Managing recurrent nosebleeds in children: a retrospective review of 718 children attending a nurse-led epistaxis clinic.

OBJECTIVE: This review assessed the effectiveness of the nurse-led children's epistaxis clinic in streamlining patient care and avoiding unnecessary general anaesthesia. METHODS: A retrospective case note review was conducted of children attending the nurse-led epistaxis clinic between 2019 and 2021. RESULTS: A total of 718 children were seen over three years. Twelve (1.7 per cent) had a known coagulopathy. Of the children, 590 (82 per cent) had visible vessels and 29 (4 per cent) had mucosal crusting. Silver nitrate cautery was attempted under topical anaesthesia in 481 children, with 463 (96 per cent) successful cauterisations. Fifteen (3 per cent) were cauterised under general anaesthesia. Of the children, 706 (99 per cent) were prescribed nasal antiseptic preparations; this was the sole treatment for 58 (8 per cent). Blood investigations were requested for eight children (1 per cent) and haematology referral for three (0.4 per cent). CONCLUSION: This is the largest published series of children's nosebleeds. Given the short-lived benefit from cautery, it is suggested that general anaesthesia should not be offered routinely. However, improved haematology referral criteria are required to increase underlying diagnosis.

Comparing recurrence between cautery techniques in pediatric epistaxis.

OBJECTIVE: To compare the risk of recurrent epistaxis between children treated with silver nitrate (SN) in the office or electrocautery (EC) in the operating room (OR). METHODS: Patients aged 2-18 diagnosed with epistaxis (ICD R04.0) in 2018 and treated with SN or EC were retrospectively reviewed. Epistaxis laterality, history of nasal trauma, and personal or family history of a bleeding disorder were recorded. Patients with prior cautery or epistaxis secondary to a procedure were excluded. Recurrence was defined as initial encounter after cautery with documented epistaxis. Patients were followed up into 2022 to track onset of recurrence. Time to recurrence between SN and EC was compared with hazard curves with predictors for recurrence analyzed via Cox's proportional hazard regression. RESULTS: Among 291 patients cauterized for epistaxis, 62 % (n = 181) received SN compared to 38 % (n = 110) who underwent EC. There was significantly higher risk of recurrence when treated with SN compared to EC (Hazard ratio 2.45, 95 % CI: 1.57-3.82, P < 0.0001). Median time to recurrence was not statistically different between techniques (6.39 months (SN) (IQR: 2.33, 14.82) vs. 4.11 months (EC) (IQR: 1.18, 20.86), P = 0.4154). Complication rates were low for both groups (1.16 % (SN) vs. 0 % (EC), P > 0.05). CONCLUSION: Among patients with epistaxis, risk of recurrence is significantly higher in those cauterized with SN compared to EC. Time to recurrence is not significantly different between cautery techniques.

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]. / Grundlagen und Praxis der Anwendung von Nasentamponaden in der endonasalen Chirurgie.

BACKGROUND AND OBJECTIVES: This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice. MATERIALS AND METHODS: Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature. RESULTS AND CONCLUSIONS: Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Anaesthetic management for caesarean section in a patient with hereditary haemorrhagic telangiectasia and severe epistaxis during pregnancy.

A primigravida patient, with a history of hereditary haemorrhagic telangiectasia (HHT) manifesting as nasal angiodysplasia and hepatic arteriovenous malformations (AVM), presented for delivery planning and anaesthetic evaluation at 29 weeks of gestation. She was hospitalised several times during the second and third trimester for serious recurrent epistaxis, leading to severe anaemia. In total, she required the transfusion of 20 units of packed red blood cells during her pregnancy as well as surgical nasal haemostasis under general anaesthesia (GA). The patient was referred to our tertiary centre for delivery. In the context of recurrent severe epistaxis and high cardiac output (due to hepatic AVM) in the third trimester, a multidisciplinary decision was made to plan an elective caesarean section at 35 4/7 weeks combined with nasal packing under GA. This report discusses the implications of HHT, the multidisciplinary planning of the caesarean section, intraoperative anaesthetic management and patient follow-up.

[Strategy of the diagnosis and treatment for epistaxis and guideline for clinical application of MasterPillar].

Epistaxis is a common otorhinolaryngological emergency with complex etiological factors and varied clinical manifestations. The key to epistaxis treatment is accurate diagnosis and adequate hemostasis. Electrocoagulation is a reliable, safe and effective treatment for epistaxis. However, there are still several deficiencies in application of the commonly used electrocoagulation surgical products. This paper introduces a new type of radiofrequency head incorporating the dynamic circulatory functions of drip, irrigation, hemostasis and aspiration. We aim to achieve noninvasive, effective and accurate hemostasis in the treatment of epistaxis or nasal sinus surgery.

[The effect of increased secretory activity of the nasal mucosa on the duration of the recovery period after anterior tamponade with gauze tampons during surgery of the nasal septum]. / Vliyanie kombinirovannoi sekretoliticheskoi i protivovospalitel'noi terapii na techenie vosstanovitel'nogo perioda posle rinoseptoplastiki.

OBJECTIVE: To assess the effect on the duration and course of the nasal mucosa function recovery after anterior nasal packing during surgery involving the nasal septum and inferior nasal conchae combined with concomitant therapy with the herbal medicinal product Sinupret extract (Bionorica SE, Germany). MATERIAL AND METHODS: The study included 25 males aged 18-50 (the main group), permanent residents of the Novosibirsk region diagnosed with deviated nasal septum at least 2 years ago. All patients underwent rhinoseptoplasty with nasal packing with gauze tampons for 24 hours at the clinical base of the Otorhinolaryngology Department of the Novosibirsk State Medical University.Patients of the main group received Sinupret extract 1 tablet BID for 10 days before the planned rhinoseptoplasty and 7 days after the rhinoseptoplasty. Patients in control group 1 (n=16) received Sinupret 2 coated tablets TID for 10 days before the surgery and 7 days after the surgery. Patients in control group 2 (n=16) did not receive secretory therapy in the preoperative and postoperative periods of rhinoseptoplasty. RESULTS: The herbal medicinal product improved nasal breathing. All studied parameters demonstrated the benefit of the treatment including Sinupret extract (p<0.05). On day 5 in patients of the main study group, nasal breathing was normal, and nasal crusting was reduced due to activation of the mucous membrane secretory function. Nasal mucosa ciliary clearance was better in patients in the main group than in patients in the control groups at all stages of the study. Sinupret extract for 10 days before and 5 days after the surgery helps reduce nasal crusting and restore nasal breathing by day 2 and normalizes ciliary clearance by day 5 after nasal packing. CONCLUSION: Due to the wide use of nasal packing with gauze tampons, otorhinolaryngologists commonly administer herbal medicinal products as a means of drug protection of the nasal mucous membrane.

Endoscopic Sphenopalatine Artery Cauterization in the Management of Recurrent Posterior Epistaxis.

Background and Objectives: Endoscopic sphenopalatine artery cauterization (ESPAC) has become a reliable and effective surgical procedure for managing posterior epistaxis. The objectives of our study were to evaluate the effectiveness of ESPAC in the management of posterior epistaxis and the possible factors that lead to the failure of the procedure. Materials and Methods: We performed a retrospective analysis of all patients who underwent ESPAC between 2018 and 2022. We retrospectively reviewed the demographic data, patients' co-morbidities, medical treatment conditions, whether other surgical procedures were performed in addition to the ESPAC, and the success rate of ESPAC. Results: 28 patients were included in our study. After ESPAC, epistaxis was successfully managed in 25 patients (89.28%). Of all patients undergoing ESPAC, three (10.7%) presented re-bleeding. In two patients, we performed an endoscopic revision surgery with re-cauterization of the sphenopalatine foramen area, together with anterior and posterior ethmoidectomy, followed by fat occlusion/obliteration of these sinuses. In one patient, fat obliteration of the anterior and posterior ethmoid was also unsuccessful, and we performed an external carotid artery ligation at the level of the neck with no recurrence afterwards. Conclusions: Endoscopic cauterization of the sphenopalatine artery remains a safe, effective, and reliable surgical procedure in the management of recurrent posterior epistaxis. The use of anticoagulant drugs and the association of hypertension and other heart and liver diseases do not materialize as factors influencing surgical failure.

Factors affecting Naseptin treatment success - A prospective cohort study.

OBJECTIVE: To assess patient factors to predict treatment success of Naseptin for recurrent paediatric epistaxis. METHODS: This prospective cohort study of paediatric patients referred to a tertiary paediatric otolaryngology clinic with recurrent epistaxis treated with Naseptin cream and education. Patients with red flag symptoms and bleeding diathesis were omitted, along with patients with concurrent otolaryngology complaints. Statistical analysis included logistic regression analysis to assess for predictive factors contributing to treatment success. RESULTS: 125 of 210 patients on the waiting list met the inclusion criteria and were given a complete trial of Naseptin. 80.8% (n = 101) of patients found that the frequency and severity of epistaxis had reduced, with the remaining 19.2% (n = 24) reporting that the episodes of epistaxis remained the same and required further management (i.e., silver nitrate cautery). Five patients (4%) reported minor side effects (skin irritation etc.) with no significant adverse events reported. CONCLUSION: We found that Naseptin is a safe, well-tolerated treatment that should be trialled in most cases of recurrent paediatric epistaxis. Most children will benefit from it with complete epistaxis cessation or at least reduced frequency and severity.

A low-cost prosthetic orbital simulation model for endoscopic anterior ethmoid artery ligation.

OBJECTIVE: This study aimed to develop and evaluate a low-cost orbital prosthesis for simulation of endoscopically assisted intra-orbital anterior ethmoidal artery ligation. METHODS: A low-cost orbital prosthesis was built and evaluated by ENT surgical trainees. Feedback was given following the assessment in the form of a face validity questionnaire. RESULTS: Results were scored on a Likert scale of 1-7 (low to high). Trainees had limited exposure to the procedure (40 per cent) and predominantly low levels of confidence (mean, 3.67) that correlated with a lack of first-hand experience. The anatomy and likeness to human tissue of the prosthesis were both ranked highly, with mean scores of 5.0 and 4.93, respectively. CONCLUSION: The results of this study support the idea that a simple anatomical prosthesis for the simulation of endoscopic anterior ethmoidal artery ligation can be created with potential value to otolaryngology surgical training. To the authors' knowledge, this is the first documentation of simulated surgical epistaxis management using an artificial anatomical model.

Transcaruncular anterior ethmoidal artery ligation.

Recurrence of epistaxis after ligation or embolization of the sphenopalatine artery may require ligation of the ipsilateral anterior ethmoidal artery, which cannot be embolized because of the risk to the ophthalmic artery. We describe a transconjunctival transcaruncular approach that allows reliable low-risk access to the anterior ethmoidal artery. This technique offers a minimally invasive approach to the surgical site, without unsightly scar.

Comparison of the Ankaferd Blood Stopper Tampon and the Merocel Nasal Tampon after Septoplasty Surgery.

OBJECTIVE: In this study, we aimed to investigate the effects of the Ankaferd Blood Stopper (ABS) on nasal bleeding, pain, eating disorders, and sleeping problems in patients undergoing septoplasty. METHODS: The prospective study included 100 patients who underwent septoplasty surgery. Patients were divided into two groups based on the chronological order of hospital admission: Group I was administered the ABS, and Group II was administered a standard Invotec Merocel nasal tampon. In both groups, the intensity of pain experienced by patients postoperatively during tampon use and tampon removal was assessed using the visual analogue scale (VAS). RESULTS: A significant difference was found between the two groups with regard to VAS scores assessed during tampon use. In the ABS group, the VAS scores assessed during tampon use were significantly lower, and the incidence of nasal obstruction, eating disorders, dripping-type bleeding before tampon removal, and sleeping problems was significantly lower in the ABS group than in the Merocel group. CONCLUSIONS: The ABS may be a viable alternative to other nasal packs, as it did not lead to a significant reduction in postoperative patient comfort during tampon use and caused a lower incidence of postoperative pain, eating disorders, sleeping problems, and nasal obstruction than standard Merocel tampons. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Multi-layer reconstruction of skull base after endoscopic transnasal surgery for invasive pituitary adenomas.

OBJECTIVE: To explore the efficacy of multi-layer skull base reconstruction after endoscopic transnasal surgery for invasive pituitary adenomas (IPAs). CLINICAL RATIONALE FOR THE STUDY: Skull base reconstruction for IPAs. MATERIAL AND METHODS: This retrospective analysis involved 160 patients with IPAs who underwent operations from October 2018 to October 2020. All patients were diagnosed with IPAs by pituitary enhanced magnetic resonance imaging, and all tumours were confirmed to be Knosp grades 3a, 3b, or 4. The experimental group and the control group comprised 80 patients in each, and we used different methods to reconstruct the skull base in each group. The comparison indicators included cerebrospinal fluid leakage, sellar floor bone flap (or middle turbinate) shifting, delayed healing of the skull base reconstructed tissue, nasal discomfort, and epistaxis. We used the chi-square test, and p < 0.05 was considered statistically significant. RESULTS: In the experimental group, cerebrospinal fluid leakage occurred intraoperatively in 73 patients, two of whom had cerebrospinal fluid leakage postoperatively. Brain CT 12 months postoperatively showed no sellar floor bone flap (or middle turbinate) shifting. Endoscopic transnasal checks performed seven days after surgery showed that the skull base reconstructed tissue had healed in 74 patients and had failed to heal in six. However, endoscopic transnasal checks showed that all six of these patients' pedicled nasoseptal flaps had healed well by 14 days after surgery. Other sequelae comprised nasal discomfort in four patients, and epistaxis in four. In the control group, cerebrospinal fluid leakage occurred intraoperatively in 71 patients, 14 of whom had cerebrospinal fluid leakage postoperatively. Brain CT 12 months postoperatively showed floor bone flap (or middle turbinate) shifting in 12 patients. Endoscopic transnasal checks performed seven days after surgery showed that the skull base reconstructed tissue had healed in 65 patients. In 12 patients, pedicled nasoseptal flaps had healed well by 14 days after surgery, while the remaining three patients required reoperation. Other sequelae comprised nasal discomfort in five patients, and epistaxis in six. CONCLUSIONS: This new method of multi-layer skull base reconstruction could play an important role in endoscopic transnasal IPA surgery.

How we do it: using the nasion as a landmark for identifying the anterior ethmoidal artery.

BACKGROUND: In severe refractory epistaxis, the anterior ethmoidal artery may need to be ligated. Previously described endonasal or transorbital approaches are not always effective, or they have suboptimal aesthetic outcomes. This paper describes a safe and effective surgical technique, with a consistent landmark allowing quick identification. TECHNICAL DESCRIPTION: A transcaruncular incision is made, oriented medially in the direction of the medial orbital wall towards the level of the nasion. Once onto bone, a subperiosteal plane is developed and an endoscope is used to dissect posteriorly at the level of the nasion, until the anterior ethmoidal artery is identified, and subsequently ligated. CONCLUSION: The nasion is an easy, constant landmark to use for ligation of the anterior ethmoidal artery in refractory epistaxis. The traditional method of identifying the anterior ethmoidal artery is not applicable or constant enough for use during the transorbital approach. The described technique avoids injury to surrounding structures and has a satisfactory aesthetic outcome.

The Arterial Pattern of the Upper Nasal Septum (S-Point) and Potential Role in Severe Epistaxis.

OBJECTIVES: The previously described S-point, corresponds to the medial projection of the middle turbinate axilla in the superior nasal septum and has been identified as a common source of severe epistaxis. The objective is to define the anatomical patterns of vascularization of the S-point area that could explain its clinical relevance. METHODS: Thirty-three nasal septums of latex-injected formalin-embalmed and fresh human cadaveric heads were dissected to analyze the arterial arrangement of the S-point area. Measurements and patterns of vascularization were described. RESULTS: The S-point area, was consistently surrounded by a single or multiple arterial anastomotic arches consistently formed superiorly by the anterior ethmoidal and posterior ethmoidal artery branches, and inferiorly by the posterior septal artery. The caliber of the arterial arches was typically larger than the caliber of the arterial branches supplying them. A single arch was present in 36.3% of septums, and multiple arches in 63.6%. The mean distance from the S-point to the anterior limit of the arch was 9 mm, to the posterior arch when the present was 3 mm, to the superior limit 6 mm, to the inferior limit 6 mm, and to the nasal roof was 10 mm. CONCLUSION: This study demonstrates the dense arterial configuration of the S point area, which is characterized by a single or multiple vascular arches of greater caliber than the branches of origin. This finding could explain why the S-point area is a frequent source of epistaxis, and guide its surgical cauterization when an obvious vascular ectasia is not visualized. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2075-2080, 2023.

Strategy of the diagnosis and treatment for epistaxis and guideline for clinical application of MasterPillar / 临床耳鼻咽喉头颈外科杂志

Epistaxis is a common otorhinolaryngological emergency with complex etiological factors and varied clinical manifestations. The key to epistaxis treatment is accurate diagnosis and adequate hemostasis. Electrocoagulation is a reliable, safe and effective treatment for epistaxis. However, there are still several deficiencies in application of the commonly used electrocoagulation surgical products. This paper introduces a new type of radiofrequency head incorporating the dynamic circulatory functions of drip, irrigation, hemostasis and aspiration. We aim to achieve noninvasive, effective and accurate hemostasis in the treatment of epistaxis or nasal sinus surgery.

[Comprehensive assessment of the respiratory function of nasal packs with airway tubes]. / Kompleksnaya otsenka respiratornoi funktsii «dyshashchikh¼ vnutrinosovykh tamponov.

Intranasal packs with breathing tubes are one of the possible methods of postoperative management of patients after endonasal surgery. The role of these devices is to provide the possibility of nasal breathing of patients to facilitate the course of the postoperative period. However, the possibility of providing proper nasal breathing with these devices has not been studied. The aim of the work is to study the calculated and clinical possibilities of nasal breathing when using intranasal packs with breathing tubes after endonasal surgical interventions. MATERIAL AND METHODS: We studied packs with air tubes from two manufacturers: Medtronic and Spiggle & Theis. During the experimental part, measurements of the air tubes and their study using acoustic rhinometry were carried out. In the clinical part, there were two groups of patients with different types of tampons and control group of volunteers with normal nasal breathing, the total number of participants was 45 people. All patients of groups 1 and 2 underwent septoplasty, bilateral lower partial conchotomy. In the postoperative period, rhinomanometry, rhinoflowmetry, a study of the duration of nasal breathing, and a subjective assessment of nasal breathing were performed. RESULTS: According to measurements and acoustic rhinometry, the airway tubes of the tampons have a cross-sectional area that is more than 4 times smaller than the narrowest part of the nasal cavity in healthy volunteers. According to the results of a clinical study, the tampons in question are not able to provide a level of nasal breathing comparable to normal, even after clearing the lumen by a doctor. Medtronic packs provide somewhat better airway function due to the larger internal diameter of the tubes, but also do not create conditions for satisfactory nasal breathing. CONCLUSION: Improving the respiratory function of tampons in the future can be achieved by increasing the internal lumen of the breathing tubes while maintaining comfort of use.

Efficacy and safety of a hypertonic nasal wash solution containing sea algae extracts in patients that underwent surgical correction of a deviated nasal septum and radiofrequency turbinate volume reduction.

OBJECTIVE: The objective of this study was to evaluate efficacy and safety of a Hypertonic Seawater Solution (2.3% NaCl) containing brown and blue-green Algae (HSS-A) in comparison to Isotonic Saline Solution (ISS) regarding the improvement of nasal breathing in patients that have undergone surgical correction of a deviated nasal septum and radiofrequency turbinate volume reduction. PATIENTS AND METHODS: A total of 101 individuals were enrolled in the study (HSS-A: 57; ISS: 44). Nasal breathing was evaluated using a Peak Nasal Inspiratory Flow (PNIF) measurement device at four timepoints: prior to surgical intervention (up to 30 days pre-surgery) and at the 2nd, 10th and 20th postoperative days. On the 20th postoperative day, patients also answered a Nasal Surgical Questionnaire (NSQ) evaluating breathing ability and overall satisfaction from the use of both nasal sprays. RESULTS: No significant differences were observed in PNIF measurements between groups at different points. On the 20th postoperative day, NSQ analysis showed that ISS-treated patients had more frequently moderate nasal bleeding compared to the HSS-A group (85.7% vs. 14.3%, p=0.038). No other statistically significant differences were observed between groups. When NSQ parameters were evaluated in a binary mode, a trend for reduced crusting scores was seen in the HSS-A group (15.9% vs. 35.5% in ISS, p=0.053). No safety concerns were reported throughout the study. CONCLUSIONS: In patients that have undergone surgical correction of a deviated nasal septum and radiofrequency turbinate volume reduction, PNIF values did not differ significantly in patients receiving HSS-A and ISS solutions. Nasal bleeding was more frequent in ISS patients versus HSS-A. Overall, both solutions provided symptomatic relief and use satisfaction in the absence of side effects.

Recurrent Epistaxis Throughout the Lifespan: A Clinical Review.

Epistaxis is a common otolaryngologic complaint experienced by 60 percent of the U.S. population and can be the result of either local or systemic disturbance. Most nosebleeds arise from an anastomotic region along the anterior nasal septum known as Kiesselbach's plexus. However, roughly ten percent of nosebleeds originate posteriorly from the sphenopalatine branch of the maxillary artery. Posterior nosebleeds can be more difficult to control and are frequently associated with systemic derangement. Patients presenting with a nosebleed should first be assessed for airway patency and hemodynamic stability. Once the patient is confirmed to be acutely stable, pre-existing clots should be cleared from the nasal cavity and the nasal alae should be compressed against the septum for ten to fifteen minutes. Application of a topical vasoconstricting agent can also be considered at this time. If the nosebleed persists and the location of the bleed can be visualized, chemical or electrical cautery can be used. If the site of the bleed cannot be identified, nasal packing materials in the form of lubricant-impregnated ribbon gauze or readymade nasal packing devices can be placed to tamponade the bleed. Following failure of these conservative treatment modalities, otolaryngologist consultation should be sought. Next steps in management may include arterial ligation or embolization.

[Recurrent epistaxis associated with Randu-Osler disease, requiring ligation of the external carotid arteries on both sides]. / Retsidiviruyushchee nosovoe krovotechenie na fone bolezni Randyu­Oslera, vyzvavshee neobkhodimost' perevyazki naruzhnykh sonnykh arterii s obeikh storon.

A rare clinical case of recurrent nosebleeds associated with Randu-Osler disease, in which drug, hemostatic, transfusion therapy and combined nasal tamponade were ineffective, required ligation of the external carotid arteries on both sides, is presented.