and expired medical supplies. METHODS: An epistaxis simulator was created and presented to attending Emergency Medicine physician-educators at Evanston Northwestern Healthcare as an adjunct for procedural training. The materials and methods for making the nosebleed simulator are outlined in this article. RESULTS: We created an epistaxis model utilizing an older CPR Trainer, i.v. tubing, and a bag of normal saline. The model provided realistic epistaxis. This simulator is able to simulate a nosebleed's response to proper positioning of nasal packing by creating hemostasis. CONCLUSIONS: Existing task trainers can be modified to provide learners with novel features that can expand the number of simulated clinical conditions.

[Practical aspects regarding endoscopic treatment for epistaxis]. / Aspectos prácticos sobre el tratamiento endoscópico de la epistaxis.

INTRODUCTION: A prospective study is presented to evaluate some practical and financial aspects regarding surgical endoscopic ligation or cauterization of sphenopalatine (SP) and anterior ethmoidal (AE) arteries performed to control posterior nasal bleeding. PATIENTS AND METHODS: 35 patients admitted at the ENT ward between 2004 and 2006 were included in the study, and distributed into two groups depending on the protocol applied in each case. Until March 2005 the surgery was performed if there was failure or insecurity of the posterior packing, and since that date a substitutive surgical protocol (not including posterior packing) was applied. RESULTS: 82.9% of the patients were male, with a mean age of 55.74 years and a left bleeding in a 60% of the cases. Ligature/cauterization was performed on SP in 28 (80%) patients, on AE in 4 (11.4%), and on both arteries in 3 cases (8.6%). 38.7% of the SP approach only one sphenopalatine foramen was observed, through which an only branch of the artery passed; 42% of the cases two branches passed through an only foramen, and in 19.3% two or more branches were present, breaking into the nose through two or more independent clefts. AE was intradural in 3 cases, intranasal attached to the cranial base in other 3 and intranasal detached to the cranial base in 1 patient. Besides, highly significant differences were found between the two protocols, observing a mean reduction of hospital stay of 3.1 days, which throws up savings of 939.3 euros per patient. DISCUSSION AND CONCLUSIONS: Surgical treatment for epistaxis has proved to be effective (91.2% in our experience) and safe, determining an important reduction in hospital stay and avoiding the morbility of posterior packing. Accurate knowledge of the anatomy of the arteries implied and specific actuation upon the correct bleeding territory are essential to perform this surgery.

Aspectos prácticos sobre el tratamiento endoscópico de la epistaxis / Practical aspects regarding endoscopic treatment for epistaxis

Introducción: Presentamos un estudio prospectivo para valorar algunos aspectos técnicos y económicos sobre el tratamiento quirúrgico de la epistaxis posterior mediante ligadura/cauterización de las arterias esfenopalatina (SP) y etmoidal anterior (EA). Pacientes y métodos: 35 pacientes ingresados en nuestro servicio por epistaxis posterior y sometidos a cirugía para su control entre 2004 y 2006, fueron incluidos y distribuidos en dos grupos según el protocolo de actuación empleado en cada caso. Hasta marzo de 2005 se empleó la cirugía por fracaso o inestabilidad del taponamiento posterior, y a partir de esa fecha un protocolo de cirugía sustitutiva (la cirugía sustituyó al taponamiento posterior). Realizamos un estudio comparativo de los dos protocolos y discutimos aspectos prácticos sobre esta cirugía. Resultados: El 82,9% de los pacientes fueron hombres, con una edad media de 55,74 años y un sangrado procedente del lado izquierdo en el 60% de los casos. En 28 (80%) pacientes se actuó sobre la SP, en 4 (11,4%) sobre la EA y en 3 (8,6%) sobre ambas. En el 38,7% de los casos se observó un solo orificio esfenopalatino por el que salía una sola rama bifurcada a los pocos milímetros de su salida, en el 42% de los casos un orificio por el que salían dos ramas, y en el 19,3% se objetivaron dos o más ramas que salían de dos o más orificios distintos. La EA fue intradural en 3 casos, intranasal en íntima relación con la base del cráneo en otros 3, y totalmente intranasal separada de la base del cráneo en 1 caso. Además, se encontraron diferencias altamente significativas entre los dos protocolos, observándose una reducción media de la estancia hospitalaria de 3,1 días con la cirugía sustitutiva, lo que supone un ahorro estimado de 939,3 euros por paciente. Discusión y conclusiones: El tratamiento quirúrgico de la epistaxis ha demostrado ser eficaz (91,2% en nuestra serie) y seguro en el manejo de estos pacientes, determinando una reducción importante de su estancia hospitalaria y eliminando la morbilidad de los taponamientos posteriores. El adecuado conocimiento de la anatomía de las arterias implicadas en estas técnicas y la actuación específica sobre el territorio sangrante son de vital importancia para la correcta realización de este tipo de cirugía

Introduction: A prospective study is presented to evaluate some practical and financial aspects regarding surgical endoscopic ligation or cauterization of sphenopalatine (SP) and anterior ethmoidal (AE) arteries performed to control posterior nasal bleeding. Patients and methods: 35 patients admitted at the ENT ward between 2004 and 2006 were included in the study, and distributed into two groups depending on the protocol applied in each case. Until March 2005 the surgery was performed if there was failure or insecurity of the posterior packing, and since that date a substitutive surgical protocol (not including posterior packing) was applied. Results: 82.9% of the patients were male, with a mean age of 55.74 years and a left bleeding in a 60% of the cases. Ligature/cauterization was performed on SP in 28 (80%) patients, on AE in 4 (11.4%), and on both arteries in 3 cases (8.6%). 38.7% of the SP approach only one sphenopalatine foramen was observed, through which an only branch of the artery passed; 42% of the cases two branches passed through an only foramen, and in 19.3% two or more branches were present, breaking into the nose through two or more independent clefts. AE was intradural in 3 cases, intranasal attached to the cranial base in other 3 and intranasal detached to the cranial base in 1 patient. Besides, highly significant differences were found between the two protocols, observing a mean reduction of hospital stay of 3.1 days, which throws up savings of 939.3 euros per patient. Discussion and conclusions: Surgical treatment for epistaxis has proved to be effective (91.2% in our experience) and safe, determining an important reduction in hospital stay and avoiding the morbility of posterior packing. Accurate knowledge of the anatomy of the arteries implied and specific actuation upon the correct bleeding territory are essential to perform this surgery

Inpatient management of epistaxis: outcomes and cost.

OBJECTIVE: Evaluate treatments for epistaxis. STUDY DESIGN AND SETTING: Retrospective review of Nationwide Inpatient Sample (1998-2000). RESULTS: A total of 9778 admissions with admitting diagnosis "epistaxis" were identified. Among admissions involving 1 treatment, 454 (9.6%) received arterial ligation, 94 (2.0%) embolization, and 4188 (88.4%) nasal packing. There were no differences in length of stay, transfusions, complications, or deaths between groups (all P > 0.05). Mean total hospital charges were USD 6,282 for the packing group, USD 12,805 for the ligation group, and USD 17,517 for the embolization group; differences between ligation and packing groups, and embolization and packing groups demonstrated significance ( P < 0.05). CONCLUSIONS: Nasal packing is used commonly for epistaxis that requires inpatient management. Although embolization and arterial ligation are associated with higher hospital charges, complications, transfusion rates, and lengths of stay are similar. Further studies are needed to quantify other outcome measures, such as recurrence rates and patient quality of life. SIGNIFICANCE: Nasal packing is associated with lower hospital charges and similar complication rates as arterial ligation or embolization.

Economic analysis of the treatment of posterior epistaxis.

BACKGROUND: The aim of this study was to compare the economic impact of controlling posterior epistaxis by transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular embolization. METHODS: We conducted a retrospective chart review of patients undergoing treatment of posterior epistaxis by either TESPAL or embolization. International Classification of Diseases 9 code 784.7 (epistaxis) was the initial screen followed by common procedural terminology codes for TESPAL and angiography with embolization. The total charges and direct costs for TESPAL and endovascular embolization were determined. An unpaired Student's t-test was used to evaluate statistical significance. RESULTS: Analysis revealed 25 patients that met inclusion criteria. The mean total charge was $14,088 for embolization and $7561 for TESPAL. The differences were statistically significant (p < 0.00006). Costs, defined as reimbursement by third-party payers and direct payments, varied widely and their difference did not reach statistical significance in this sample. CONCLUSION: Our data established no economic advantage for angiography and, in fact, show a trend toward this treatment being more expensive than TESPAL. TESPAL is a procedure that can be performed quickly and on an outpatient basis without the need for angiography equipment or expertise. Additionally, the procedure provides the advantage of a comprehensive endoscopic nasal evaluation for ruling out tumors or other intranasal lesions. With equal efficacy, at least equal costs and equal risk, and additional diagnostic advantages, TESPAL is a more rational treatment for posterior epistaxis.