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1.  Rigid Nasal Endoscopy in the Diagnosis and Treatment of Epistaxis 
Background and Objectives: Epistaxis is one of the common symptoms encountered in the Otorhinolaryngology department. Many times the cause for epistaxis is not found on anterior and posterior rhinoscopy. The present study was undertaken to assess the role of rigid nasal endoscope in the diagnosis and treatment of epistaxis, where normal anterior and posterior rhinoscopy did not reveal any specific finding.
Methods: Fifty patients with epistaxis were studied using rigid nasal endoscope under local anaesthesia. Patients who were above 15 years with nasal bleeding and who were willing for rigid nasal endoscopy were included in the study. Patients less than 15 years were not included in the study because nasal endoscopy was difficult in them under local anaesthesia. Only those patients in whom, the cause for epistaxis could not be made out on anterior and posterior rhinoscopy were chosen for the study, this was done in order to remove the bias for nasal endoscopy.
Results: The use of the nasal endoscope allowed diagnosis of bleeding points and treating them directly. Epistaxis was more in male patients especially in the 3rd and after the 5th decade. On endoscopic examination,the bleeding points were identified as coming from the crevices of the lateral nasal wall, posterior spur on the septum, posterior deviation of the septum with ulcer, congested polyps, enlarged and congested adenoids, scabs or crusts in the crevices of the lateral nasal wall and angiofibroma. Endoscope also helps in the treatment of epistaxis, which includes endoscopic selective nasal packing using gelfoam, endoscopic cautery or diathermy and endoscopic polypectomy. Other patients with adenoids, scabs and crusts and angiofibroma were managed on their merits.
Interpretation and Conclusion: Nasal endoscopy helps not only in the localisation of the bleeding point but also in the treatment of those bleeding areas that are situated in the posterior and lateral part of the nose.
doi:10.7860/JCDR/2013/4421.2995
PMCID: PMC3681049  PMID: 23814722
Epistaxis; Rigid nasal endoscope; Selective nasal packing; Cautery or diathermy
2.  Endoscopic Management of Posterior Epistaxis 
The traditional method of management of posterior epistaxis has been with anteroposterior nasal packing. Apart from the high failure rate of 26–50% reported in various series, nasal packing is associated with marked discomfort and several complications. In order to avoid nasal packing, we started doing endoscopic cauterization in cases of posterior epistaxis. A total of 23 patients with posterior epistaxis were subjected to nasal endoscopy with the intent to stop bleeding by cauterization of the bleeding vessel. Of these, in four cases unsuspected diagnosis was made. Of the remaining 19, in three patients, the bleeding point could not be localized accurately and these patients were managed by anteroposterior packing. The rest of the 16 patients were managed by endoscopic cauterization. In four patients, there was recurrence of bleeding within 24 h. In one of these, cauterization controlled the bleeding while in the rest nasal packing had to be resorted to. Thus, of the 23 patients of posterior epistaxis subjected to nasal endoscopy, we could avoid nasal packing in 17 (74%). To conclude, endoscopic nasal cauterization is recommended as the first line to treatment in all cases of posterior epistaxis. This will not only prevent the uncomfortable and potentially dangerous nasal packing but also help in finding the underlying pathology.
doi:10.1007/s12070-010-0054-0
PMCID: PMC3102162  PMID: 22468250
3.  Recurrent epistaxis caused by an intranasal supernumerary tooth in a young adult 
Patient: Male, 27
Final Diagnosis: Recurrent epistaxis
Symptoms: Nasal bleeding
Medication: —
Clinical Procedure: —
Specialty: Pediatrics and Neonatology
Objective:
Congenital defects/diseases
Background:
Recurrent epistaxis is a common disorder among children and young adults. We report an unusual cause, intranasal supernumerary tooth causing friction with Little’s area of the nasal septum.
Case Report:
A 22-year-old male presented with recurrent, mild, unilateral left-sided epistaxis once to twice per month for 3 years. This usually occurred after minor nasal trauma or rubbing his nose. The patient also suffered from recurrent tonsillitis. There was neither history of blood transfusion or nasal packing, nor a history suggestive of bleeding diathesis.
Anterior rhinoscopy revealed ivory white nasal mass antero-inferiorly in the left nasal cavity touching Little’s area. There was no bleeding. Nasal endoscopy showed a white cylindrical bony mass 1 cm long arising from the floor of the nose, with no attachment to the nasal septum or the lateral wall of the nose. Examination of the right nasal cavity was unremarkable.
Conclusions:
Nasal teeth result from the ectopic eruption of supernumerary teeth and may cause a variety of symptoms including recurrent epistaxis. Their clinical and radiologic presentation is so characteristic that their diagnosis is not difficult. CT scan is helpful in planning management. Early extraction prevents further complications and prevents further attacks of epistaxis.
doi:10.12659/AJCR.890710
PMCID: PMC4099208  PMID: 25031783
Epistaxis; Nasal Cavity; Tonsillitis; Tooth, Supernumerary
4.  The role of surgical audit in improving patient management; nasal haemorrhage: an audit study 
BMC Surgery  2007;7:19.
Background
Nasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified.
The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit.
Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care.
Methods
Retrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March).
Prospective: 60consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent.
New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel®) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use.
Results
Previously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days.
In the prospective audit the total number of admissions was significantly reduced, by over 70%, (χ2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (χ2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (χ2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over £50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work.
Conclusion
Exclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.
This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care.
doi:10.1186/1471-2482-7-19
PMCID: PMC2034528  PMID: 17854499
5.  Nasal packing aspiration in a patient with Alzheimer’s disease: a rare complication 
Nasal bleeding is a frequent problem for patients receiving anticoagulant agents. Most cases are successfully managed with anterior or posterior nasal packing. However, the complications of nasal packing should be always considered. We report the case of a 78-year-old man with Alzheimer’s disease who was treated for anterior epistaxis with anterior nasal packing using three pieces of antibiotic-soaked gauze. Two days later, the patient was admitted to the emergency department in respiratory distress. A chest x-ray demonstrated atelectasis of the right lung. During an examination of the nasal cavities, the nasal packing was removed, and one of the gauze pieces was missing. The patient underwent rigid bronchoscopy, and the missing gauze was found to be obstructing the right main bronchus. The patient’s respiratory function improved considerably after removal of the foreign body. It is assumed that gauze packs should be used with caution in patients with an impaired level of consciousness and neurodegenerative diseases.
doi:10.2147/IJGM.S34676
PMCID: PMC3413305  PMID: 22879779
epistaxis; nasal packing; aspiration; Alzheimer’s disease; cough reflex
6.  Utility of a Commercially Available Multiplex Real-Time PCR Assay To Detect Bacterial and Fungal Pathogens in Febrile Neutropenia ▿  
Journal of Clinical Microbiology  2009;47(8):2405-2410.
Infection is the main treatment-related cause of mortality in cancer patients. Rapid and accurate diagnosis to facilitate specific therapy of febrile neutropenia is therefore urgently warranted. Here, we evaluated a commercial PCR-based kit to detect the DNA of 20 different pathogens (SeptiFast) in the setting of febrile neutropenia after chemotherapy. Seven hundred eighty-four serum samples of 119 febrile neutropenic episodes (FNEs) in 70 patients with hematological malignancies were analyzed and compared with clinical, microbiological, and biochemical findings. In the antibiotic-naïve setting, bacteremia was diagnosed in 34 FNEs and 11 of them yielded the same result in the PCR. Seventy-three FNEs were negative in both systems, leading to an overall agreement in 84 of 119 FNEs (71%). During antibiotic therapy, positivity in blood culture occurred only in 3% of cases, but the PCR yielded a positive result in 15% of cases. In six cases the PCR during antibiotic treatment detected a new pathogen repetitively; this was accompanied by a significant rise in procalcitonin levels, suggestive of a true detection of infection. All patients with probable invasive fungal infection (IFI; n = 3) according to the standards of the European Organization for Research and Treatment of Cancer had a positive PCR result for Aspergillus fumigatus; in contrast there was only one positive result for Aspergillus fumigatus in an episode without signs and symptoms of IFI. Our results demonstrate that the SeptiFast kit cannot replace blood cultures in the diagnostic workup of FNEs. However, it might be helpful in situations where blood cultures remain negative (e.g., during antimicrobial therapy or in IFI).
doi:10.1128/JCM.00491-09
PMCID: PMC2725651  PMID: 19571034
7.  Modified Technique of Anterior Nasal Packing: A Comparative Study Report 
Anterior nasal packing, which is a common procedure in otorhinolaryngology practice, has different complications. Pain during introduction and removal of pack, bleeding after removal due to mucosal damage and synechia formation are common among them. A continuous effort is going on worldwide to combat those by modifying the nature of pack material or inventing new materials for nasal packing. In the present study an effort was made to compare a new modification of conventional gauze pack by using aluminum foil prepared from the cover of suture materials as septal splint (to reduce the mucosal damage) with conventional gauze pack and another costly material, nasal tampon (merocel). Comparisons were done in terms of cost, efficacy and complications. Prospective hospital based interventional study. Patients were distributed into three groups according to the material used for anterior nasal packing. Comparisons were made in terms of cost of the material used, pain during introduction of pack, rise of systolic blood pressure, incidences of bleeding while pack in situ, incidences of bleeding after removal of pack that required repacking and incidences of synechia formation after pack removal. The episodes of bleeding while pack in situ, within first 48 h and forced for repacking was observed to be significantly more prevalent among nasal tampon groups (12.5%) of patients but only 2.1 and 2.4% with use of conventional gauze pack and our modification respectively. Regarding bleeding after removal of pack, 10.6% patients experienced bleeding with conventional gauze pack, whereas with our modification it was only 2.4%. Synechia formation was found to be highest among the cases with conventional gauze pack (14.9%), but with our modification it is only 2.4%. In this study it is found that use of aluminum foil prepared from the cover of suture materials can be very useful and cost effective method to reduce some of the complications of anterior nasal packing.
doi:10.1007/s12070-011-0343-2
PMCID: PMC3477445  PMID: 24294575
ANS packing; Epistaxis; Septal splint; Nasal tampon
8.  Waldenstrom Macroglobulinemia Presenting as Isolated Persistent Epistaxis: A Very Rare Presentation 
Nose bleed is the most common rhinological emergency. There are multiple risk factors for the development of epistaxis and it can affect any age group, but it is the elderly population with their associated morbidity who often require more intensive treatment and subsequent admission. Most cases of epistaxis occur in the Little’s area, a location readily accessible and treatable by cautery or anterior nasal packing. However, posterior epistaxis often requires more aggressive measures including posterior nasal packing and endoscopic cauterization. After posterior nasal packing, the two most common therapies for intractable epistaxis are transantral ligation of the internal maxillary artery and percutaneous embolization of the distal internal maxillary artery. However, optimal management of intractable posterior epistaxis remains controversial. We hereby report fourth case of Waldenstrom Macroglobulinemia in English literature, which presented as isolated persistent epistaxis and was treated by therapeutic plasmapheresis.
doi:10.1007/s12070-012-0613-7
PMCID: PMC3649036  PMID: 24427564
Epistaxis; Little’s area; Embolization; Plasmapheresis; Waldenstrom macroglobulinemia
9.  Etiological profile and treatment outcome of epistaxis at a tertiary care hospital in Northwestern Tanzania: a prospective review of 104 cases 
Background
Epistaxis is the commonest otolaryngological emergency affecting up to 60% of the population in their lifetime, with 6% requiring medical attention. There is paucity of published data regarding the management of epistaxis in Tanzania, especially the study area. This study was conducted to describe the etiological profile and treatment outcome of epistaxis at Bugando Medical Centre, a tertiary care hospital in Northwestern Tanzania.
Methods
This was a prospective descriptive study of the cases of epistaxis managed at Bugando Medical Centre from January 2008 to December 2010. Data collected were analyzed using SPSS computer software version 15.
Results
A total of 104 patients with epistaxis were studied. Males were affected twice more than the females (2.7:1). Their mean age was 32.24 ± 12.54 years (range 4 to 82 years). The modal age group was 31-40 years. The commonest cause of epistaxis was trauma (30.8%) followed by idiopathic (26.9%) and hypertension (17.3%). Anterior nasal bleeding was noted in majority of the patients (88.7%). Non surgical measures such as observation alone (40.4%) and anterior nasal packing (38.5%) were the main intervention methods in 98.1% of cases. Surgical measures mainly intranasal tumor resection was carried out in 1.9% of cases. Arterial ligation and endovascular embolization were not performed. Complication rate was 3.8%. The overall mean of hospital stay was 7.2 ± 1.6 days (range 1 to 24 days). Five patients died giving a mortality rate of 4.8%.
Conclusion
Trauma resulting from road traffic crush (RTC) remains the most common etiological factor for epistaxis in our setting. Most cases were successfully managed with conservative (non-surgical) treatment alone and surgical intervention with its potential complications may not be necessary in most cases and should be the last resort. Reducing the incidence of trauma from RTC will reduce the incidence of emergency epistaxis in our centre.
doi:10.1186/1472-6815-11-8
PMCID: PMC3175172  PMID: 21892930
Epistaxis; etiology; treatment outcome; Tanzania
10.  Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis 
Intractable posterior epistaxis remains a challenging problem for our specialty. Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entirely satisfactory because of morbidity, high failure rates and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior epistaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described.
The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior and posterior nasal packing.
doi:10.1007/BF02907693
PMCID: PMC3451447  PMID: 23120200
11.  Management of intractable spontaneous epistaxis 
Background:
Epistaxis is a common otolaryngology emergency and is often controlled with first-line interventions such as cautery, hemostatic agents, or anterior nasal packing. A subset of patients will continue to bleed and require more aggressive therapy.
Methods:
Intractable spontaneous epistaxis was traditionally managed with posterior nasal packing and prolonged hospital admission. In an effort to reduce patient morbidity and shorten hospital stay, surgical and endovascular techniques have gained popularity. A literature review was conducted.
Results:
Transnasal endoscopic sphenopalatine artery ligation and arterial embolization provide excellent control rates but the decision to choose one over the other can be challenging. The role of transnasal endoscopic anterior ethmoid artery ligation is unclear but may be considered in certain cases when bleeding localizes to the ethmoid region.
Conclusion:
This article will focus on the management of intractable spontaneous epistaxis and discuss the role of endoscopic arterial ligation and embolization as it pertains to this challenging clinical scenario.
doi:10.2500/ajra.2012.26.3696
PMCID: PMC3906521  PMID: 22391084
Anterior; artery; embolization; endoscopic; endovascular; epistaxis; ethmoid; packing; posterior; sphenopalatine
12.  Bilateral Tri-Arterial Embolization for the Treatment of Epistaxis 
Background:
Intractable epistaxis is treated by ipsilateral trans-arterial embolization of the internal maxillary artery, but there is 13–26% recurrence of bleeding. Preemptive embolization of both internal maxillary arteries along with the ipsilateral facial artery could provide maximal protection against recurrent epistaxis. We report our experience with 8 patients treated with bilateral tri-arterial embolization.
Methods:
We performed a retrospective review of the patients who were treated with bilateral internal maxillary artery and ipsilateral facial artery embolization from January 2005 to January 2007. All patients had bleeding that was refractory to nasal packing.
Results:
Eight patients were treated with bilateral tri-arterial embolization. The median age was 65 years (range, 35–90 years). Risk factors included hypertension (n=4), smoking (n=2), alcohol (n=2), and use of anticoagulation (n=2). All but 2 of the patients were treated under local anesthesia. All patients had complete obliteration of bleeding during the procedure, with no residual vascular blush. No major peri- or post-procedural complications were noted. Patients stayed in the hospital for 2–4 days (average 2.6 days). One patient developed ipsilateral temporofacial pain which resolved during hospitalization. Another patient had minor recurrent epistaxis on post operative day 2 which resolved with temporary repacking and the patient was discharged the next day.
Conclusion:
In our experience with 8 cases, bilateral internal maxillary artery and/or ipsilateral facial artery embolization was achieved without complication and was associated with complete obliteration of vascular blush and no significant recurrent epistaxis.
PMCID: PMC3317326  PMID: 22518233
Epistaxis; arterial embolization; internal maxillary artery; polyvinyl alcohol particles
13.  Efficacy of conservative treatment modalities used in epistaxis 
Objective
To assess the efficacy of conservative modalities in the management of epistaxis.
Study design
Prospective case studies.
Setting
Rural medical college hospital.
Patients
Indoor and outdoor patients with epistaxis.
lntervention
Conservative(non surgical) management techniques in epistaxis.
Results
Chemical cauterization was successful in 72.07% cases, anterior nasal packing in 84.5% and posterior nasal packing in 95.6% cases.
Conclusion
Out of 300 cases of epistaxis included in the study (except for one case that required internal maxillary artery ligation). all cases were treated successfully with conservative treatment alongwith treating the underlying pathology causing epistaxis.
doi:10.1007/BF02968765
PMCID: PMC3451969  PMID: 23120019
Epistaxis; cauterization; nasal packing
14.  Endoscopic sphenopalatine artery ligation for refractory posterior epistaxis 
Intractable posterior epistaxis remains a challenging problem for our specialty Conventional management options in the form of anterior and posterior packing, arterial ligation of the internal maxillary or the external carotid artery and embolization, are not entively satisfactory because of morbidity, high failure rates, and occasional significant complication. Our experience with endoscopic sphenopalatine artery ligation for four patients with posterior existaxis is described. All patients had epistaxis refractory to anterior and posterior nasal packing, which was rapidly controlled following the procedure. The technique of spheno-palatine artery ligation is described. The technique is simple and effective and prevents the morbidity and complications of nasal packing. It is especially useful in systemically compromised individuals who otherwise tolerate nasal packing poorly. and should be one of the treatment options to be considered relatively early in the management of epistaxis refractory to anterior & posterior nasal packing.
doi:10.1007/BF03008017
PMCID: PMC3451351  PMID: 23120175
15.  Nasal endoscopy-evaluation in epistaxis 
Epistaxis is generally of two types : one where a cause is recognised ( Local or Systemic ) and the other where the cause is not known. All cases of nose bleeds with no evident cause is customarily categorised into an Idiopathic type. Anterior rhinoscopy ordinarily gives a very limited view of the nose and the probable cause of epistaxis, and this, we feel could he one of the reasons why a proper diagnosis is not always likely. Another problem is the poor localisation of the site of bleeding point. Such cases pose a problem in implementing treatment, as the cause or the site is not easily located. This study tries to venture the exquisite and wide vision provided by the Nasal endoscope. This study also tries to investigate the possibility of reaching the inaccessible bleeding points, to treat them directly. The study was conducted on 60 patients who attended the Out Patient Department and the Indoor ward with complaints of Epistaxis.
doi:10.1007/BF03000330
PMCID: PMC3451285  PMID: 23119651
16.  Endoscopic management of posterior epistaxis: a review 
SUMMARY
The paradigm for the management of epistaxis, specifically posterior epistaxis, has undergone significant changes in the recent past. Recent prospective and retrospective data has shown that the endonasal surgical management of posterior epistaxis is superior to posterior nasal packing and angiography/embolization with regards to various factors including pain, cost-effectiveness, risk and overall control of bleeding. Endonasal endoscopic surgical techniques for posterior epistaxis include direct cauterization and transnasal endoscopic sphenopalatine/ posterior nasal artery ligation or cauterization with or without control of the anterior ethmoidal artery. Despite the evidence provided by the current literature, a universal treatment protocol has not yet been established. This review article provides an up-to-date assessment of the available literature, and presents a structured paradigm for the management of posterior epistaxis.
PMCID: PMC3970224  PMID: 24711676
Epistaxis; Endoscopic sphenopalatine artery ligation; Posterior epistaxis; Sphenopalatine artery
17.  Intractable Anemia: A Case of Bleeding Nasal Cavernous Hemangioma 
Cavernous haemangioma of the nose is rare, but when it occurs it usually presents with severe epistaxis. This nasal pathology is mostly seen in adult patient patients. Standard approach to dealing with such haemangiomas is surgical resection. A 30-year-old woman presented to General Physician with history of haemoptysis, haematemesis and weakness. She was admitted for investigation of her severe anaemia. On examination there was no obvious source of bleeding in the mouth or oropharynx, and Upper GI endoscopy did not reveal any pathology. She was referred to us after a trivial episode of epistaxis. Anterior and posterior rhinoscopy did not reveal any abnormality. Her extreme anxiety made indirect laryngoscopy and post-nasal space examination difficult but no obvious abnormality was seen. Diagnostic nasal endoscopy was done, and a small haemangiomatous mass was found in the postero superior part of inferior turbinate. Excision of the mass was done under local anaesthesia and sent for histopathological evaluation. The mass on histopathology came out to be Cavernous haemangioma.
doi:10.1007/s12070-011-0176-z
PMCID: PMC3146694  PMID: 22754827
Severe anaemia; Cavernous haemangioma; Endoscopic excision
18.  Endoscopic Cauterization of the Sphenopalatine Artery to Control Severe and Recurrent Posterior Epistaxis 
Introduction:
Epistaxis is one of the most common medical emergencies, making the management of posterior epistaxis a challenging problem for the ear, nose, and throat (ENT) surgeon. In the cases of conservative management failure, ligation of the major arteries or percutaneous embolization of the maxillary artery is performed routinely in most units, but rates of failure and complications are high. The objective of this study was to assess the effectiveness of endoscopic sphenopalatine artery (SPA) cauterization in patients with refractory posterior epistaxis.
Materials and Methods:
Between April 2011 and January 2012, 27 patients (15 males and 12 females) with refractory posterior epistaxis underwent endoscopic SPA cauterization in two tertiary referral hospitals in Shiraz. Three patients underwent bilateral cauterization.
Results:
Four patients (from 30 arteries) had new epistaxis after surgery, three experienced subsequent epistaxis requiring medical treatment, and one patient had a minor epistaxis not needing treatment.
Conclusion:
The SPA electrocoagulation technique seems to be safe, simple, fast, and effective with low rates of morbidity and complications for the management of refractory posterior epistaxis. Endoscopic SPA cauterization should be considered as an immediate second-line management when conservative treatment as first-line management fails.
PMCID: PMC3846233  PMID: 24303435
Epistaxis; Endoscopic sphenopalatine artery cauterization; SPA electrocoagulation technique
19.  Exploring the predictive value of the evoked potentials score in MS within an appropriate patient population: a hint for an early identification of benign MS? 
BMC Neurology  2012;12:80.
Background
The prognostic value of evoked potentials (EPs) in multiple sclerosis (MS) has not been fully established. The correlations between the Expanded Disability Status Scale (EDSS) at First Neurological Evaluation (FNE) and the duration of the disease, as well as between EDSS and EPs, have influenced the outcome of most previous studies. To overcome this confounding relations, we propose to test the prognostic value of EPs within an appropriate patient population which should be based on patients with low EDSS at FNE and short disease duration.
Methods
We retrospectively selected a sample of 143 early relapsing remitting MS (RRMS) patients with an EDSS < 3.5 from a larger database spanning 20 years. By means of bivariate logistic regressions, the best predictors of worsening were selected among several demographic and clinical variables. The best multivariate logistic model was statistically validated and prospectively applied to 50 patients examined during 2009–2011.
Results
The Evoked Potentials score (EP score) and the Time to EDSS 2.0 (TT2) were the best predictors of worsening in our sample (Odds Ratio 1.10 and 0.82 respectively, p=0.001). Low EP score (below 15–20 points), short TT2 (lower than 3–5 years) and their interaction resulted to be the most useful for the identification of worsening patterns. Moreover, in patients with an EP score at FNE below 6 points and a TT2 greater than 3 years the probability of worsening was 10% after 4–5 years and rapidly decreased thereafter.
Conclusions
In an appropriate population of early RRMS patients, the EP score at FNE is a good predictor of disability at low values as well as in combination with a rapid buildup of disability. Interestingly, an EP score at FNE under the median together with a clinical stability lasting more than 3 years turned out to be a protective pattern. This finding may contribute to an early identification of benign patients, well before the term required to diagnose Benign MS (BMS).
doi:10.1186/1471-2377-12-80
PMCID: PMC3488473  PMID: 22913733
Multiple Sclerosis; EP score; Disability prediction; Multivariate analysis; ROC analysis; Benign MS; Evoked potentials
20.  Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs? 
Introduction
The current mainstream practice in otolaryngology departments relating to the use of prophylactic antibiotics in epistaxis patients requiring nasal packing is highly variable. This is due primarily to the lack of any validated guidelines. As such, we introduced a new treatment algorithm resulting in significant reduction of use in the systemic antibiotics, with emphasis instead on the use of topical antibiotics. The results were validated through a complete audit cycle.
Methods
A total of 57 patients undergoing nasal packing for spontaneous epistaxis were studied. Reaudit occurred after the implementation of new guidelines. Telephone surveys were conducted six weeks after hospital discharge, assessing infective nasal symptoms as well as rebleeding and readmission rates.
Results
Systemic antibiotic prescribing in anterior nasal packing fell by 58.2% between audit cycles with no statistically significant associated increase in infective nasal symptoms, rebleeding or readmission rates six weeks following hospital discharge.
Conclusions
Systemic prophylactic antibiotics are unnecessary in the majority of epistaxis patients with nasal packs. The use of topical antibiotics such as Naseptin® may be more appropriate, cheaper and as effective. Implementation of this treatment algorithm will help standardise systemic antibiotic usage in epistaxis patients with nasal packing and should reduce costs associated with unnecessary use of such medication.
doi:10.1308/003588413X13511609954734
PMCID: PMC3964636  PMID: 23317726
Epistaxis; Guidelines; Antibiotics; Audit; Nasal; Packing
21.  Internal maxillary artery ligation for idiopathic intractable epistaxis 
Epistaxis though common, is rarely life threatening. Routinely nose pinching, anterior find posterior nasal packing and endoscopic cauterization of bleeding points is sufficient to control epistaxis in 99% of the cases. It is mandatory to rule out local and systemic causes before labeling a case as idiopathic by using a battery of investigative modalities. Here are two interesting cases of epistaxis which did not respond to conventional therapeutic modalities in which transantral internal maxillary artery ligation was attempted leading to complete cure.
doi:10.1007/BF02968757
PMCID: PMC3450951  PMID: 23119939
Epistaxis; IMA (interanal maxillary artery)
22.  The innervation of the human acetabular labrum and hip joint: an anatomic study 
Background
The aim of the current study was to evaluate the innervation of the acetabular labrum in the various zones and to understand its potential role in nociception and proprioception in hips with labral pathology.
Methods
A total of twenty hip labrums were tagged and excised intraoperatively from patients undergoing a total hip replacement. After preparation, the specimens were cut to a thickness of 10 μm and divided into four quadrants (zones) using a clock face pattern. Neurosensory structure distribution was then evaluated using Hematoxylin and Eosin (H and E), and immunoreactivity to S-100.
Results
All specimens had abundant free nerve endings (FNEs). These were seen predominantly superficially and on the chondral side of the labrum. In addition, predominantly three different types of nerve end organs (NEOs) were identified in all twenty specimens. FNEs and NEOs were more frequently seen in the antero-superior and postero-superior zones. Four specimens had abundant vascularity and disorganised architecture of FNEs in the deeper zones of the antero-superior quadrant suggestive of a healed tear. Myofibroblasts were present in abundance in all the labral specimens and were distributed uniformly throughout all labral zones and depth.
Conclusions
The current study shows that the human acetabular labrum has abundant FNEs and NEOs. These are more abundant in the antero-superior and postero-superior zones. The labrum, by virtue of its neural innervation, can potentially mediate pain as well as proprioception of the hip joint, and be involved in neurosecretion that can influence connective tissue repair.
doi:10.1186/1471-2474-15-41
PMCID: PMC3927620  PMID: 24529033
Labrum; Innervation; Femoro-acetabular impingement; Hip arthroscopy; Labral tear
23.  Radiological Diagnosis and Management of Epistaxis 
The majority of episodes of spontaneous posterior epistaxis treated with embolisation are idiopathic in nature. The angiographic findings are typically normal. Specific angiographic signs are rare and may include the following: a tumour blush, telangiectasia, aneurysm, and/or extravasation. Selective internal carotid artery (ICA) angiography may show rare causes of epistaxis, such as traumatic or mycotic aneurysms, which require different treatment approaches. Complete bilateral selective external and internal carotid angiograms are essential to evaluation. The images should be analysed for detection of central retinal blush in the external carotid artery (ECA) and anastomoses between the branches of the ECA and ICA. Monocular blindness and stroke are two of the most severe complications. Embolisation aims to decrease flow to the bleeding nasal mucosa while avoiding necrosis of the nasal skin and palate mucosa. Embolisation is routinely performed with a microcatheter positioned in the internal maxillary artery distal to the origin of the meningeal arteries. A guiding catheter should be placed in the proximal portion of the ECA to avoid vasospasm. Embolisation with microparticles is halted when the peripheral branches of the sphenopalatine artery are occluded. The use of coils is not recommended because recurrent epistaxis may occur due to proximal embolization; moreover, the option of repeat distal embolisation is lost. The success rate of embolisation therapy (accounting for late recurrence of bleeding) varies between 71 and 94 %. Results from endoscopic surgery are quite comparable. When epistaxis is refractory to nasal packing or endoscopic surgery, embolisation is the treatment of choice in some centres.
doi:10.1007/s00270-013-0776-y
PMCID: PMC3895177  PMID: 24232035
Posterior epistaxis; Selective percutaneous embolisation; Endovascular intervention
24.  Extranodal nasal-type NK/T-cell lymphoma of the palate and paranasal sinuses 
Summary
Background:
Extranodal nasal-type natural killer (NK)/T-cell lymphoma represents a rare entity, typically originating in the nasal cavity, palate or midfacial region. Signs and symptoms include non-specific rhinitis and/or sinusitis, nasal obstruction, epistaxis, facial swelling and development of deep necrotic ulceration in the midline of the palate, causing an oronasal defect. Differential diagnosis includes fungal infections, Wegener’s granulomatosis, tertiary syphilis, other non-Hodgkin’s lymphomas and malignant epithelial midline tumors.
Case Report:
We present a case of a 40-year-old man complaining of headache, facial pain, nasal congestion and fever. Examination revealed a large deep necrotic ulcer in the middle of the palate, presenting as an oronasal defect. Endoscopic rhinoscopy revealed crusts in the nasal cavities, moderate perforation of the nasal septum cartilage and contraction of the middle and inferior conchae. Computer tomography showed occupation of the maxillary sinuses, ethmoidal cells and sphenoidal sinus by a hyperdense soft tissue mass. Laboratory investigation revealed increased erythrocyte sedimentation rate. A wide excision of the lesion was performed. Histopathological and immunohistochemical evaluation established the diagnosis of extranodal nasal-type NK/T-cell lymphoma. The patient was treated with CHOP chemotherapy, involved-field radiotherapy and autologous bone marrow transplantation. A removable partial denture with obturator was fabricated and inserted to relieve problems caused by the oronasal defect.
Conclusions:
Extranodal nasal-type NK/T-cell lymphoma is a very aggressive, rapidly progressing malignant neoplasm with a poor prognosis, which can be improved by early diagnosis and combined treatment.
doi:10.12659/AJCR.882802
PMCID: PMC3615940  PMID: 23569495
extranodal NK/T-cell lymphoma; oral midline malignant tumors
25.  Intensity-Modulated Radiotherapy for a Rendu-Osler-Weber Disease Patient with Recurrent Severe Epistaxis: A Case Report 
Case Reports in Medicine  2010;2010:321835.
We present a case of a Rendu-Osler-Weber disease patient with recurrent life threatening epistaxis demanding multiple blood transfusions despite of repetitive endoscopic laser and electrocoagulations, endovascular embolisation, septodermoplasty, and long-term intranasal dressings. As alternative treatment modalities repeatedly failed and the patient became almost permanently dependent on nasal dressing, we performed a highly conformal intensity-modulated radiotherapy of the nasal cavity; a total dose of 50 Gy in 2 Gy single fractions was applied. The therapy was very well tolerated, no acute toxicities occurred. Two weeks after the last radiation dose had been applied, the nasal dressing could be removed without problems. Endoscopical control revealed an almost avascular white mucosa without any trace of bleeding spots; previously existing hemangiomas and crusts had disappeared. After a 1-year-follow up, the patient had no significant recurrent epistaxis.
doi:10.1155/2010/321835
PMCID: PMC2846684  PMID: 20368796

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