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Int. J. Odontostomat., 12(4) :343-347, 2018.
Arterial Embolization in the Treatment
of Severe Epistaxis: A Case Report
Embolización Arterial en el Tratamiento de la Epistaxis Severa: Reporte de un Caso
Ferdinando de Conto^1 ; Simone Siqueira^2 ; Jaqueline Colaço^2 ; Leonardo Tonietto^3 ; Rafael D’Agostini Annes^5 & José Ricardo Vanzin^5
CONTO, F.; SIQUEIRA, S.; COLAÇO, J.; TONIETTO, L.; ANNES, R. D. & VANZIN, J. R. Arterial embolization in the treatment of severe epistaxis: A case report. Int. J.Odontostomat., 12(4) :343-347, 2018.
ABSTRACT: Nasal hemorrhage or epistaxis is a common finding in the emergency department. The causes of epistaxis are varied and can be classified as local, systemic or a combination of both. The aim of this study was to report a case of embolization of branches of the maxillary artery for treatment of epistaxis secondary to facial trauma. A 43-year-old man suffered blunt trauma in the frontonasal area as a result of a bicycle accident. It presented with amnesia, severe epistaxis, panfacial edema and nasal deformity. The patient was hypotensive and hypothermic, with evidence of hemorrhagic intracranial. Orotracheal intubation was performed immediately to protect the airways and prevent aspiration of blood to the lower respiratory tract. The occlusion of the artery was successful and was immediately followed by cessation of oronasal bleeding. The patient was discharged after ten days. Arterial embolization should be the gold-standard treatment, which provides a safe and effective alternative for the control of epistaxis.
KEY WORDS: diagnosis, traumatology, bleeding.
INTRODUCTION
Nosebleed, or epistaxis, is a common finding in the emergency department. Approximately 60 % of the population will experience at least one episode of epistaxis during their lives, with only 6 % of such episodes requiring specialized care (Beck et al ., 2018). More severe cases of epistaxis can lead to hemodynamic instability, jeopardize airway patency, and cause cerebral hypoperfusion (Wu et al ., 2007). Rapid and effective management of these episodes is essential to keep morbidity and mortality to a minimum (Fig. 1).
The causes of epistaxis are varied, and can be classified as local (anatomical defects in the nasal septum, trauma, surgical complications, vascular malformations, neoplasms), systemic (hypertension, use of nonsteroidal anti-inflammatory drugs, hereditary hemorrhagic telangiectasia, disorders of hemostasis), or a combination thereof (Strach et al ., 2011).
Facial trauma often causes some degree of na- sal bleeding. Therefore, oral and maxillofacial surgeons and trauma specialists must be familiarized with the anatomy, diagnosis and management of epistaxis and its systemic complications (Yas, 2015).
Epistaxis usually resolves spontaneously or is amenable to local measures, such as manual compression, topical vasoconstrictors, electrocautery, and anterior and/or posterior nasal packing. More severe cases may be unresponsive to these local measures; in these cases, invasive procedures such as vessel ligation, endoscopic surgery, and arterial embolization may be indicated (Strach et al .; de Bonnecaze et al ., 2017).
We report a case of embolization of maxillary artery branches for treatment of epistaxis secondary to facial trauma. A review of the literature highlights
(^1) Surgery and Traumatology Residence Service Bucomaxillofacial of the University of Passo Fundo (UPF) and Hospital of the City of Passo Fundo - RS, Brazil. (^2) Dentist Surgery University of Passo Fundo - RS, Brazil. (^3) Bucomaxillofacial Surgery and Traumatology Service Bom Pastor Hospital, Igrejinha - RS, Brazil. (^4) Neurosurgery Department, Hospital da Cidade, Passo Fundo, Brazil. (^5) Residence of neurosurgery service Hospital City Passo Fundo - RS, Brazil.
the importance of establishing a protocol for management of epistaxis, which is still an underrepresented topic in oral and maxillofacial surgery and trauma surgery journals.
Anatomical considerations. The most common site of epistaxis is the anterior septal region, also known as Kiesselbach’s plexus or Little’s area4. Bleeding originating in this area of the anterior nares usually resolves spontaneously or can be controlled with conservative local measures. The nasal cavity is irrigated by the internal carotid artery (ICA), which gives off the ophthalmic artery and its branches, the anterior and posterior ethmoid arteries, and the external carotid artery (ECA), via the internal maxillary artery and its sphenopalatine and descending palatine branches (Strach et al .; Yas). The anterior-most aspect of the nasal septum contains small ramifications of the su- perior labial artery, which is itself a branch of the facial artery.
The blood supply of the posterior septal region originates from the sphenopalatine and descending palatine arteries, which, as mentioned above, are branches of the maxillary artery. The posterior ethmoid artery often provides a minor contribution to the irrigation of this area (Yas).
Severe bleeding originating in the ethmoid arteries usually can only be controlled by surgical means, through a modified Lynch procedure and ligation of the anterior ethmoid artery (a branch of the ICA) (Yas).
The main vessel leading into the nasal cavity is the sphenopalatine artery, which irrigates both the na- sal septum and the lateral wall of the cavity (Noy et al ., 2017). Severe epistaxis nearly always originates from the sphenopalatine artery, usually from its septal portion and, less commonly, from its posterior lateral portion (Djindjian et al ., 1973).
CASE REPORT
A 43-year-old male sustained direct blunt trau- ma to the frontonasal area as the result of a bicycle accident. He was brought to the Emergency Department of Hospital da Cidade de Passo Fundo, Rio Grande do Sul, Brazil, with amnesia, severe epistaxis, panfacial edema, and nasal deformity. On admission, the patient underwent routine trauma assessment, including a neurological and oral/ maxillofacial examination, which revealed no abnormalities beyond the aforementioned craniofacial injuries. Due to copious, simultaneous bleeding from the anterior nares and oral cavity, posterior nasal packing was performed with the aid of a 16F Foley catheter, despite full knowledge of the risk of cerebral penetration through a fractured cribriform plate. Bila- teral anterior nasal packing with ribbon gauze was also performed.
The patient underwent a period of 18 hours for observation, but persisted bleeding, he was hypotensive and hypothermic, providing further evidence of the severity of his condition. Orotracheal intubation was performed immediately to secure the airway and prevent aspiration of blood into the lower respiratory tract, and two units of packed red blood cells were transfused to maintain hemodynamic stability. A computed tomography scan of the head and face showed multiple frontal, nasal, orbital, and ethmoid fractures, as well as blood in all paranasal sinuses (Fig. 2). There was, however, no evidence of intracranial hemorrhage. Repeat examination over the 24 hours following nasal packing revealed persistent active bleeding despite a substantial reduction in blood loss. The patient was transferred to the interventional radiology department for cerebral angiography, which revealed an area of contrast blush suggestive of bleeding from a branch of the right maxillary artery.
Fig. 1. Vascular anatomy of the nasal region.
Fig. 2. Computed tomography of the head and face. A) Three- dimensional reconstruction showing panfacial (frontal/nasal/ orbital/ethmoid) fractures. B) Axial image showing blood-filled paranasal sinuses.
Int. J. Odontostomat., 12(4) :343-347, 2018.
embolization. The Emergency Department staff of Hospital da Cidade de Passo Fundo, prefer use arterial embolization as a treatment option, as currently offers huge benefit in the management of epistaxis (Reyre et al ., 2015).
Arterial embolization provides several advantages over vessel ligation. Surgical exploration of complex wounds, with attendant edema, soft tissue defects and comminuted fractures, can be extremely challenging. Microcatheter angiography can be performed at sites remote from the actively bleeding lesion and different sources of bleeding—often bilate- ral—can be identified by fluoroscopy (as extravasation of contrast media from the affected artery) and controlled by embolization, a procedure that can be performed relatively quickly and under local anesthesia (Chen et al .; Yas). Angiography can also identify bleeding originating from the ethmoid arteries, branches of the ophthalmic artery, an event that requires direct surgical access and vessel ligation for hemostasis (Debelmas et al .). Furthermore, pre- embolization angiography can provide valuable information on vascular abnormalities and the extent of the site of bleeding (Strach et al .; Beck et al .).
Strach et al. note that arterial embolization is a quick procedure and can easily be repeated as necessary; furthermore, early endovascular intervention can shorten length of stay and minimize transfusion requirements. Wu et al. state that early arterial embolization minimizes hypoperfusion, thus preventing further neurologic damage.
The occlusive agents used in arterial embolization are polyvinyl alcohol particles, gelatin sponge, butyl-cyanoacrylate, metal coils, and concentrated alcohol (Yas).
Several authors have reported high success rates (87.5-96 %) with arterial embolization for control of epistaxis, with a low rate of complications (1.9- %), which, nevertheless, have included tissue necrosis, blindness, facial nerve palsy, and migration of the embolus to the ICA and vertebral arteries (Djindjian et al .; Wu et al .; Cogbill et al .; de Bonnecaze et al .).
CONCLUSION
In the management of epistaxis, there are several forms of treatment for, conservative measures
should always precede more invasive interventions. When nonsurgical measures fail, arterial embolization should be the treatment of choice, as it provides a safe and effective alternative for control of severe epistaxis.
CONTO, F.; SIQUEIRA, S.; COLAÇO, J.; TONIETTO, L.; ANNES, R. D. & VANZIN, J. R. Embolización arterial en el tratamiento de la epistaxis severa: Reporte de un caso. Int. J. Odontostomat., 12(4) :343-347, 2018.
RESUMEN: La hemorragia nasal o epistaxis es un hallazgo común en el servicio de urgencias. Las causas de la epistaxis son variadas y pueden clasificarse como loca- les, sistémicas o una combinación. El objetivo de este estu- dio fuerelatar un caso de embolización de ramas de la arte- ria maxilar para el tratamiento de epistaxis secundaria a trau- ma facial. Um hombre de 43 años de edad sufrió traumatis- mo contuso en la zona frontonasal como consecuencia de un accidente de bicicleta. Se presentaba con amnesia, epistaxis grave, edema panfacial y deformidad nasal. El pa- ciente fue hipotenso y hipotermático, con evidencia de he- morragia intracraneal. La intubación orotraqueal fue realiza- da inmediatamente para proteger las vías aéreas y evitar la aspiración de sangre para el tracto respiratorio inferior. La oclusión de la arteria fue exitosa y fue seguida inmediata- mente por cesación de sangramiento oronasal. El paciente fue dado de alta después de diez días. La embolización arterial debe ser el tratamiento de elección, que proporciona una alternativa segura y eficaz para el control de la epistaxis.
PALABRAS CLAVE: diagnóstico, traumatología, sangramiento.
REFERENCES
Beck, R.; Sorge, M.; Schneider, A. & Dietz, A. Current approaches to epistaxis treatment in primary and secondary care. Dtsch. Arztebl. Int., 115(1-2) :12-22, 2018. Chen, Y. F.; Tzeng, I. H.; Li, Y. H.; Lo, Y. C.; Lin, W. C.; Chiang, H. J.; Chen, R. F. & Shen, W. C. Transcatheter arterial embolization in the treatment of maxillofacial trauma induced life-threatening hemorrhages. J. Trauma, 66(5) :1425-30, 2009. Cogbill, T. H.; Cothren, C. C.; Ahearn, M. K.; Cullinane, D. C.; Kaups, K. L.; Scalea, T. M.; Maggio, L.; Brasel, K. J.; Harrison, P. B.; Patel, N. Y.; Moore, E. E.; Jurkovich, G. J. & Ross, S. E. Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective. J. Trauma, 65(5) :994-9, 2008. de Bonnecaze, G.; Gallois, Y.; Chaynes, P.; Bonneville, F.; Dupret- Bories, A.; Chantalat, E. & Serrano, E. Intractable epistaxis: which arteries are responsible? An angiographic study. Surg. Radiol. Anat., 39(11) :1203-7, 2017. Debelmas, A.; Lanciaux, S. & Schouman, T. A case of epistaxis. J. Stomatol. Oral Maxillofac. Surg., 118(6) :383-4, 2017. Djindjian, R.; Merland, J. J.; Rey, A.; Thurel, J. & Houdart, R. Super- selective arteriography of the external carotid artery. Importance of this new technic in neurological diagnosis and in embolization. Neurochirurgie, 165-71, 1973.
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Int. J. Odontostomat., 12(4) :343-347, 2018.
Corresponding author: Ferdinando de Conto Universidade de Passo Fundo BR 285, Bairro São José 99052-900, Passo Fundo - RS BRAZIL
E-mail: 122981@upf.br
Received: 13-04- Accepted: 08-10-
