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Laser management of anterior epistaxis
@ @ LASER MANAGEMENT OF ANTERIOR EPISTAXlS YOSEF P. KRESPI, MD, EDGAR H. LING, MD
Epistaxis is a common condition that often resolves with home remedies or with the attention of a primary care physician. However, 5% to 10% of patients suffer intractable epistaxis that requires the attention of an otolaryngologist. Among these cases, we may be faced with a patient who suffers recurrent epistaxis over a period of weeks to months that is associated with an anterior septal source. Conservative methods of packing and cauterization have failed and the patient suffers the annoyance, disability, and possible serious medical sequelae of significant blood loss. We introduce the results of a new surgical method for the management of intractable epistaxis from an anterior source. This technique abandons the laser ablation of septal vessels from outside the mucosa in favor of an approach from beneath the tissue surface. Standard septal surgical instruments are used to create familiar mucoperichondrial flaps where endoscopic visualization then permits Nd-YAG or argon laser obliteration of the septal vessels from beneath the mucosal surface.
METHODS This series of 42 patients ranged in age from 33 to 79 years. Twenty-seven (64%) were m e n and 15 (36%) were women. The follow-up period ranged from 2 to 26 months. All patients had experienced two or more episodes of anterior epistaxis associated with a septal source. Thirty-three patients (79%) were hospitalized for their acute bleeds and underwent this procedure urgently. For the remaining nine patients (21%) the procedure was electively performed in an ambulatory setting. Each patient u n d e r w e n t a Killian or transfixion approach, contralateral to the side of bleeding (Fig 1A). The septal cartilage is incised and a submucous resection of cartilage performed to correct septal deformities. The ipsilateral septal mucosa is then elevated along the mucoperichondrial dissection plane (Fig 1B). Both arms of a nasal speculum are inserted into this internal subperichondrial pocket (Figs 2A, B). The fine vascular architecture of the perichondrium is then visualized with From the Department of Otolaryngology, St Luke's/Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, NY. Address reprint requests to Yosef P. Krespi, MD, 425 W 59th St, Suite 4E, New York, NY 10019. Copyright 9 1994 by W.B. Saunders Company 1043-1810/94/0504-0011 $05.00/0
the aid of a 4-mm, 0~ sinus endoscope (Karl Storz, Germany) and optional video camera. A 400- or 600-1~m laser fiber (Sharplan Lasers Inc, Allendale, NJ) is inserted through a 135~ laser nasal probe (Sharplan Lasers Inc). Both the laser nasal probe and the endoscope are introduced between the blades of the nasal speculum into the submucosal pocket, targeting the perichondrial septal vessels. Argon laser (HGM Lasers, Salt Lake City, UT) or Nd-YAG laser (Sharplan Lasers Inc) energy is then delivered through the laser fiber and the vessels ablated (Fig 3). The tip of the fiber is positioned 1 to 2 m m from the target vessel and the laser energy is delivered using continuous mode. The septal vessels are photocoagulated or blanched through the perichondrium. Power settings of 10 to 12 W are appropriate for the argon laser and slightly lower settings (8 to 10 W) for the Nd-YAG unit. At the completion of the laser ablation, the septal cartilage and mucosa are placed in their anatomic position. Killian incisions are not primarily closed to allow blood to drain. Formal postoperative packing is not required and the nasal cavity is filled with an antibiotic ointment. For patients with severe septal deformity with limited airway or bilateral septal epistaxis, a limited cartilage resection is indicated before the laser ablation.
RESULTS All patients experienced relief from their recalcitrant episodes of epistaxis. No patients experienced recurrent bleeding requiring packing. At the first postoperative visit (days 5 to 7), physical examination showed minimal crusting and satisfactory septal incision healing. One patient (2.4%) developed a septal perforation measuring 3 x 4 mm. This patient underwent a submucous resection of cartilage at the time of the procedure to correct an obstructing septal spur. The patient did not experience any symptoms and their care was managed conventionally. One patient (2.4%) experienced a concurrent posterior bleeding and underwent an ipsilateral internal maxillary artery ligation at the time of the laser ablation of the septal vessels.
DISCUSSION Patients with intractable anterior septal epistaxis have not responded to conventional packing and external chemical or diathermic cauterization. Therapeutic options then
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 5, NO 4 (DEC), 1994: PP 271-273
271
,g
j
iiiii!i!i .
A
B
CORONAL
i
CORONAL
FIGURE 1. (A) Killian mcision on the contralateral septum exposes cartilaginous septum. (B) Cartilage is incised and ipsilateral mucoperichondrial pocket is developed. Submucous resection of septal cartilage may be performed to correct septal deformity.
'\
\
A
B AXIAL
CORONAL
FIGURE 2. (A) Axial view of ipsilateral perichondrial pocket through a contralateral Killian incision. (B) Coronal view of FIG 2A. Note the speculum blades expose the subperichondrial blood vessels.
:,'
600 micron YAG fiber
272
focused on reduction of the pressure gradients in the local vascular bed and correction of anatomic deformities susceptible to trauma and bleeding. Vascular control has been achieved by angiographic arterial emboIization or by surgical ligation of the major feeding vessels (external carotid, maxillary, or ethmoidal arteries). 1 Wang et al compared surgical ligation with conventional packing therapies in the management of posterior epistaxis and found better rates of success, shorter hospitalization, and fewer overall complications in those patients receiving arterial ligation. 2 Anterior septal epistaxis arises in a region of extensive fine vascular anastomoses (Kiesselbach's plexus). This blood supply includes contributions from the septal branch of the superior labial artery (branch of facial artery, external carotid system) and the anterior ethmoid artery (branch of ophthalmic artery and internal carotid system). 3 This rich collateral flow may contribute to septal epistaxis resistant to conventional therapy and may explain the success of local laser photocoagulation. Whereas external methods treat a bleeding point, the transperichondrial laser therapy precisely ablates feeding vessels, ensuring the goal of local vascular control. Experimental and clinical investigators have noted the effectiveness of laser energy in the ablation of fine mucosal vessels as approached from the external surface. Lenz studied hamster mucosal vascular networks and documented that graded obliteration depended on the power of the laser dose. 4 The wavelength of the argon laser is preferentially absorbed by hemoglobin, making it ideal for photocoagulation therapies. The Nd-YAG is a near-infrared energy and can achieve significant thermal photocoagulation. ~ Several studies have showed the usefulness of both argon and Nd-YAG lasers in the external treatment of nasal epistaxis secondary to hereditary hemorrhagic telangiectasia, and inherited abnormality of subepidermal vessels. 6'7 Use of these lasers re-
;'
,J
To Smoke Evacuator
FIGURE 3. Endoscopic visualization of subperichondrial septal vessels and laser ablation of these vessels using the nasal probe. LASERS IN EPISTAXIS
quires care to avoid excess soft tissue damage that, if present in opposing septal mucosal sites, m a y predispose the patient to a septal perforation, s In this series, resolution of the recurrent epistaxis is achieved by local vascular control from beneath the mucosa at a surgically created dissection plane. The involved feeding septal vessels are first exposed by standard septal approaches a n d t h e n obliterated by laser energy. Associated cartilaginous septal deformities m a y be addressed at the same time if necessary. The use of sinus endoscopes permits excellent illumination and a magnified view of the exposed vascular network. This allows accurate laser delivery using lower power settings, which can reduce the degree of thermal damage to the s u r r o u n d i n g nonvascular tissue. Accurate ablation of these feeding vessels effectively minimizes postoperative bleeding and eliminates the need for packing. Limiting thermal a n d mechanical trauma promotes proper mucosal healing that prevents recurrent bleeding.
CONCLUSION Intractable anterior septal epistaxis is a troublesome problem that m a y require attention by a rhinologic surgeon. A n e w surgical m e t h o d for treating this problem with argon or Nd-YAG lasers is introduced. This unique submucosal approach for laser ablation of involved vascular
KRESPI AND LING
structures preserves the integrity of the septal mucosa and offers access for the correction of a n y associated septal deformity. The procedure offers advantages of decreased hospitalization a n d e n h a n c e d patient comfort. This technique does incur the expense of laser e q u i p m e n t and appropriate technical training for its safe operation; however, these factors m a y become minimal b u r d e n s as such instruments become more widely available.
REFERENCES 1. Welsh LW: Role of angiography in management of refractory epistaxis. Ann Otol Rhinol Laryngol 99:69, 1990 2. Wang L, Vogel DH: Posterior epistaxis: Comparison of treatment. Otolaryngol Head Neck Surg 89:1001-1003, 1981 3. Abelson TI: Epistaxis, in Paparella, MM (ed): Otolaryngology(ed 3). Philadelphia, PA, Saunders, 1991, pp 1831-1837 4. Lenz H, EichlerJ: The effect of the argon laser on the vessels, the macro- and microcirculation of the mucosa of the hamster cheekpouch. Laryngorhinootologie54:609-612, 1975 5. Enderby CE: Laser instrumentation, in Dixon JA (ed): Surgical Application of Lasers (ed 2). Chicago, IL, Yearbook Medical, 1987, pp 52-78 6. Shapshay SN, Oliver P: Treatment of hereditary hemorrhagic telangiectasia by Nd:YAG laser photocoagulation. Laryngoscope 94: 1554-1556, 1984 7. Parkin JL, Dixon JA: Laser photocoagulation in hereditary hemorrhagic telangiectasia. Otolaryngol Head Neck Surg 89:204-208, 1981 8. Hoffman JF, Parkin JL: Rhinologic applications of laser surgery. Otolaryngol Clin North Am 23:19-28, 1990
273
Epistaxis is a common condition that often resolves with home remedies or with the attention of a primary care physician. However, 5% to 10% of patients suffer intractable epistaxis that requires the attention of an otolaryngologist. Among these cases, we may be faced with a patient who suffers recurrent epistaxis over a period of weeks to months that is associated with an anterior septal source. Conservative methods of packing and cauterization have failed and the patient suffers the annoyance, disability, and possible serious medical sequelae of significant blood loss. We introduce the results of a new surgical method for the management of intractable epistaxis from an anterior source. This technique abandons the laser ablation of septal vessels from outside the mucosa in favor of an approach from beneath the tissue surface. Standard septal surgical instruments are used to create familiar mucoperichondrial flaps where endoscopic visualization then permits Nd-YAG or argon laser obliteration of the septal vessels from beneath the mucosal surface.
METHODS This series of 42 patients ranged in age from 33 to 79 years. Twenty-seven (64%) were m e n and 15 (36%) were women. The follow-up period ranged from 2 to 26 months. All patients had experienced two or more episodes of anterior epistaxis associated with a septal source. Thirty-three patients (79%) were hospitalized for their acute bleeds and underwent this procedure urgently. For the remaining nine patients (21%) the procedure was electively performed in an ambulatory setting. Each patient u n d e r w e n t a Killian or transfixion approach, contralateral to the side of bleeding (Fig 1A). The septal cartilage is incised and a submucous resection of cartilage performed to correct septal deformities. The ipsilateral septal mucosa is then elevated along the mucoperichondrial dissection plane (Fig 1B). Both arms of a nasal speculum are inserted into this internal subperichondrial pocket (Figs 2A, B). The fine vascular architecture of the perichondrium is then visualized with From the Department of Otolaryngology, St Luke's/Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, New York, NY. Address reprint requests to Yosef P. Krespi, MD, 425 W 59th St, Suite 4E, New York, NY 10019. Copyright 9 1994 by W.B. Saunders Company 1043-1810/94/0504-0011 $05.00/0
the aid of a 4-mm, 0~ sinus endoscope (Karl Storz, Germany) and optional video camera. A 400- or 600-1~m laser fiber (Sharplan Lasers Inc, Allendale, NJ) is inserted through a 135~ laser nasal probe (Sharplan Lasers Inc). Both the laser nasal probe and the endoscope are introduced between the blades of the nasal speculum into the submucosal pocket, targeting the perichondrial septal vessels. Argon laser (HGM Lasers, Salt Lake City, UT) or Nd-YAG laser (Sharplan Lasers Inc) energy is then delivered through the laser fiber and the vessels ablated (Fig 3). The tip of the fiber is positioned 1 to 2 m m from the target vessel and the laser energy is delivered using continuous mode. The septal vessels are photocoagulated or blanched through the perichondrium. Power settings of 10 to 12 W are appropriate for the argon laser and slightly lower settings (8 to 10 W) for the Nd-YAG unit. At the completion of the laser ablation, the septal cartilage and mucosa are placed in their anatomic position. Killian incisions are not primarily closed to allow blood to drain. Formal postoperative packing is not required and the nasal cavity is filled with an antibiotic ointment. For patients with severe septal deformity with limited airway or bilateral septal epistaxis, a limited cartilage resection is indicated before the laser ablation.
RESULTS All patients experienced relief from their recalcitrant episodes of epistaxis. No patients experienced recurrent bleeding requiring packing. At the first postoperative visit (days 5 to 7), physical examination showed minimal crusting and satisfactory septal incision healing. One patient (2.4%) developed a septal perforation measuring 3 x 4 mm. This patient underwent a submucous resection of cartilage at the time of the procedure to correct an obstructing septal spur. The patient did not experience any symptoms and their care was managed conventionally. One patient (2.4%) experienced a concurrent posterior bleeding and underwent an ipsilateral internal maxillary artery ligation at the time of the laser ablation of the septal vessels.
DISCUSSION Patients with intractable anterior septal epistaxis have not responded to conventional packing and external chemical or diathermic cauterization. Therapeutic options then
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 5, NO 4 (DEC), 1994: PP 271-273
271
,g
j
iiiii!i!i .
A
B
CORONAL
i
CORONAL
FIGURE 1. (A) Killian mcision on the contralateral septum exposes cartilaginous septum. (B) Cartilage is incised and ipsilateral mucoperichondrial pocket is developed. Submucous resection of septal cartilage may be performed to correct septal deformity.
'\
\
A
B AXIAL
CORONAL
FIGURE 2. (A) Axial view of ipsilateral perichondrial pocket through a contralateral Killian incision. (B) Coronal view of FIG 2A. Note the speculum blades expose the subperichondrial blood vessels.
:,'
600 micron YAG fiber
272
focused on reduction of the pressure gradients in the local vascular bed and correction of anatomic deformities susceptible to trauma and bleeding. Vascular control has been achieved by angiographic arterial emboIization or by surgical ligation of the major feeding vessels (external carotid, maxillary, or ethmoidal arteries). 1 Wang et al compared surgical ligation with conventional packing therapies in the management of posterior epistaxis and found better rates of success, shorter hospitalization, and fewer overall complications in those patients receiving arterial ligation. 2 Anterior septal epistaxis arises in a region of extensive fine vascular anastomoses (Kiesselbach's plexus). This blood supply includes contributions from the septal branch of the superior labial artery (branch of facial artery, external carotid system) and the anterior ethmoid artery (branch of ophthalmic artery and internal carotid system). 3 This rich collateral flow may contribute to septal epistaxis resistant to conventional therapy and may explain the success of local laser photocoagulation. Whereas external methods treat a bleeding point, the transperichondrial laser therapy precisely ablates feeding vessels, ensuring the goal of local vascular control. Experimental and clinical investigators have noted the effectiveness of laser energy in the ablation of fine mucosal vessels as approached from the external surface. Lenz studied hamster mucosal vascular networks and documented that graded obliteration depended on the power of the laser dose. 4 The wavelength of the argon laser is preferentially absorbed by hemoglobin, making it ideal for photocoagulation therapies. The Nd-YAG is a near-infrared energy and can achieve significant thermal photocoagulation. ~ Several studies have showed the usefulness of both argon and Nd-YAG lasers in the external treatment of nasal epistaxis secondary to hereditary hemorrhagic telangiectasia, and inherited abnormality of subepidermal vessels. 6'7 Use of these lasers re-
;'
,J
To Smoke Evacuator
FIGURE 3. Endoscopic visualization of subperichondrial septal vessels and laser ablation of these vessels using the nasal probe. LASERS IN EPISTAXIS
quires care to avoid excess soft tissue damage that, if present in opposing septal mucosal sites, m a y predispose the patient to a septal perforation, s In this series, resolution of the recurrent epistaxis is achieved by local vascular control from beneath the mucosa at a surgically created dissection plane. The involved feeding septal vessels are first exposed by standard septal approaches a n d t h e n obliterated by laser energy. Associated cartilaginous septal deformities m a y be addressed at the same time if necessary. The use of sinus endoscopes permits excellent illumination and a magnified view of the exposed vascular network. This allows accurate laser delivery using lower power settings, which can reduce the degree of thermal damage to the s u r r o u n d i n g nonvascular tissue. Accurate ablation of these feeding vessels effectively minimizes postoperative bleeding and eliminates the need for packing. Limiting thermal a n d mechanical trauma promotes proper mucosal healing that prevents recurrent bleeding.
CONCLUSION Intractable anterior septal epistaxis is a troublesome problem that m a y require attention by a rhinologic surgeon. A n e w surgical m e t h o d for treating this problem with argon or Nd-YAG lasers is introduced. This unique submucosal approach for laser ablation of involved vascular
KRESPI AND LING
structures preserves the integrity of the septal mucosa and offers access for the correction of a n y associated septal deformity. The procedure offers advantages of decreased hospitalization a n d e n h a n c e d patient comfort. This technique does incur the expense of laser e q u i p m e n t and appropriate technical training for its safe operation; however, these factors m a y become minimal b u r d e n s as such instruments become more widely available.
REFERENCES 1. Welsh LW: Role of angiography in management of refractory epistaxis. Ann Otol Rhinol Laryngol 99:69, 1990 2. Wang L, Vogel DH: Posterior epistaxis: Comparison of treatment. Otolaryngol Head Neck Surg 89:1001-1003, 1981 3. Abelson TI: Epistaxis, in Paparella, MM (ed): Otolaryngology(ed 3). Philadelphia, PA, Saunders, 1991, pp 1831-1837 4. Lenz H, EichlerJ: The effect of the argon laser on the vessels, the macro- and microcirculation of the mucosa of the hamster cheekpouch. Laryngorhinootologie54:609-612, 1975 5. Enderby CE: Laser instrumentation, in Dixon JA (ed): Surgical Application of Lasers (ed 2). Chicago, IL, Yearbook Medical, 1987, pp 52-78 6. Shapshay SN, Oliver P: Treatment of hereditary hemorrhagic telangiectasia by Nd:YAG laser photocoagulation. Laryngoscope 94: 1554-1556, 1984 7. Parkin JL, Dixon JA: Laser photocoagulation in hereditary hemorrhagic telangiectasia. Otolaryngol Head Neck Surg 89:204-208, 1981 8. Hoffman JF, Parkin JL: Rhinologic applications of laser surgery. Otolaryngol Clin North Am 23:19-28, 1990
273