Clinical Study Of Epistaxis After Endoscopic Nasal-sinus Or Skull Base Surgery

OBJECTIVES: The endoscopic techniques in clinical works has been used for more than three decades.It has made the appearance of surgical complications significantly less than that of traditional surgical methods.However,with the endoscopic techniques developing,its applications have evolved from simple nasal-sinus disease to skull base lesions,and the difficulty of surgery has also increased.Otherwise,the popularity of endoscopic techniques in primary hospitals may be unequal to their operational capabilities,therefore,the complications are not reduced due to its advantages.Postoperative hemorrhage is one of the complications after endoscopic nasal-sinus and skull base surgery.Although the incidence is not very high,it is extremely fatal when epistaxis is severe.This study mainly analyzes and discusses the clinical features,preventions and treatments of epistaxis after endoscopic nasal-sinus or skull base surgery in the form of case review and provides constructive suggestions for future clinical works.METHODS: Retrospective analysis was done on the 22 cases of patients with severely postoperative epistaxis after endoscopic nasal-sinus or skull base surgery,which were admitted from January 2013 to December 2017 at the Department of Otolaryngology Head and Neck Surgery in Tianjin Huanhu Hospital.The gender,age,postoperative diagnosis,other combined medical history,types of operation,bleeding time,bleeding site,bleeding volume,examinations,treatments and outcomes were summarized to analyze the clinical features,causes,treatments and preventions of postoperative epistaxis.RESULTS: Among the 22 patients,there were 12 males and 10 females,age was between 27 and 70 years old.12 cases underwent endoscopic nasal-sinus surgery.Preoperative diagnosis involved nasal septal deviation,chronic rhinitis,sinusitis,sinus cysts,nasal polyps,cerebrospinal fluid rhinorrhea,occupying lesions in pterygopalatine fossa,and so on.10 cases underwent endoscopic skull base surgery,with preoperative diagnosis including pituitary tumors and craniopharyngiomas.Some patients had hypertension,diabetes,allergic rhinitis,coronary disease with coronary stent implantation,long-term aspirin usage,prolonged clotting time,infection,anemia,and hemorrhagic shock.The bleeding time ranged from the 5th day to the 25 th day after surgery.The average time was postoperative 11.5th day after operation(median in postoperative 10 th day),and 68.18% of cases was after 1-2 weeks postoperatively.The responsible vessels in bleeding site involved sphenopalatine artery and its branches in 17 cases(77.27%),arteriae posteriores nasales laterales in 40.91% of cases,maxillary artery in 2 cases(9.09%),and internal carotid artery in 3 cases(13.64%).Except for 2 patients directly performed digital subtraction angiography(DSA),the remaining 20 patients preferred endoscopic examination to determine bleeding site.15 cases underwent electrocoagulation to stop bleeding;1 patient who had undergone endoscopic examination and DSA had no clear bleeding site,and nasal packing with iodoform gauze was used to stop bleeding;other 4 patients further preformed DSA examination,which showed that 2 cases of maxillary artery pseudoaneurysm and 2 cases of internal carotid artery(ICA)pseudoaneurysm.They were treated by vascular interventional embolization.Its complications included blindness(ICA)and facial numbness(maxillary artery).Some patients were treated with symptomatic supported treatments.Except 1 case patient died,the remaining cases patients all successfully stopped bleeding.No epistaxis occurred after more than three months follow-up.CONCLUSIONS: Postoperative epistaxis occurred mostly in 1-2 weeks after surgery.The major responsible vessels were sphenopalatine artery and its branch.Epistaxis originated from ICA occurred only after skull base surgery in my study.The posterior and posterior ethmoidal arteries were the least likely to have postoperative epistaxis.With maintaining patient's vital signs stability,the preferred method was endoscopic examination and electrocoagulation.Epistaxis after skull base surgery had no clear bleeding site,should be diagnosis by DSA for locating bleeding site,and vascular interventional therapy should be performed if necessary.The sphenopalatine artery electrocoagulation was a good way to stop bleeding when bleeding site was unknown in patients who underwent endoscopic nasal-sinus surgery.Preoperative imaging examinations to clarify the relationship between important anatomical structures and lesions,paying attention to the protection of important anatomical structures during surgery,controlling underlying diseases and eliminating adverse factors that affect postoperative recovery,targeted postoperative nasal cavity clearance may reduce postoperative epistaxis occurrence.And the active and deep multidisciplinary cooperation in the preoperative,intraoperative and postoperative period is beneficial to the patient's prognosis.