Experimental for Recurrent

Surgical Treatment Epistaxis

Isaac Dano, MD, Eric Dangoor, MB, BS, MRCGP, Jean-Yves Sichel, MD, Ron Eliashar, MD
Purpose: To evaluate a new technique of submucosal supraperichondrial (SMSP) dissection of the nasal septum and its subsequent effect on the vascularity of the mucosa. A reduction may decrease the rate of recurrent anterior epistaxis. Materials and Methods: The procedure was performed on one side of the nasal septum of 16 laboratory rabbits. After healing occurred 3 months later, the animals septa were excised and stained. Both sides were then compared by using standardized microscopic field analysis. Results: The reduction in both the number of blood vessels on the operated side of the septum and the proportion of area occupied by these vessels was statistically significant (P < .004).Conclusion: This technique led to a reduction in the vascularity of the nasal septal mucosa, 3 months after dissection was performed. Healing, which occurs by a process of fibrosis, yielded a less vascularized tissue. Although further laboratory and clinical assessment is recommended, this technique may prove valuable in reducing the rate of recurrent anterior epistaxis. Copyright 0 1998 by W.B. Saunders Company.

Epistaxis is one of the most common conditions encountered by the otolaryngologist, both in the emergency room and in outpatient departments. It is estimated that 60% of individuals suffering from epistaxis have had at least one episode of nasal bleeding in their lifetime, and of those persons, only 10% seek medical attention.lJ Generally, the exact cause of bleeding is unknown except for cases in which there is an underlying condition, such as a hematologic clotting disorder, the presence of a tumor, or a primary cause such as Osler-WeberRendu disease. Furthermore, anterior bleeding from Kiesselbaths area of the nasal septum is encountered more commonly in the young and is usually from either an arterial or a venous source. In contrast, posterior epistaxis is more common in older patients,3l4 and is more likely to be isolated and of a severe and prolonged nature.5

From the Department of Otolatyngology/Head and Neck Surgery, Hadassah University Hospital, Jerusalem, Israel. Address reprint requests to Isaac Dano, MD, Department of Otolaryngology/Head and Neck Surgery, Hadassah Universitv Hosoital. Jerusalem, Israel. Copyright 0 1998 byW.6. Saunders Company 0196-0709/98/l 906-0002$8.00/O American Journal of Otolaryngology, Vol
19,

Anterior nasal bleeding is usually not life threatening, although frequently recurring cases can harm ones quality of life. Treatment of epistaxis ranges from relatively conservative procedures, such as cautery, and insertion of packs and balloons, to surgical approaches such as ligation of ethmoidal, maxillary, or external carotid arteries.j Other procedures include local injection of lidocaine in the posterior palatine canal and selective arterial embolization.7 There are isolated reports in the medical literature on the use of septoplasty for epistaxis. The recommendations for this procedure are not only to allow better access and treatment of areas behind a deviated septum,3 but also to reduce the nasal septal vascularity8 for cases in which the septum is relatively straight. On review of the literature, this latter effect has been shown to be of limited success. Its mechanism of action is thought to be disruption of the blood supply to the mucosa after elevation of the mucoperichondrium from the septal cartilage (in the subperichondrial plane). However, to our knowledge, there has been no detailed study to date analyzing the efficacy of septoplasty for recurrent epistaxis. Furthermore, the subperichondrial plane used
No 6 (November-December), 1998: pp 357-359
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in this procedure is known to be much less vascular than between the perichondrium and the overlying mucosa.3 This animal study was therefore conducted to analyze the outcome of elevation of the nasal septal mucosa in this submucosal supraperichondrial (SMSP) plane. MATERIALS AND METHODS

TABLE 1.

Postoperative Comparison Vascular Area (PVA) as a Percentage No. in Male and Female Rabbits Operated Side No. of Blood Vessels Male 6 3 2 5 3 7 4 6 Female 7 10 6 5 1 2 10 8 3 9 6 2 2 5 6 7 Rabbits 20 18 25 10 30 26 13 20 Rabbits 17 14 8 14 9 16 25 20

of Proportionate and Blood Vessel

Nonoperated

Side No. of Blood Vessels

PVA

PVA

We used 16 rabbits (8 males and 8 females) in our study. Following anesthetization, the nasal septa of all rabbits were infiltrated with lidocaine 2% solution on the right side. The mucosa was subsequently separated from the perichondrium by dissection with iris scissors, a technique that we call SMSP dissection. A Telfa gauze pack (Kendall Healthcare, Mansfield, MA) was then inserted in the nostril of each rabbit for 2 days and then removed. Three months after this procedure, the nasal septum of each animal was excised and histologically sectioned in a coronal plane by using hematoxylin and eosin stain. Each slide was examined under a light microscope by using standardized fields over the tissue section. Information was then gathered over a randomly chosen area as follows: 1 By using a computerized morphometric technique, we calculated the total area of blood vessels in each microscope field in both the dissected and the nondissected portion of the animal septum. The overall percentage of the field occupied by blood vessels was then obtained. We termed this percentage as the proportionate vascular area (PVA). 2. In each field, we counted the number of blood vessels seen in both the operated and nonoperated sides of each septum.

19 14 13 11 20 24 9 17

9 11 11 10 13 16 21 15

RESULTS All rabbits underwent the same procedure in which their septal PVA and the number of blood vessels were calculated at the end of the s-month period. The results were tabulated (Table 1) and statistically analyzed using t-tests for paired samples and Wilcoxon matchedpaired signed rank tests. We compared the PVA in both the male and female groups. There was no statistical difference between both sexes within the operated group (P < .l) or the unoperated group (P < .l) (Table 1). Similarly, we compared the number of blood vessels in the male and female groups. Here, again, there was no significant statistical differ-

ence in the operated group of both sexes (P < .7). Likewise, there was no appreciable difference in the nonoperated side in both sex groups (P < .2) (Table 1). We then compared the percentage PVA and the number of blood vessels in all animals between the operated and nonoperated sides. Here, there was a clear statistical difference (P < .004) in that the operated side of septum contained a significantly smaller PVA and number of blood vessels. DISCUSSION This study shows that use of the SMSP dissection technique significantly reduces the total number of blood vessels and the percentage area occupied by blood vessels, PVA, when compared with the nonoperated side of the nasal septum. We found no significant statistical differences between the sexes. The basic assumption of this study was that areas of the nasal septum with a richer vascular supply have a higher likelihood of bleeding. The fundamental basis of our surgical approach was the known physiologic process

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of scar formation, the final phase of which a relatively poor vascular supply.g CONCLUSION

has

tribute to treatment and improvement in the quality of life of those suffering from recurrent anterior epistaxis. REFERENCES

We propose that by using this new SMSP technique, the number of septal blood vessels and proportion of tissue area occupied by blood vessels are significantly reduced in the rabbit model. This outcome is thought to occur as a result of direct disruption of the blood supply to the septal mucosa from their origin in the mucoperichondrium, which is highly vascular. Furthermore, the traumatic process of dissection induces a healing process that ultimately gives rise to fibrosis and thus less vascular tissue. Therefore, longer term recurrent epistaxis may be diminished. We found no statistical difference between both sexes and propose that the healing process occurs similarly in both groups. The use of this technique in humans suffering with recurrent anterior epistaxis, should be considered further, and future clinical trials should be conducted to prove its efficacy and validity. If successful, the technique may con-

1. Monux A, Tamas M, Kaiser C, et al: Conservative management of epistaxis. Laryngol Otol 104:868-870, 1990 2. Schaitkin B, Strauss M, Honck JR: Epistaxis: Medical vs surgical therapy. A comparison of efficacy, complication and economic consideration. Laryngoscope 97:13921396,1987 3. Abelson TI: Epistaxis, in Paparella MM, Shumrich DA, Gluckman JL, Meyerhoff WL (eds): Otolaryngology, (ed 3). Philadelphia, PA, Saunders, 1991, pp 1831-1841 4. Wang L, Vagel DH: Posterior epistaxis: Comparison of treatment. Otolaryngol Head Neck Surg 89:1001-1006, 1981 5. Wetmore SJ, Scrims L, Hiller FC: Sleep apnea in epistaxis patients treated with nasal packs. Otolaryngol Head Neck Surg 98:596-599,1988 6. Simpson GT, Janfaza P, Becker GD: Transantral sphenopalatine artery ligation. Laryngoscope 92:1001-1005, 1982 7. Breda SD, Choi IS, Persky MS, et al: Embolization in the treatment after failure of internal maxillary artery ligation. Laryngoscope 99:1027-1029, 1989 8. Watkinson JC: Epistaxis: Scott-Browns Otolaryngology, vol 4 (ed 6). Oxford, England, Butterworth-Heinemann, 1997, chap 18, pp 10 9. Clark RA: Cutaneous tissue repair: Basic biologic consideration. Am Acad Dermatol 13:701-725, 1985