A new ligation approach to the management of chronic epistaxis.

Abstract

Standard cauterization therapy for chronic epistaxis is less than ideal because of the inadequacy of topical anesthesia and the difficulty of treating young, often uncooperative patients. The author has developed a new procedure for treating these patients, which entails ligation and cauterization while the patient is under light general anesthesia in an outpatient surgical facility. Of the approximately 7S procedures the author has performed, only one failed to achieve expected results. This article describes how this safe, simple, and ultimately cost-effective procedure is performed.

Introduction

General otolaryngologists are frequently called on to diagnose and treat nosebleeds in children and young adults. For the most part, diagnosis is easy, because at least 95% of nosebleeds are located in the anterior of Kiesselbach's area.

Patients usually seek treatment when self-control of bleeding with pressure or packing has failed. Although chronic nosebleeds can be profuse, they are usually intermittent, so patients usually do not seek care on an emergency basis. Epistaxis is usually unilateral. When both sides are involved, it is rarely simultaneous.

The anatomy of Kiesselbach' s area is significant. Blood is supplied to this area by a labial artery that branches off the facial artery. This vessel enters the nose just anterior to the inferior turbinate, courses along the floor of the nose in the mucocutaneous junction of the vestibule, and branches out in the nasal septum in several directions. The bleeding point is usually at one of these branch vessels.

When physician care is necessary for chronic epistaxis, treatment usually consists of electrical or chemical cautery under topical anesthesia. It is not a simple matter to cauterize these patients, because the anesthesia is not as potent as one would desire and the young age of most patients usually does not engender high levels of cooperation.

Description of a new technique

With these drawbacks in mind, the author developed a new procedure for treating chronic epistaxis and has been performing it for approximately 7 years. This simple procedure involves ligating the vessel in the mucocutaneous junction on the floor of the nose bilaterally. It is performed while the patient is under light general anesthesia in an outpatient surgical facility.

The ligation is performed with a 2-0 Vicryl suture and a tapered UR-6 needle with a 2/3 circle (Ethicon; Somerville, N.J.). The suture is passed beneath the blood vessel into the floor of the nose. When the ligation is completed, the branches are sealed distally by either chemical or electrocautery. Both sides are cauterized because the branches on both sides are usually prominent and can be the source of further bleeding.

Treatment success rates

The author has used this technique in approximately 75 cases over the past 7 years, and the results have been extremely gratifying. Patients were followed for approximately 1 year postoperatively with one office visit and other followup telephone calls. In only one case did this procedure fall to achieve the desired result (although the frequency of nosebleeds in that patient was markedly reduced). In the rest of the cases, nosebleeds did not recur and patients or parents expressed satisfaction with the success of the procedure.

In the author's estimation, this procedure is cost-effective because it obviates the need for multiple office visits and multiple cauterizations, which are often necessary with other forms of treatment.

This is a rather simple, effective means of controlling anterior nosebleeds in the pediatric and young-adult population. It carries no complications and it has virtually a 100% success rate.