Persistent rhinorrhea can be treated minimally invasively via nasal endoscopy. Most of them are located at the front of the nasal cavity, and most of the persistent nasal bleeding is caused by bleeding from small arteries deep in the nasal cavity. Now it can be precisely localized and minimally invasive to stop the bleeding with the help of nasal endoscopy technology.
Patient, female, 67 years old. She had recurrent bleeding from the left nasal cavity for one week, the amount was large and could not be easily stopped. She was referred to our hospital for emergency treatment after two anterior and posterior nostril fillings, angiography and selective maxillary artery embolization failed to stop the bleeding. 20 years ago, she underwent resection of left nasal sinus tumor and major left maxillary osteotomy for left nasal sinus tumor. He had a history of hypertension for 15 years. The patient was admitted with assistance and was extremely nervous and anxious.
Physician: Upon admission, the patient was conscious, weak, and the left nasal cavity was filled with oil gauze. Body temperature 37.8 degrees, blood pressure 150/90 mmHg. hematocrit 9.6 g/dl. sinus CT: postoperative changes in the lateral wall of the left sinus after major nasal resection, no obvious tumor recurrence or other occupying lesions, no traumatic lesions.
Patient: 20 years had nasal tumor surgery and radiotherapy, regular postoperative review has been good so far. A week ago, the left nasal cavity suddenly bleeds heavily, sometimes 6 or 7 times a day, and it is always blocked, what is the cause?
Physician: Rhinorrhea is the most common emergency in ENT, and the common causes are divided into two categories: local factors and systemic factors, or multiple factors can coexist. Local factors such as trauma, surgery, inflammation, nasal septal deviation or perforation, tumor, etc.; systemic factors such as cardiovascular disease (hypertension), hematologic diseases, acute infectious diseases, endocrine disorders, severe nutritional disorders, vitamin deficiency, etc. Most of the nasal bleeding sites are in the bleeding-prone area in the lower part of the nasal septum (Little area), and almost all nasal bleeding in children occurs in the anterior part of the nasal cavity. Nasal bleeding caused by local disorders is mostly limited to one nasal cavity; in cases caused by systemic diseases (such as hematological diseases), bleeding can occur alternately or simultaneously in both nasal cavities. According to the patient’s current and past medical history and the bleeding characteristics, local and systemic factors coexist, and the bleeding site should be a small artery in the deep nasal cavity.
Patient: Since the nasal vessels are broken, why can’t the bleeding be stopped after the nasal cavity was filled twice and arterial embolization was done?
Physician: The main treatment for nasal bleeding is to find the bleeding point and stop the bleeding quickly. Nasal tamponade is the most commonly used method to stop bleeding. For anterior nasal bleeding, oil gauze, hemostatic capsule or tumescent material can be applied under the direct view of anterior nasoscope and removed after 48-72 hours, which is more effective. However, if it is posterior nasal bleeding, it is mostly seen in the branch of pterygopalatine artery, with thicker blood vessels, more violent bleeding, difficult to see directly, blinded by anterior nasal filling, and the patient has a history of nasal sinus surgery, the nasal space on the bleeding side is enlarged, the filling is not easily fixed, and the compression is poor, so repeated filling still bleeds. For the filling method or endoscopic local hemostasis is not effective, trauma or surgery injury to large vessels can choose the radiological intervention arterial embolization method to stop the bleeding, but for the internal carotid artery branches of the pre-sieve and post-sieve artery caused by nasal bleeding is not effective, nasal artery embolization can generally only block to the level of the external carotid artery branches of the internal jaw artery, and the nasal artery vascular mostly has traffic branches, and the patient has a history of nasal sinus tumor and radiation therapy, nasal cavity The patient has a history of sinus tumor and radiation therapy, so it is difficult to block the end responsible vessels by arterial embolization, and the efficacy is poor.
Patient: Due to the difficulty of treatment at the local hospital, it was recommended to transfer here for nasal endoscopic hemostasis, is this method reliable?
Physician: Nasal endoscopic hemostasis refers to the application of anesthetic tampons to anesthetize the mucosal surface of the nasal cavity. If the hemostasis is exact, the nasal cavity can be left unfilled or partially filled with a small amount of filling, with precise hemostasis, less damage to the nasal mucosa and less pain. Local treatment is followed by control of systemic related diseases (e.g. hypertension) and adjunctive systemic anti-inflammatory and supportive therapies, with a success rate generally above 90%.
Prognosis: After admission to the operating room for nasal endoscopic bipolar electrocoagulation to stop the bleeding, the bleeding point was the branch of the posterior superior pterygopalatine artery of the left nasal septum.
Physician’s tip: Persistent rhinorrhea refers to deep nasal bleeding that cannot be cured by repeatedly filling the anterior nostril and posterior nostril. Most of the patients are middle-aged and elderly, and most of them are combined with cardiovascular diseases, with hypertension and arteriosclerosis being the most common. Most of the bleeding points are located in the deep and posterior end of the nasal cavity, and bleeding from the branch of the pterygopalatine artery is most common. Due to the complex internal structure of the nasal cavity and blind operation, the conventional anterior and posterior nostril filling is often not easy to fill in place, and the patients suffer a lot from long-term or repeated filling, and it is easy to cause complications such as infection, local necrotic adhesions and septal perforation. Since the introduction of nasal endoscopy technology, it can directly penetrate into the deep part of the nasal cavity and each nasal tract, and through intra-cavity illumination and local magnification, it can be accurately positioned under direct vision and minimally invasive treatment, which is less painful and highly effective for patients.