31 pletcher epistaxis - continuing medical education ... powerpoint - 31_pletcher_epistaxis.ppt...
Post on 29-Apr-2018
214 Views
Preview:
TRANSCRIPT
1
Endoscopic Control of Endoscopic Control of EpistaxisEpistaxis
Steven D. Pletcher MDSteven D. Pletcher MDAssistant Professor Assistant Professor
Department of Otolaryngology Department of Otolaryngology ––Head and Neck SurgeryHead and Neck Surgery
University of California, San FranciscoUniversity of California, San Francisco
EpidemiologyEpidemiology
60% of the population will develop 60% of the population will develop nosebleeds during their lifetimenosebleeds during their lifetime6% of these will seek medical care for 6% of these will seek medical care for their symptomstheir symptoms
2
AnatomyAnatomy
Primary blood supply to the Primary blood supply to the sinosino--nasal nasal cavity is via the cavity is via the sphenopalatinesphenopalatine and and anterior ethmoid arteriesanterior ethmoid arteries
SPA branch of the internal maxillary artery SPA branch of the internal maxillary artery from the external carotid systemfrom the external carotid systemAnterior ethmoid artery is a branch of the Anterior ethmoid artery is a branch of the ophthalmic artery, originating from the ophthalmic artery, originating from the internal carotid systeminternal carotid system
AnatomyAnatomy
Levine & Clemente. Sinus Surgery: Endoscopic and Microscopic Approaches
3
How Do Endoscopes Help in How Do Endoscopes Help in the Management of the Management of EpistaxisEpistaxis??
How Do Endoscopes Help in the How Do Endoscopes Help in the Management of Management of EpistaxisEpistaxis??
Identification of bleeding siteIdentification of bleeding siteDirect Direct cauterycauteryDirected packingDirected packing
Identification and Ligation of Feeding Identification and Ligation of Feeding VesselsVessels
SphenopalatineSphenopalatine ArteryArteryAnterior Ethmoid Artery Anterior Ethmoid Artery
5
IndicationsIndications
IntraoperativeIntraoperative BleedingBleedingRefractory Refractory EpistaxisEpistaxis
Epistaxis Refractory to Packing
EmbolizationOperative Control
6
Posterior PackingPosterior Packing
5050--80% efficacy in 80% efficacy in controlling controlling epistaxisepistaxisDoes not require Does not require General Anesthesia or General Anesthesia or SedationSedation
ComplicationsComplicationsMinor: Minor: AlarAlar soft tissue soft tissue injury, sinusitis, injury, sinusitis, septalseptalperforationperforationMajor: Hypoxia, Major: Hypoxia, Arrhythmia, Arrhythmia, SepticemiaSepticemia
Uncomfortable/Poor Uncomfortable/Poor patient satisfactionpatient satisfaction
Schaitkin et al, Laryngoscope ’87; Pollice et al, OTO/HNS ‘97
Klotz et al, Laryngoscope ’02; Cannon et al, OTO/HNS ‘93
7
EmbolizationEmbolization8080--90% efficacy in 90% efficacy in controlling controlling epistaxisepistaxisCan be performed Can be performed under sedationunder sedation
Does not address Does not address anterior ethmoid anterior ethmoid artery bleedsartery bleedsComplicationsComplications
Minor: facial pain, Minor: facial pain, temporary temporary paresthesiasparesthesiasMajor: CVA (1%), Soft Major: CVA (1%), Soft tissue necrosis, CN tissue necrosis, CN PalsyPalsy
AvailabilityAvailability
Tseng et al, Laryngoscope ’98; Christensen et al, OTO/HNS ‘05
Gurney et al, AJR ’04
Endoscopic SurgeryEndoscopic Surgery
90% success rate90% success rateSurgical access to all Surgical access to all major feeding vesselsmajor feeding vesselsCombine with Combine with cauterizationcauterizationIncludes thorough Includes thorough examination of the examination of the nasal cavitynasal cavity
Requires general Requires general anesthesiaanesthesiaComplications: Complications: crusting, palatal crusting, palatal paresthesiasparesthesiasPublished experience Published experience limited to several limited to several small seriessmall series
Snyderman et al, AJR ’99; Voegels et al OTO/HNS ‘01Wormald et al AJR ‘00
9
Endoscopic Control of Endoscopic Control of EpistaxisEpistaxis
Wait to remove packing until all Wait to remove packing until all instruments are available and patient is instruments are available and patient is anesthetizedanesthetizedInspectionInspectionCauterizationCauterizationArtery ligationArtery ligationDirected packingDirected packing
CauterizationCauterization
10
SphenopalatineSphenopalatine Artery LigationArtery Ligation
Identification Identification IsolationIsolationClippingClipping
11
IdentificationIdentification
IdentificationIdentification
Posterior Maxillary WallPosterior Maxillary WallCristaCrista EthmoidalisEthmoidalisMiddle TurbinateMiddle Turbinate
13
SphenopalatineSphenopalatine Artery LigationArtery Ligation
Wide maxillary Wide maxillary antrostomyantrostomyLook for the impression of the artery on Look for the impression of the artery on the posterior maxillary wallthe posterior maxillary wallOpen the foramen laterally, removing a Open the foramen laterally, removing a portion of the posterior wall of the portion of the posterior wall of the maxillary sinusmaxillary sinusLook for multiple foraminaLook for multiple foraminaPlace clips proximal on the arteryPlace clips proximal on the artery
Anterior Ethmoid ArteryAnterior Ethmoid Artery
IdentificationIdentificationTransTrans--facialfacialEthmoid roofEthmoid roof
CauteryCautery or clippingor clipping
15
TransTrans--nasal Anterior Ethmoid nasal Anterior Ethmoid Artery LigationArtery Ligation
CauteryCauteryClippingClipping
Identification Identification –– Ethmoid RoofEthmoid Roof
22
SummarySummary
EpistaxisEpistaxis is a common disorder that is is a common disorder that is typically treated with conservative typically treated with conservative measuresmeasuresIn severe, refractory cases endoscopic In severe, refractory cases endoscopic surgery is an effective treatment with surgery is an effective treatment with minimal morbidityminimal morbidity
SummarySummary
top related