Head Jiri
J. Vitek,
MD,
patients
pathic
epistaxis
Intractable Therapy’
with intractable idiowere treated with endovascular therapy. Embolization of the internal maxillary artery controlled the epistaxis in 87% of the patients, and the success rate was increased to 97% after supplemental embolization of the facial artery. The only complication observed was fransient postembolization hemiparesis, which occurred in one of the 30 patients. Intractable idiopathic epistaxis is defined as epistaxis of unknown cause that is refractory to nasal packing.
Such
epistaxis
of the
internal
maxillary
artery and the ethmoid arteries. An alternative approach is performance of endovascular therapy. In our opinion, embolization is a safe and effective procedure when it is carried out by appropriately trained personnel. In most patients, its performance requires use of only neuroleptanalgesia; surgery can be avoided, and the duration of hospitalization is significantly shortened. We recommend that embolization be adopted as the primary modality for the treatment of idiopathic intractable epistaxis. Index terms: Arteries, therapeutic 261.1299 #{149}Nose, abnormalities, Nose, hemorrhage, 261.492 Radiology
1991;
E
is a common
PISTAXIS
experienced
event
that
is
by approximately
60% of the population. Fortunately, only 6% of these cases require medical treatment. Most epistaxis originates in the readily accessible anterior septal area (i). Anterior epistaxis is usually a self-limiting event that does
not require intervention (2). Posterior and superior epistaxis, however, occur in relatively inaccessible regions and usually require active treatment (2).
Most
cases
trobled
with
are
successfully
conservative
blockade, 261.492
is defined
con-
treatment
as intractable
babbe and quired.
gicab
further This
or uncontrol-
intervention
intervention
is recan
be sur-
or endovascular.
In 1974, Sokoboff duced the method
et al (3) intro-
of embobization,
describing
its use
intractable
epistaxis.
in two
patients
In spite
with
of the
ease and effectiveness of this treatment, endovascular therapy has not been accepted as the primary treat-
ment
modality
when
epistaxis
is re-
fractory to conventional, nonsurgical therapies. The purpose of this study was to establish a protocol for endovascular therapy of intractable idiopathic epistaxis, to determine its efficacy, and to identify potential complications.
From tractable diobogy
AND
to 1990, 35 patients epistaxis were referred Service at this institution
with
in-
to the Rafor performance of angiography and endovascular therapy. All of the patients were treated From
the Department
of Radiology,
Univer-
sity ofAlabama at Birmingham, 619 5 19th St. Birmingham, AL 35233. Received March28, 1991; revision requested May 1; revision received May 17; accepted May 22. Address reprint requests to the author. C RSNA, 1991
initially
nor nasal
with
anterior
packing.
and
poste-
In four patients
the
epistaxis was posttraumatic case it was due to hereditary
and in one tebangi-
ectasia;
excluded
from
classified
as
these
patients
this study. Thirty patients
having
idiopathic
who
were were
epistaxis
were
the
study.
Of
these
accepted
30 patients,
21
were men and nine were women, with an average age of 62 years (range, 28-83 years). The treatment protocol is summarized
in the
Figure.
The angiographic procedures
and endoascular
were
performed
with
neuro-
leptanabgesia, except in two cases in which the procedures were performed with the patient under general anesthesia. The femoral approach was used in all cases. Cutaneous nitroglycerine was applied to all patients. The posterior and anterior packing was never removed prior to the embolization. carotid arteries,
The
common
and
internal
later the external caon the side of the clinically and
rotid artery determined epistaxis, were catheterized and investigated at angiography by using a 5-F catheter. Once it was determined that there were no vascular anomalies in the territory of either the external or internal carotid arteries, a variable-stiffness catheter was placed coaxially in the pterygopalatine segment of the internal maxillary artery, and angiography was performed to determine if there were any large anastomoses to the internal carotid or ophthalmic arteries. In two patients the pterygopabatine portion of the internal maxillary artery was directly catheterized with the 5-F catheter. The pterygopalatine segment of the internal maxillary artery was then embolized with shredded gelatin sponge (Gelfoam; Upjohn, Kalamazoo, Mich) mixed with
was easily
METHODS
1988
into
50% saline and 50% resulted in a sludge
181:113-116
MATERIALS
I
Radiology
Epistaxis:
and insertion of posterior nasal packing, but occasionally refractory cases occur. If the posterior nasal packing fails to stop the bleeding, the epistaxis
is commonly
treated with surgical intervention, including ligation of the terminal segments
Neck
PhD
Idiopathic Endovascular Thirty
and
injected
stiffness syringe.
catheter
stiffness
catheter
contrast of gelatin
through by using
agent. sponge
This that
the variablea i-mL
or 3-mL
The progress of embolization was monitored with fluoroscopy and control angiography. After this stage of embolization was completed, several larger plugs of gelatin sponge were injected through the same catheter into the terminal internal maxillary artery. After completion of this second stage of embobization the nasal packing was removed and the nasal pathway checked for bleeding. If the nasal pathway stayed dry for i5 minutes, the variablewas
removed
and
a con-
trol arteriogram of the external carotid tery was obtained. If necessary the ipsilateral facial artery also underwent
arem-
bolization.
113
All the digital
studies
were
equipment
traction,
performed
capable
real-time
subtraction,
mapping.
Most
of the
obtained
in only
the
with
of instant
arteriograms lateral
sub-
and road were
projection.
RESULTS In 26 patients the epistaxis was controbbed after embobization of the internab maxillary artery. In four patients the epistaxis continued, and the nasal pathway was partially repacked. The facial artery was catheterized with the variable-stiffness
catheter
distal
a.
b.
C.
d.
e.
f.
to the
inferior labial artery. In two cases the arteriogram showed a bleeding point anteriorly and laterally on the nasal ala (Figure), and in two cases the arteriogram was normal. In all four patients the facial artery was
embobized
with
gelatin
sponge
and then the nasal packing was removed. In three of these patients the pathway was completely dry. In one patient there was minimal oozing from underneath the middle turbinate. This patient’s nose was repacked. The packing was removed in 12 hours, and the nasal pathway was dry. Twenty-eight patients were discharged 24-48 hours after embobization.
One
multiple mained
patient
other in the
experienced
who
experienced
medical hospital.
problems reOne patient
postembobization
hemi-
paresis but recovered completely 48 hours. None of these patients returned with recurrent bleeding.
in has
DISCUSSION Epistaxis can be a life-threatening event. There is a traditional, ascending scale of treatment for epistaxis, starting with performance of anterior nasal packing, endoscopicably guided ebectrocoagubation, posterior nasal packing,
the
and
internal
nation
transantral
maxillary
with
ligation
ligation
artery of the
of
in combiethmoid
arteries. Currently, endovascular embolization has an adjunctive robe in the treatment of cases of nasal hemorrhage that are refractory to conventional management. two
In i974 cases
Sokoloff et ab (3) described of epistaxis treated with
embobization. nasal packing nal maxillary with
gelatin
stressed catheter bleeding ing was
In both cases after the was removed, the interartery was embolized sponge;
the
#{149} Radiology
h.
Steps in endovascular treatment of idiopathic epistaxis. (a) Angiogram of common carotid artery shows internal maxillary artery (arrowhead). (b) Angiogram of internal carotid artery shows ophthalmic artery (arrow). (c) Angiogram of external carotid artery shows internal maxillary artery (arrowhead). (d) Angiogram shows the sphenopalatine segment of the internal maxillary artery with variable-stiffness catheter in place. (e, f) Angiograms show progressive steps in embolization of the internal maxillary artery (arrowhead in f). (g) Angiogram
shows shows
embolization of the internal maxillary artery the facial artery (arrow) (Figure continues).
(arrowhead)
terminated.
(h) Angiogram
authors
the importance of placing the as close as possible to the site. Because the nasal packremoved prior to the embolization, aspiration of blood resulted. This report was followed by a series 114
g.
of articles (i,2,4-i7), most of which describe solitary cases but some of which describe larger series of embobizations in cases of idiopathic epistaxis.
In i979 Robertson and Reardon (6) performed embolization in iO patients with epistaxis by using gelatin sponge bleeding recurred in two. In i979 Riche et al (7) and in i980 Merland et October
1991
aspiration,
alar
necrosis,
infections. It can tory compromise, sodes of nocturnal tion.
Early
and
also result hypoxia, oxygen
removal
of the
sinus
in respiraand epidesaturapostnasal
packing is a necessity (1). Posterior nasal packing has a failure rate of 25%-52% 20%-68%
ternal formed (18),
and a complication (i9,2i). Ligation
maxillary artery has been persince the middle of the 1960s with
(1,20,21)
a failure
and
40%-47%
(continued). the facial
(i) Selective angiogram artery with variable-stiffness
ter in place. Arrow
indicates
bleeding.
control (k)
angiogram Postembolization
0)
Postembolization shows the facial
artery.
control artenogram nal maxifiary artery
shows cathe-
shows
embobized
(arrowhead)
and
facial
arteries.
54 patients
results
with
in a series
epistaxis
who
of
were
treated with embolization. Eight patients had idiopathic epistaxis. Those authors concluded that preembolization angiography did not play a major role in the determination of the bleeding site and that embolization is the most
effective
treatment,
ated with fewer gation (9). In 1988 Wehrli their experience
risks
being
than
associ-
arterial
li-
experienced complications ranging from facial paralysis and soft-tissue necrosis to swelling of the cheek. Therefore surgery was recommended as the
primary
therapy
for
intractable
epistaxis. In 1990
reported lization There
Strutz
and
Schumacher
a 90% success as the treatment is incomplete
(1)
rate for embofor epistaxis. agreement
in
the literature concerning the defimtion of intractable epistaxis, specifically whether it means the need for posterior nasal packing (1) or the failure of such packing. We define intractable epistaxis as the failure of nasal packing and the need for further therapy. There are multiple causes of intractable epistaxis, including facial trauma, postsurgical complications, vascular abnormalities in the territory of the internal and external carotid arteries (such as aneurysms and arteVolume
181
#{149} Number
1
heavy
smokers,
The
intractable epiof the patients
In most
cases
is not determined; these cases fall into the category of idiopathic epistaxis. Some of these patients are hypertensive, ics, but viduals bleed.
et al (16) published with embolizations
in i9 patients with staxis. Fifty percent
riovenous malformations), expanding lesions (juvenile angiofibromas, malignant expanding lesions, etc), hemostatic disorders, and hereditary hemorrhagic telangiectasia. of epistaxis the cause
most who
or borderline
alcohol-
of them are healthy indihave a sudden nose-
treatment
for
epistaxis
of estab-
lished origin is dictated by the problems associated with the underlying cause, and therefore the endovascular therapy performed in such cases is different from that performed in cases of idiopathic epistaxis. Therefore, we restricted our report of endovascubar therapy to treatment of cases of intractable expistaxis of idiopathic origin. It should be noted, however, that regardless of the cause, treatment of intractable epistaxis requires performance
of angiography.
As mentioned previously, well-established ascending treatment for epistaxis; the
there is a scale of treatment ligation of
culminates with transantral the internal maxillary and bilateral ethmoid arteries if nasal packing (18-20). There are several problems
associated nal
packing.
with The
performance procedure
fails
of choais not
only painful and stressful, but prolonged packing is associated
(i9-2i).
use of with
This
maxillary
If surgery most always phy. not
al (9) published
of 9.5%-i5.0%
rate
of
approach
is
contraindicated in approximately of patients because of the presence antrum
fails, the referred
Usually
epistaxis,
k.
rate
a complication
a hypopbastic
inter-
rate of of the in-
(22).
patients are for angiogra-
in cases
al-
of idiopathic
angiography
to determine
6% of
is performed the
bleeding
point
but rather to rube out the presence of unusual causes of epistaxis, such as vascular abnormalities or technical failures of clipping of the internal maxillary artery (9,14,23,24); this is especially true when the patient is not bleeding actively during angiography. To remove the packing prior to angiography is unwise and dangerous because of the risk of aspiration of blood (3,14) and agitation of the patient, who may become uncooperative. Endovascubar therapy with embolization
is the
diagnostic
angiography.
In 1979
bogicab
Lasjaunias
sequel
to
et al (24)
de-
scribed
the radioanatomic basis and protocol for arterial embolization as treatment for epistaxis and stressed the importance of the preembolization arteriogram for evaluation of dangerous anastomosis between the branches of the external and internal carotid arteries. Davis (14) in i986 recommended a similar protocol for angiography and embolization that was applicable to all causes of epistaxis but was mainly developed for use in cases of juvenile angiofibromas. Both Lasjaunias et al and Davis recommended that embolization be performed as distally as possible. Davis occasionally used a coaxial catheter system to enter the distal segment of the internal maxillary artery or other branches of the external carotid artery. Our protocol and technique, including both angiography and embolization,
and easy accurately (1).
In the
are
simple,
to perform. pinpoint patient
efficient,
quick,
The clinician the bleeding population
can side
reported
herein, there was no doubt about the side of the hemorrhage in 27 cases. In three patients the epistaxis was “bilateral.” Radiology
#{149} 115
Embobization was performed in all patients with use of shredded Gelfoam. Gelatin sponge, a readily available embobic agent that is easily injected through the variable-stiffness catheter, is a “smooth” embolic agent
nopabatine maxillary
with
ping,
particles
embolized tion
that
travel
vessels.
with
distally
Effective
gelatin
sponge
into
provide
was who
immediately
after
complication
sis after
tery;
emboliza-
rate
3%, consisting experienced
in this
of one transient
embolization
study
patient hemipare-
of the
artery.
Several
neurobogic and associated with ment of epistaxis
facial
judgment
the
authors
ar-
to ca-
describe
other complications embolization for treat(12,13,i5,i6). In my complications
are
gen-
erabby caused by overembolization, use of particles that are too small, by reflux into the internal carotid tery.
If the
arteries with
internal
are
especially
permanent
embolization
postembolization
eventual ischemic If the emboli are
by and ar-
or facial
overembolized,
a more
agent,
maxillary
pain
necrosis too small,
and
can occur. the arteri-
29 (97%),
ping
of the
ethmoid
bolization.
most
likely
to the
ies and epistaxis.
116
The
only
medial
not
arteries
ethmoid and
collateral lateral
the primary If the branches
#{149} Radiology
em-
and
reported mance
more
Efficient occurrence
ar10.
procedure.
modality epistaxis.
ii.
12.
13.
3.
14.
15.
In
5.
6.
super
16.
17.
18.
#{149}
(ASS.)
Wyck
LG, Vinuela
F, Heeneman
H.
embobization for severe J Otolaryngol 1982; 11:271-274.
epistaxis. Metson R, Hanson DC. nerve paralysis following
epistaxis.
Bilateral facial embolization
Otolaryngol
Surg 1983; 91:299-303. DeVries N, Vershuis Facial nerve paralysis
Head
RJ, ValkJ, following
epistaxis.
for
Neck
Snow GB. emboliza-
J Laryngol
Otol
1986; 100:207-210. Davis KR. Embolization of epistaxis juvenile nasopharyngeal angiofibromas. AJNR 1986; 7:953-962. Parnes LS, Heeneman H, Vinuela F. cutaneous embolization for control of blood circulation. Laryngoscope 1987; Wehrli
M, Lieberherr
perselective
for idio-
selective
J Neuroradiol
and
Pernasal 97:
1312-1315.
results
Strutz J, Schumacher M. Uncontrollable epistaxis. Arch Otolaryngol Head Neck Surg 1990; 116:697-699. Breda SD, Choi IS, Persky NS, Weiss M. Embolization in the treatment of epistaxis after failure of internal maxillary artery ligation. Laryngoscope 1989; 99:809-815. SokoloffJ, Wickbom I, McDonald D, Brahme F, Goergen IC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974; iii: 285-287. Djindjian R, Merland ll Theron J.
L’arteriographie
Van
tion for severe
19.
2.
II.
treatment 1979;
6:207-220. Wills P1, Russell RD. Percutaneous embolization to control intractable epistaxis. Laryngoscope 1979; 89:1385-1388. Merland JJ, MelkiJP, Chiras J, Riche MC, Hadjean E. Place of embolization in treatment of severe epistaxis. Laryngoscope 1980; 90:1694-1704. DeFilipp CJ, Steffey D, Rubinstein M, Drake A, Koopmann CH. The role of angiography and embolization in the man-
severe
herein, I suggest that perforof embolization not be limited
treatment intractable
epistaxis.
in the
agement of recurrent epistaxis. Otolaryngol Head Neck Surg 1988; 99:597-600.
a simpler,
and
Melki JP, Merland
of embolization
Therapeutic
embolizaof this
with
efficient
9.
within
branch of the posterior to carry blood into the
experience
8.
References
pathways arter-
maxillary
to use in the medically compromised patient who is unable to undergo surgicab intervention (1,7,9,14). Instead, embolization should become the pri-
are
source of of the sphe-
If the
proximally
embolization of the
4.
after
septal artery
safer,
never clip-
arteries
internal
occluded
view
after
septab
of the
are
derwent
procedure.
and
happens.
role
of severe
anasto-
source of epistaxis. Findings in this study differ from findings that were published previousby. In this study more patients un-
1.
artery
opposite
ethmoid arteries. tion prevents the
ful injection of emboli, especially during embobization of the facial artery, and usually occurs at the end of the
embolization of both the internal maxilbary and facial arteries. We needed to proceed with surgical
of the
nasal cavity and then into the patent medial and lateral nasal branches of the sphenopalatine artery. Thus, clipping of the internal maxillary artery facilitates epistaxis arising from the
mary pathic
In this series it is of interest that the ethmoid arteries were not involved in epistaxis. Of 30 patients treated with embolization, 26 (87%) were cured after embolization of the internal
site
the sphenopabatine fossa, this gives the impetus for the anterior nasal branch of the anterior ethmoid artery
oles can be occluded. This results in ischemic symptoms including facial paralysis. Reflux into the internal carotid artery results from overly force-
maxillary
the
and the ethmoid
we attributed this condition of emboli into the internal
reflux rotid
to
the
Riche MC, Chirasj, The
moses with the ethmoid arteries, these vessels will be eliminated as the source of epistaxis. In surgical clip-
tery
several days of relative ischemia, which allows the bleeding mucosa heal. The nasal packing can be removed tion. The
beyond
branches
embolizacan
tion
7.
segment of the internal artery undergo emboliza-
et
l’embolisation dans les epistaxis graves. Ann Otol Laryngol (Paris) 1976; 93:23-33. Kendall B, Moselev I. Therapeutic embolization of the external carotid artery tree. Neurol Neurosurg Psychiatry 1977; 40:937950. Robertson GH, Reardon EJ. Angiography and embolization of the internal maxillary artery for posterior epistaxis. Arch Otolaryngol 1979; 105:333-337.
21.
22.
23.
24.
A.
Su-
epistaxis: Otolaryngol 1988; 13:415-420. Hicks JN, VitekJJ. Transarterial embolization to control posterior epistaxis. Laryngoscope 1989; 99:1027-1029. ChandlerJR, Sevrins AJ. Transantral ligation of the internal maxillary artery for epistaxis. Laryngoscope 1965; 75:11511160. Schaitkin B, Strauss M, Houck JK, Hershey PA. Epistaxis: medical surgical therapy-
a comparison
20.
U, Valavanis
embolization for intractable experience with 19 patients. Clin
of efficacy,
complications
and
economic considerations. Laryngoscope 1987; 97:1392-1397. Metson R, Lane R. Internal maxillary artery ligation for epistaxis: an analysis of failures. Laryngoscope 1988; 98:760-764. Wang L, Vogel DM. Posterior epistaxis: comparison of treatment. Otolaryngol Head Neck Surg 1981; 89:1001-1006. Pearson BW, MacKensie RG, Goodman WS. The anatomical basis of transantral ligation of the maxillary artery in severe epistaxis. Laryngoscope 1969; 79:969-984. Rosnagle RS, Allen WE III, Kier EL, Rochman LG. Use of selective arteriography in the treatment of epistaxis. Arch Otolaryngol 1980; 106:137-142. Lasjaunias P, Marsot-Dupuch J, Doyon D. The radio-anatomical basis of arterial embolization for epistaxis. J Neuroradiol 1979; 6:45-52.
October
1991
J. Vitek,
MD,
patients
pathic
epistaxis
Intractable Therapy’
with intractable idiowere treated with endovascular therapy. Embolization of the internal maxillary artery controlled the epistaxis in 87% of the patients, and the success rate was increased to 97% after supplemental embolization of the facial artery. The only complication observed was fransient postembolization hemiparesis, which occurred in one of the 30 patients. Intractable idiopathic epistaxis is defined as epistaxis of unknown cause that is refractory to nasal packing.
Such
epistaxis
of the
internal
maxillary
artery and the ethmoid arteries. An alternative approach is performance of endovascular therapy. In our opinion, embolization is a safe and effective procedure when it is carried out by appropriately trained personnel. In most patients, its performance requires use of only neuroleptanalgesia; surgery can be avoided, and the duration of hospitalization is significantly shortened. We recommend that embolization be adopted as the primary modality for the treatment of idiopathic intractable epistaxis. Index terms: Arteries, therapeutic 261.1299 #{149}Nose, abnormalities, Nose, hemorrhage, 261.492 Radiology
1991;
E
is a common
PISTAXIS
experienced
event
that
is
by approximately
60% of the population. Fortunately, only 6% of these cases require medical treatment. Most epistaxis originates in the readily accessible anterior septal area (i). Anterior epistaxis is usually a self-limiting event that does
not require intervention (2). Posterior and superior epistaxis, however, occur in relatively inaccessible regions and usually require active treatment (2).
Most
cases
trobled
with
are
successfully
conservative
blockade, 261.492
is defined
con-
treatment
as intractable
babbe and quired.
gicab
further This
or uncontrol-
intervention
intervention
is recan
be sur-
or endovascular.
In 1974, Sokoboff duced the method
et al (3) intro-
of embobization,
describing
its use
intractable
epistaxis.
in two
patients
In spite
with
of the
ease and effectiveness of this treatment, endovascular therapy has not been accepted as the primary treat-
ment
modality
when
epistaxis
is re-
fractory to conventional, nonsurgical therapies. The purpose of this study was to establish a protocol for endovascular therapy of intractable idiopathic epistaxis, to determine its efficacy, and to identify potential complications.
From tractable diobogy
AND
to 1990, 35 patients epistaxis were referred Service at this institution
with
in-
to the Rafor performance of angiography and endovascular therapy. All of the patients were treated From
the Department
of Radiology,
Univer-
sity ofAlabama at Birmingham, 619 5 19th St. Birmingham, AL 35233. Received March28, 1991; revision requested May 1; revision received May 17; accepted May 22. Address reprint requests to the author. C RSNA, 1991
initially
nor nasal
with
anterior
packing.
and
poste-
In four patients
the
epistaxis was posttraumatic case it was due to hereditary
and in one tebangi-
ectasia;
excluded
from
classified
as
these
patients
this study. Thirty patients
having
idiopathic
who
were were
epistaxis
were
the
study.
Of
these
accepted
30 patients,
21
were men and nine were women, with an average age of 62 years (range, 28-83 years). The treatment protocol is summarized
in the
Figure.
The angiographic procedures
and endoascular
were
performed
with
neuro-
leptanabgesia, except in two cases in which the procedures were performed with the patient under general anesthesia. The femoral approach was used in all cases. Cutaneous nitroglycerine was applied to all patients. The posterior and anterior packing was never removed prior to the embolization. carotid arteries,
The
common
and
internal
later the external caon the side of the clinically and
rotid artery determined epistaxis, were catheterized and investigated at angiography by using a 5-F catheter. Once it was determined that there were no vascular anomalies in the territory of either the external or internal carotid arteries, a variable-stiffness catheter was placed coaxially in the pterygopalatine segment of the internal maxillary artery, and angiography was performed to determine if there were any large anastomoses to the internal carotid or ophthalmic arteries. In two patients the pterygopabatine portion of the internal maxillary artery was directly catheterized with the 5-F catheter. The pterygopalatine segment of the internal maxillary artery was then embolized with shredded gelatin sponge (Gelfoam; Upjohn, Kalamazoo, Mich) mixed with
was easily
METHODS
1988
into
50% saline and 50% resulted in a sludge
181:113-116
MATERIALS
I
Radiology
Epistaxis:
and insertion of posterior nasal packing, but occasionally refractory cases occur. If the posterior nasal packing fails to stop the bleeding, the epistaxis
is commonly
treated with surgical intervention, including ligation of the terminal segments
Neck
PhD
Idiopathic Endovascular Thirty
and
injected
stiffness syringe.
catheter
stiffness
catheter
contrast of gelatin
through by using
agent. sponge
This that
the variablea i-mL
or 3-mL
The progress of embolization was monitored with fluoroscopy and control angiography. After this stage of embolization was completed, several larger plugs of gelatin sponge were injected through the same catheter into the terminal internal maxillary artery. After completion of this second stage of embobization the nasal packing was removed and the nasal pathway checked for bleeding. If the nasal pathway stayed dry for i5 minutes, the variablewas
removed
and
a con-
trol arteriogram of the external carotid tery was obtained. If necessary the ipsilateral facial artery also underwent
arem-
bolization.
113
All the digital
studies
were
equipment
traction,
performed
capable
real-time
subtraction,
mapping.
Most
of the
obtained
in only
the
with
of instant
arteriograms lateral
sub-
and road were
projection.
RESULTS In 26 patients the epistaxis was controbbed after embobization of the internab maxillary artery. In four patients the epistaxis continued, and the nasal pathway was partially repacked. The facial artery was catheterized with the variable-stiffness
catheter
distal
a.
b.
C.
d.
e.
f.
to the
inferior labial artery. In two cases the arteriogram showed a bleeding point anteriorly and laterally on the nasal ala (Figure), and in two cases the arteriogram was normal. In all four patients the facial artery was
embobized
with
gelatin
sponge
and then the nasal packing was removed. In three of these patients the pathway was completely dry. In one patient there was minimal oozing from underneath the middle turbinate. This patient’s nose was repacked. The packing was removed in 12 hours, and the nasal pathway was dry. Twenty-eight patients were discharged 24-48 hours after embobization.
One
multiple mained
patient
other in the
experienced
who
experienced
medical hospital.
problems reOne patient
postembobization
hemi-
paresis but recovered completely 48 hours. None of these patients returned with recurrent bleeding.
in has
DISCUSSION Epistaxis can be a life-threatening event. There is a traditional, ascending scale of treatment for epistaxis, starting with performance of anterior nasal packing, endoscopicably guided ebectrocoagubation, posterior nasal packing,
the
and
internal
nation
transantral
maxillary
with
ligation
ligation
artery of the
of
in combiethmoid
arteries. Currently, endovascular embolization has an adjunctive robe in the treatment of cases of nasal hemorrhage that are refractory to conventional management. two
In i974 cases
Sokoloff et ab (3) described of epistaxis treated with
embobization. nasal packing nal maxillary with
gelatin
stressed catheter bleeding ing was
In both cases after the was removed, the interartery was embolized sponge;
the
#{149} Radiology
h.
Steps in endovascular treatment of idiopathic epistaxis. (a) Angiogram of common carotid artery shows internal maxillary artery (arrowhead). (b) Angiogram of internal carotid artery shows ophthalmic artery (arrow). (c) Angiogram of external carotid artery shows internal maxillary artery (arrowhead). (d) Angiogram shows the sphenopalatine segment of the internal maxillary artery with variable-stiffness catheter in place. (e, f) Angiograms show progressive steps in embolization of the internal maxillary artery (arrowhead in f). (g) Angiogram
shows shows
embolization of the internal maxillary artery the facial artery (arrow) (Figure continues).
(arrowhead)
terminated.
(h) Angiogram
authors
the importance of placing the as close as possible to the site. Because the nasal packremoved prior to the embolization, aspiration of blood resulted. This report was followed by a series 114
g.
of articles (i,2,4-i7), most of which describe solitary cases but some of which describe larger series of embobizations in cases of idiopathic epistaxis.
In i979 Robertson and Reardon (6) performed embolization in iO patients with epistaxis by using gelatin sponge bleeding recurred in two. In i979 Riche et al (7) and in i980 Merland et October
1991
aspiration,
alar
necrosis,
infections. It can tory compromise, sodes of nocturnal tion.
Early
and
also result hypoxia, oxygen
removal
of the
sinus
in respiraand epidesaturapostnasal
packing is a necessity (1). Posterior nasal packing has a failure rate of 25%-52% 20%-68%
ternal formed (18),
and a complication (i9,2i). Ligation
maxillary artery has been persince the middle of the 1960s with
(1,20,21)
a failure
and
40%-47%
(continued). the facial
(i) Selective angiogram artery with variable-stiffness
ter in place. Arrow
indicates
bleeding.
control (k)
angiogram Postembolization
0)
Postembolization shows the facial
artery.
control artenogram nal maxifiary artery
shows cathe-
shows
embobized
(arrowhead)
and
facial
arteries.
54 patients
results
with
in a series
epistaxis
who
of
were
treated with embolization. Eight patients had idiopathic epistaxis. Those authors concluded that preembolization angiography did not play a major role in the determination of the bleeding site and that embolization is the most
effective
treatment,
ated with fewer gation (9). In 1988 Wehrli their experience
risks
being
than
associ-
arterial
li-
experienced complications ranging from facial paralysis and soft-tissue necrosis to swelling of the cheek. Therefore surgery was recommended as the
primary
therapy
for
intractable
epistaxis. In 1990
reported lization There
Strutz
and
Schumacher
a 90% success as the treatment is incomplete
(1)
rate for embofor epistaxis. agreement
in
the literature concerning the defimtion of intractable epistaxis, specifically whether it means the need for posterior nasal packing (1) or the failure of such packing. We define intractable epistaxis as the failure of nasal packing and the need for further therapy. There are multiple causes of intractable epistaxis, including facial trauma, postsurgical complications, vascular abnormalities in the territory of the internal and external carotid arteries (such as aneurysms and arteVolume
181
#{149} Number
1
heavy
smokers,
The
intractable epiof the patients
In most
cases
is not determined; these cases fall into the category of idiopathic epistaxis. Some of these patients are hypertensive, ics, but viduals bleed.
et al (16) published with embolizations
in i9 patients with staxis. Fifty percent
riovenous malformations), expanding lesions (juvenile angiofibromas, malignant expanding lesions, etc), hemostatic disorders, and hereditary hemorrhagic telangiectasia. of epistaxis the cause
most who
or borderline
alcohol-
of them are healthy indihave a sudden nose-
treatment
for
epistaxis
of estab-
lished origin is dictated by the problems associated with the underlying cause, and therefore the endovascular therapy performed in such cases is different from that performed in cases of idiopathic epistaxis. Therefore, we restricted our report of endovascubar therapy to treatment of cases of intractable expistaxis of idiopathic origin. It should be noted, however, that regardless of the cause, treatment of intractable epistaxis requires performance
of angiography.
As mentioned previously, well-established ascending treatment for epistaxis; the
there is a scale of treatment ligation of
culminates with transantral the internal maxillary and bilateral ethmoid arteries if nasal packing (18-20). There are several problems
associated nal
packing.
with The
performance procedure
fails
of choais not
only painful and stressful, but prolonged packing is associated
(i9-2i).
use of with
This
maxillary
If surgery most always phy. not
al (9) published
of 9.5%-i5.0%
rate
of
approach
is
contraindicated in approximately of patients because of the presence antrum
fails, the referred
Usually
epistaxis,
k.
rate
a complication
a hypopbastic
inter-
rate of of the in-
(22).
patients are for angiogra-
in cases
al-
of idiopathic
angiography
to determine
6% of
is performed the
bleeding
point
but rather to rube out the presence of unusual causes of epistaxis, such as vascular abnormalities or technical failures of clipping of the internal maxillary artery (9,14,23,24); this is especially true when the patient is not bleeding actively during angiography. To remove the packing prior to angiography is unwise and dangerous because of the risk of aspiration of blood (3,14) and agitation of the patient, who may become uncooperative. Endovascubar therapy with embolization
is the
diagnostic
angiography.
In 1979
bogicab
Lasjaunias
sequel
to
et al (24)
de-
scribed
the radioanatomic basis and protocol for arterial embolization as treatment for epistaxis and stressed the importance of the preembolization arteriogram for evaluation of dangerous anastomosis between the branches of the external and internal carotid arteries. Davis (14) in i986 recommended a similar protocol for angiography and embolization that was applicable to all causes of epistaxis but was mainly developed for use in cases of juvenile angiofibromas. Both Lasjaunias et al and Davis recommended that embolization be performed as distally as possible. Davis occasionally used a coaxial catheter system to enter the distal segment of the internal maxillary artery or other branches of the external carotid artery. Our protocol and technique, including both angiography and embolization,
and easy accurately (1).
In the
are
simple,
to perform. pinpoint patient
efficient,
quick,
The clinician the bleeding population
can side
reported
herein, there was no doubt about the side of the hemorrhage in 27 cases. In three patients the epistaxis was “bilateral.” Radiology
#{149} 115
Embobization was performed in all patients with use of shredded Gelfoam. Gelatin sponge, a readily available embobic agent that is easily injected through the variable-stiffness catheter, is a “smooth” embolic agent
nopabatine maxillary
with
ping,
particles
embolized tion
that
travel
vessels.
with
distally
Effective
gelatin
sponge
into
provide
was who
immediately
after
complication
sis after
tery;
emboliza-
rate
3%, consisting experienced
in this
of one transient
embolization
study
patient hemipare-
of the
artery.
Several
neurobogic and associated with ment of epistaxis
facial
judgment
the
authors
ar-
to ca-
describe
other complications embolization for treat(12,13,i5,i6). In my complications
are
gen-
erabby caused by overembolization, use of particles that are too small, by reflux into the internal carotid tery.
If the
arteries with
internal
are
especially
permanent
embolization
postembolization
eventual ischemic If the emboli are
by and ar-
or facial
overembolized,
a more
agent,
maxillary
pain
necrosis too small,
and
can occur. the arteri-
29 (97%),
ping
of the
ethmoid
bolization.
most
likely
to the
ies and epistaxis.
116
The
only
medial
not
arteries
ethmoid and
collateral lateral
the primary If the branches
#{149} Radiology
em-
and
reported mance
more
Efficient occurrence
ar10.
procedure.
modality epistaxis.
ii.
12.
13.
3.
14.
15.
In
5.
6.
super
16.
17.
18.
#{149}
(ASS.)
Wyck
LG, Vinuela
F, Heeneman
H.
embobization for severe J Otolaryngol 1982; 11:271-274.
epistaxis. Metson R, Hanson DC. nerve paralysis following
epistaxis.
Bilateral facial embolization
Otolaryngol
Surg 1983; 91:299-303. DeVries N, Vershuis Facial nerve paralysis
Head
RJ, ValkJ, following
epistaxis.
for
Neck
Snow GB. emboliza-
J Laryngol
Otol
1986; 100:207-210. Davis KR. Embolization of epistaxis juvenile nasopharyngeal angiofibromas. AJNR 1986; 7:953-962. Parnes LS, Heeneman H, Vinuela F. cutaneous embolization for control of blood circulation. Laryngoscope 1987; Wehrli
M, Lieberherr
perselective
for idio-
selective
J Neuroradiol
and
Pernasal 97:
1312-1315.
results
Strutz J, Schumacher M. Uncontrollable epistaxis. Arch Otolaryngol Head Neck Surg 1990; 116:697-699. Breda SD, Choi IS, Persky NS, Weiss M. Embolization in the treatment of epistaxis after failure of internal maxillary artery ligation. Laryngoscope 1989; 99:809-815. SokoloffJ, Wickbom I, McDonald D, Brahme F, Goergen IC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974; iii: 285-287. Djindjian R, Merland ll Theron J.
L’arteriographie
Van
tion for severe
19.
2.
II.
treatment 1979;
6:207-220. Wills P1, Russell RD. Percutaneous embolization to control intractable epistaxis. Laryngoscope 1979; 89:1385-1388. Merland JJ, MelkiJP, Chiras J, Riche MC, Hadjean E. Place of embolization in treatment of severe epistaxis. Laryngoscope 1980; 90:1694-1704. DeFilipp CJ, Steffey D, Rubinstein M, Drake A, Koopmann CH. The role of angiography and embolization in the man-
severe
herein, I suggest that perforof embolization not be limited
treatment intractable
epistaxis.
in the
agement of recurrent epistaxis. Otolaryngol Head Neck Surg 1988; 99:597-600.
a simpler,
and
Melki JP, Merland
of embolization
Therapeutic
embolizaof this
with
efficient
9.
within
branch of the posterior to carry blood into the
experience
8.
References
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are
source of of the sphe-
If the
proximally
embolization of the
4.
after
septal artery
safer,
never clip-
arteries
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occluded
view
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role
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1.
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opposite
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of the
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mary pathic
In this series it is of interest that the ethmoid arteries were not involved in epistaxis. Of 30 patients treated with embolization, 26 (87%) were cured after embolization of the internal
site
the sphenopabatine fossa, this gives the impetus for the anterior nasal branch of the anterior ethmoid artery
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the
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to
the
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October
1991
