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Early Operative Intervention versus Conventional Treatment in Epistaxis:

Randomized Prospective Trial

Article in The Journal of otolaryngology · July 2004

DOI: 10.2310/7070.2004.00185 · Source: PubMed

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 The Journal of Otolaryngology, Volume 33, Number 3, 2004

Early Operative Intervention versus

Conventional Treatment in Epistaxis:
Randomized Prospective Trial
Ali Moshaver, MSc, MD, Jeffrey Richard Harris, MD, FRCSC,
Richard Liu, MD, FRCSC, Chris Diamond, MD, and Hadi Seikaly, MD, FRCSC

Abstract
Objective: This prospective randomized trial was designed to compare intranasal endoscopic sphenopalatine artery ligation
(ESAL) with conventional nasal packing in the treatment of recurrent epistaxis.
Methods: Patients were registered in the study databank following referral for epistaxis control to the otolaryngology service
at the University of Alberta. All patients were initially packed using Merocel (Xomed Surgical Products, Jacksonville, FL)
nasal dressings bilaterally. Patients were enrolled in the study following failure of Merocel packings. Informed consent was
obtained in accordance with the Health Research Ethics Board. The patients were then managed with Vaseline nasal packs
or ESAL. Patient demographics, treatment characteristics, number of hospitalization days, and rates of recurrence were
recorded prospectively. The total cost of treatment for each patient was calculated.
Results: Nineteen patients were enrolled in the study. There was a significant reduction in cost and length of hospitalization
of the patients undergoing ESAL compared with the conventional nasal packings. ESAL was also 89% effective in control-
ling the bleeding and had minimal sequelae or complications. The overall calculated cost of patients undergoing ESAL was
$5133 compared with $12 213 in the conservative group, resulting in an average saving of $7080 per patient. There was
overwhelming patient satisfaction with ESAL compared with nasal packings.
Conclusion: ESAL is an excellent, well-tolerated, and cost-effective method of treating recurrent epistaxis.
Sommaire
Objectif: Cette étude prospective compare la ligature endoscopique de l’artère sphénopalatine (LEAS) avec le paquettage
conventionnel dans le traitement des épistaxis récidivants.
Méthodes: Nous enregistrons dans une banque de données tous les patients transférés au service d’ORL de l’Université de
l’Alberta à Edmonton. Tous les patients avaient été traités initialement par l’insertion bilatérale de Merocel (Xomed Surgical
Products, Jacksonville, FL). Les patients ont donc été inclus dans l’étude à la suite de l’échec de cette stratégie. Avec le
consentement des patients, nous les avons traités soit par paquettage conventionnel soit par LEAS. La démographie, les
caractéristiques des traitements, le nombre de jours d’hospitalisation et le taux de récidive ont été colligés de manière
prospective.
Résultats: Dix-neuf patients ont été recrutés pour cette étude. Nous avons documenté une diminution significative du
nombre de jours d’hospitalisation et du coût chez les patients traités par LEAS. Cette technique était aussi efficace dans 89%
des cas pour contrôler le saignement avec des risques de complications et séquelles minimaux. Le coût total pour un patient
subissant une LEAS est de $5133 comparé à $12 213 pour celui traité par paquettage nasal, résultant en une économie nette
de $7080 par patient traité. Inutile de dire que la satisfaction des patients est nettement meilleure avec le traitement
chirurgical par rapport au traitement conservateur.
Conclusion: La LEAS est une excellente technique, bien tolérée et efficiente dans le traitement de l’épistaxis récidivant.
Key words: cost analysis, endoscopic sinus surgery, epistaxis, nasal packing, randomized clinical trial, sphenopalatine artery

Received 06/18/03. Received revised 06/18/03. Accepted for pub-

lication 06/18/03.

Presented in part, at the Xomed Meeting, Calgary, 2003.

E pistaxis is one of the most common maladies an oto-
laryngologist is called on to treat. Most epistaxis
episodes are mild, originating from Kiesselbach’s plexus
A. Moshaver, Jeffrey Richard Harris, R. Liu, C. Diamond, and on the anterior nasal septum, and are easily controlled at
Hadi Seikaly: Division of Otolaryngology-Head and Neck home or by the primary care physician. A small subset of
Surgery, University of Alberta, Edmonton, AB. patients have significant and persistent bleeding, usually
Address reprint requests to: Dr. Jeffrey R. Harris, 1E4.29 W C from branches of sphenopalatine and anterior ethmoid
Mackenzie Health Sciences Center, Edmonton, AB T6G 1B7. arteries, resulting in a potentially life-threatening hemor-

185
186 The Journal of Otolaryngology, Volume 33, Number 3, 2004

rhage and complications.1 These patients usually require Study

management within a hospital setting, resulting in a sig- Patients were enrolled in the study following failure of
nificant economic burden to the health care system. Merocel packings. Informed consent was obtained in
Recurrent epistaxis is a difficult condition to man- accordance with the Health Research Ethics Board. The
age, and a variety of treatment methods have been patients were then managed with the treatment protocol
described in the medical literature.1–3 Traditionally, and were randomized at the time of initial contact. All
nonsurgical management in the form of anterior and patients enrolled in the study were admitted to the oto-
posterior packs has been the first-line therapy. This laryngology-head and neck surgery ward for observation.
treatment modality is effective in controlling most epis- Conservative Treatment. Patients randomized to the
taxis episodes but is extremely uncomfortable for conservative arm were repacked with Vaseline packs
patients and has been shown to cause hypoxia, sinusi- anteriorly and, if necessary, posteriorly. The packs were
tis, aspiration, sepsis, myocardial infarcts, cerebral removed 24 to 48 hours after the cessation of bleeding.
ischemia, and even death.1,2
The surgical approaches used for control of recurrent Surgical Treatment. Patients randomized to the surgical
epistaxis include transantral ligation of the internal max- arm were taken to the operating room, and ESAL was
illary artery, transantral ligation of the sphenopalatine performed. A vertical incision above and anterior to the
artery, ligation of ethmoidal arteries, and percutaneous posterior insertion of the middle turbinate was made.
embolization of the internal maxillary artery and its The mucosa of the lateral wall was then elevated until
branches. These procedures are very effective in control- the sphenopalatine artery at the sphenopalatine foramen
ling epistaxis, but they are also associated with significant was identified. The different branches of the SPA were
morbidity and an extended hospital stay. 1–4 More initially cauterized using the Xomed intranasal bipolar
recently, intranasal endoscopic sphenopalatine artery lig- cautery and were subsequently clipped. An anterior eth-
ation (ESAL) has been described as a safe and effective moid artery ligation on the bleeding side and septoplas-
method for controlling epistaxis.5–11 ESAL allows for bet- ties were also performed as deemed necessary by the
ter visualization and access to bleeding vessels, which can operating surgeon. The packs were removed 24 to 48
then be subsequently clipped. This technique avoids com- hours after the cessation of bleeding.
plex surgery and its associated complications.
Treatment Failures. Failure of therapy in the study was
The most optimum and cost-effective treatment of
defined as rebleeding anteriorly or posteriorly, necessi-
patients with intractable epistaxis is still controversial,
tating further treatment. These patients were treated
with conflicting results reported in the literature.2,12,13
with repacking, arterial embolization, or surgical inter-
To date, there are no studies that compare ESAL with
vention as deemed necessary by the admitting surgeon.
conventional epistaxis treatment. We hypothesized that
ESAL is an effective and cost-saving method of recur-
Data Collection
rent epistaxis treatment. This prospective randomized
Patient demographics, treatment characteristics, num-
trial was, therefore, designed to compare ESAL with
ber of hospitalization days, and rates of recurrence
conventional nasal packing in the treatment of recur-
were recorded prospectively. The total cost of treat-
rent epistaxis.
ment for each patient was calculated by adding the cost
of the procedure, the cost of hospitalization, and doc-
Methods
tors’ fees (radiologists, surgeons, and anaesthetists).
Institutional Review Board
Follow-up
The Health and Research Ethics Board of the Univer-
A postdischarge telephone questionnaire (Table 1) was
sity of Alberta approved this study.
used to assess patient satisfaction with the therapy. Fol-
low-ups ranged from 3 to 14 months.
Patients
Patients were registered in the study databank follow-
Statistical Analysis
ing referral for epistaxis control to the otolaryngology
Statistical analysis was performed using SPSS for Win-
service at the University of Alberta. All patients were
dows, version 11.0 (SPSS Inc, Chicago, IL). Fisher’s
initially packed using Merocel (Xomed Surgical Prod-
exact test was used for comparison of dichotomous
ucts, Jacksonville, FL) nasal dressings bilaterally and
outcomes between groups, whereas the Mann-Whitney
were randomized to the conservative or surgical arm of
test was used for mean comparison of continuous data.
the study. Patients with bleeding disorders, systemic
anticoagulation, a recent history of nasal surgery,
Results
Rendu-Osler-Weber syndrome, or nasal malignancy
and patients found to be medically unfit for the opera- Nineteen patients were enrolled in the study. Ten
tion were excluded from the study. patients were randomized to the conservative arm and
 Moshaver et al, Early Operative Intervention vs Conventional Treatment in Epistaxis 187

Table 1 Questionnaire Used for Follow-up of Patients Table 3 Treatment Outcome of Patients in ESAL and
Enrolled in the Study Conservative Arms
1. Have you had had any further nosebleeds since last hos- Demographic Factor Conservative ESAL
pitalization?
None Total number of patients 10 9
Few; insignificant Sex (M:F) 7:3 4:5
Large amount requiring medical attention Age (range, yr) 48–89 41–77
Large amount requiring hospitalization Age (average, yr) 66.2 57.3
2. Overall, how satisfied were you with your therapy? ESAL = endoscopic sphenopalatine artery ligation.
Not at all
Somewhat unsatisfied
Neutral None of the patients had any further bleeding following
Satisfied discharge from the hospital. All of the patients in the
Very satisfied
surgical arm were very satisfied with their therapy and
3. Would you recommend this treatment to a relative with
would recommend this procedure to others. On the
severe nosebleeds?
Yes other hand, all of the patients in the conservative arm
No described the experience as painful and unpleasant.

Discussion
nine to the surgical arm. The patient demographics are
included in Table 2. There was no significant difference This study is one of the first randomized prospective
between groups in the distribution of age or sex. Eight trials comparing ESAL and conservative treatment
of the nine patients (89%) in the surgical arm under- methods for the control of recurrent epistaxis. We
went ESAL and anterior ethmoid artery ligation. One found a significant reduction in the cost and length of
of the nine patients (11%) did not have ligation of the hospitalization of the patients undergoing ESAL com-
anterior ethmoid artery, and two required septoplasty. pared with conventional packings. ESAL was also 89%
The observed treatment failure in the conservative effective in controlling the bleeding and had minimal
group was 50% compared with 11% in the surgery sequelae or complications.
arm (Table 3). Although this difference was not found The overall calculated cost of patients undergoing
to be statistically significant (p = .141), there was a ESAL was $5133, compared with $12 213 in the con-
trend toward better resolution of bleeding following servative group, resulting in an average saving of a
surgery in these patients. Epistaxis was controlled in $7080 per patient. This is a significant saving consider-
the five patients who failed conservative therapy ing the number of patients requiring treatment for
through a combination of ESAL, arterial embolization, recurrent epistaxis yearly.
and repacking. The patient who failed in the surgical There was overwhelming patient satisfaction with
arm was controlled with arterial embolization. ESAL compared with nasal packings. All of the
The length of hospitalization is shown in Table 4. patients reported that they would recommend this
There was a statistically significant difference between treatment to another patient.
the average hospital stay of the surgical (1.6 days) and
the conservative (4.7 days) groups (p = .001). The aver-
age cost per patient in the surgical arm was $5133, Table 4 Length of Hospitalization of Patients Treated with
compared with $12 213 in the conservative arm (Table ESAL and Nasal Packings
5). The average saving per patient for early surgical Treatment Modality Mean Range SD
intervention is calculated as $7080.
ESAL 1.6* 1–4 1.01
Thirteen (68%) patients responded to the follow-up Conservative 4.7* 3–7 1.77
telephone questionnaire; six patients were in the surgi-
ESAL = endoscopic sphenopalatine artery ligation.
cal arm and patients were in the conservative arm. *Statistically significant (p = .001).

Table 2 Patient Demographics: Patients Treated by ESAL or Table 5 Comparison of Treatment Cost of ESAL and Nasal
Nasal Packings at the University of Alberta Packings
Demographic Factor Conservative ESAL Cost (%)
Total number of patients 10 9 Outcome Conservative ESAL
Sex (M:F) 7:3 4:5
Age (range, yr) 48–89 41–77 Successful outcome 7620 4298.42
Age (average, yr) 66.2 57.3 Unsuccessful outcome 15 275.31 11 811.88
Average 12 213.19 5133.25
ESAL = endoscopic sphenopalatine artery ligation.
188 The Journal of Otolaryngology, Volume 33, Number 3, 2004

Conclusion tion of the sphenopalatine artery for refractory posterior

epistaxis. Am J Rhinol 2000;14:261–4.
ESAL is an excellent, well-tolerated, and cost-effective 7. White, PS. Endoscopic ligation of the sphenopalatine artery
method for treating recurrent epistaxis. (ELSA): a preliminary description. J Laryngol Otol 1996;
110:27–30.
References 8. Ram B, White, PS, Saleh HA, et al. Endoscopic endonasal lig-
ation of the sphenopalatine artery. Rhinology 2000;38:147–9.
1. Wurman LH, Sack JG, Flannery JV, Lipsman RA. The man- 9. Snyderman CH, Goldman, SA, Carrau RL, et al. Endoscopic
agement of epistaxis. Am J Otolaryngol 1992;13:193–209. sphenopalatine artery ligation is an effective method of treat-
2. Schaitkin B, Stauss M, Houck JR. Epistaxis: medical versus ment for posterior epistaxis. Am J Rhinol 1999;13:137–40.
surgical therapy: a comparison of efficacy, complications, 10. Marcus MJ. Nasal endoscopic control of epistaxis. Oto-
and economic consideration. Laryngoscope 1987;97:1392–6. laryngol Head Neck Surg 1990;102:273–5.
3. Shaw CB, Wax MK, Wetmore SJ. Epistaxis: a comparison 11. Budrovich R, Saetti R. Microscopic and endoscopic ligation of
of treatment. Otolaryngol Head Neck Surg 1993;109:60–5. the sphenopalatine artery. Laryngoscope 1992;102:1390–4.
4. Pollice PA, Yoder MG. Epistaxis: a retrospective review of 12. Cullen MM, Tami TA. Comparison of internal maxillary
hospitalized patients. Otolaryngol Head Neck Surg 1997; artery ligation versus embolization for refractory posterior
117:49–53. epistaxis. Otolaryngol Head Neck Surg 1998;118:636–42.
5. Christmas DA. Transnasal endoscopic ligation of the 13. Monte ED, Belmonte MJ, Wax MK. Management paradigms
sphenopalatine artery. Ear Nose Throat J 1998;77:524–5 for posterior epistaxis: a comparison of costs and complica-
6. Wormald PJ, Wee DTH, van Hasselt CA. Endoscopic liga- tions. Otolaryngol Head Neck Surg 1999;121:103–6.
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