Key words
Epistaxis; Big Data; Distributed Map; Nasal Endoscope;Bipolar
Radiofrequency
To the Editor:
Epistaxis is a frequently encountered otolaryngologic emergency,
occurring in up to 60% of the general population, with one in ten of
those affected seeking for medical attention. It accounts for one in 200
emergency department visits1. Here are a few classic
cases in nearly a year in our hospital. We received and cured three
classic cases referred by lower hospitals, who were elderly patients
with recurrent epistaxis (Fig. 1). All the patients failed to stop
bleeding after repeated anterior and posterior nostril packing and even
interventional embolization of internal maxillary artery from external
carotid artery, with a total cost of more than 50,000 yuan. At the first
visit, the patients had anemic appearance and were suffering from pain,
emotional anxiety due to anterior and posterior nostril packing.
According to the ”distributed map” we drew before, the bleeding point
was quickly located in both patients, showing that the bleeding site was
the second most common location of refractory epistaxis. Stopped
bleeding via bipolar radiofrequency ablation under nasal endoscope
without any stuffing. The treatment takes only 3 minutes and costs
hundreds. The treatment is satisfying, cheap and time-saving. Here, it
is difficult to pack sufficiently because of middle turbinate blocking.
Additionally, it is supplied by the posterior ethmoidal artery, so the
interventional embolization of the external carotid artery system is
ineffective.
Previously, we searched the Chinese literature from 2009 to 2019 with
the key words ”intractable epistaxis, concealed epistaxis, refractory
epistaxis and severe epistaxis”. Besides, the same type of epistaxis
patients in our hospital were analyzed. After classifying the most
common concealed sites of epistaxis, we figured out that
the frequency of bleeding areas came
as follows: the vault of inferior nasal meatus in 3843 cases(31.58%),
the olfactory sulcus of middle turbinate in 3606 cases(29.63%), the
posterior regions of middle meatus in 1398 cases(11.49%), the regions
of deviation of nasal septum in 1094 cases(8.99%), the foremost regions
of nasal cavity in 775 cases(6.37%), and the others or uncertain in
1453 cases(11.94%) Finally, we drew a concise ”distributed map” of
epistaxis on the basis of the concealed bleeding areas and offending
vessels (Fig.2).
In addition, we summarized the optimal diagnosis and treatment of
refractory epistaxis. Firstly, maximum nasal contraction and topical
anesthesia under nasal endoscope (1:1000 epinephrine combined with 1%
tetracaine cotton patch; pure epinephrine cotton patch if necessary).
Then, sufficient clearance of bleeding with a suitable sucker. Sometimes
the fracture displacement of the middle / inferior turbinate was
required. Then, from the surface to the deep interior, we search the
bleeding sites based on the ”distributed map” in turn as follows: the
foremost regions of nasal cavity, the regions of common nasal meatus and
nasal septum; the posterior regions of middle meatus (medial turbinate
fracture to inside), the olfactory sulcus area of nasal septum (middle
turbinate fracture to outside) and the vault of inferior nasal meatus
(inferior turbinate fracture to inside).
Locate the bleeding site accurately
and stop bleeding via bipolar radiofrequency ablation under nasal
endoscope without nasal packing. Patients who were not clear were
treated with interventional examination and embolization as appropriate,
and were followed up for 1 to 3 months.
As far as I’m concerned, we think that some epistaxis is difficult to
treat because it is unable to define the bleeding site and the
traditional packing has an anatomical ”blind spot”. In this paper, we
consider this kind of epistaxis as refractory epistaxis, which refers to
a large amount of blood gushing out from the front nose or oropharynx,
but routine anterior rhinoscopy or nasal endoscopy can’t identify the
bleeding site, and conventional nasal packing is often ineffective as
well. The main responsible vessels are sphenopalatine artery, anterior
and posterior ethmoidal artery. The key is to find the bleeding site
accurately and stop the bleeding effectively. However, it is not easy.
First of all, the middle turbinate, inferior turbinate and deviation of
the nasal septum block the searching areas described above. Thus, it is
difficult to identify the bleeding point without rich experience and
illuminating system. In this study, the hidden bleeding sites and
responsible blood vessels were drawn into a ”distributed map” of
epistaxis (Fig.2). It shows the two closely adjacent anatomical areas of
the lateral wall of the nasal cavity and the nasal septum as well as the
situation of occult epistaxis by the effect of turning pages like a
book. We aim to take the picture as a guide to search for key bleeding
sites, in order to improve management of epistaxis for young doctors and
reduce blind nasal packing.
For epistaxis, nasal packing is still a common treatment in ENT
emergency, especially in county hospitals. However, the traditional
nasal packing not only brings great pain to patients, but also has poor
hemostatic effect, as well as serious complications such as nasal
mucosal injury, nasal septum perforation, nasal alar injury and so
on5. Therefore, in accordance with Nikolaou,
G6, we strongly suggest that in the era of nasal
endoscope and Precision Medicine, we should optimize the mode of
diagnosis and treatment of epistaxis, sticking to the principle of ”from
surface to deep, from simple to complex, from non-invasive to invasive”,
focusing on searching for bleeding sites in concealed areas based on the
map. We search for bleeding sites under
nasal endoscope and stop bleeding, so
as to avoid nasal packing as far as possible and improve the quality of
life of patients on the basis of improving the level of diagnosis and
treatment.