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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 116 120 www.elsevier.com/locate/amjoto

Epistaxis after partial middle turbinectomy: the role of sphenopalatine artery ligation
Michele Cassano, MD, Pasquale Cassano, MD
Department of Otorhinolaryngology, University of Foggia, 71100 Foggia, Italy Received 2 March 2011

Abstract

Purpose: Extensive nasal polyposis could involve the middle turbinate inducing the surgeon to partially remove it. We initiated this retrospective study to evaluate the effect of a partial middle turbinectomy (PMT) on postoperative epistaxis and if sphenopalatine artery ligation (SPAL) could reduce the risk of bleeding in patients without nasal packing. Material and Methods: Twenty-seven patients with extended bilateral nasal polyposis and submitted to primary functional endoscopic sinus surgery (FESS) with PMT on 40 sides were retrospectively selected. Postoperative bleeding and other complications were evaluated and compared with those of a control group of 27 patients who underwent FESS with middle turbinate preservation on 40 sides. The study group was furthermore divided into 2 groups according to the execution of SPAL. The incidence of postoperative bleeding of both groups and of the 2 parts of the study group was compared using the Fisher exact test. Results: A SPAL was necessary to stop intraoperative bleeding in 21 (52.5%) sides of the study group patients and in 7 (17.5%) of the control group patients. After surgery, epistaxis occurred in 8 cases (20%) in the PMT group (1 submitted to SPAL) and in 2 (5%) of the control group. The comparison with the Fisher exact test confirmed the major tendency of postoperative bleeding in the study group and in those not submitted to SPAL (P b .05). Conclusions: Partial middle turbinectomy causes a higher incidence of postoperative bleeding in patients who are not packed during the FESS operation. The execution of SPAL greatly reduces this risk. 2012 Elsevier Inc. All rights reserved.

1. Introduction Epistaxis is the most frequent complication after functional endoscopic sinus surgery (FESS) [1]. It may occur in a postoperative period up to 15 days after the surgery. Many rhinologists adopt nose packing as a routine measure for preventing postoperative bleeding. Although typically effective, nasal packing causes pain, rhinorrhea, nasal obstruction, and inconvenience, and its removal is painful and often associated with rebleeding [2]. Such considerations have started different studies that are finalized to demonstrate the

No funding source has supported this investigation. Corresponding author. Via Crispi 34/C, 70123 Bari, Italy. Tel.: +39 0881 736282; fax: +39 0881 736031. E-mail address: m.cassano@unfig.it (M. Cassano). 0196-0709/$ see front matter 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2011.04.007

uselessness of the routine appeal of nasal packing, especially after FESS in relation to the low incidence of postoperative epistaxis and the relationship between costs and benefits [2-5]. Nevertheless, there are pathologic conditions that require a more aggressive FESS approach to achieve results with the consequence of an increased risk of postoperative epistaxis. For example, extensive nasal polyposis could involve the middle turbinate, inducing the surgeon to partially remove it (Fig. 1). In fact, many rhinologists agree that a diseased, destabilized, or obstructive middle turbinate should be partially removed because of the postoperative decreased incidence of synechiae formation, long-term patency of middle meatus antrostomy, improved nasal airflow, decreased nasal resistance, and improved intraoperative and postoperative access to the ethmoidal labyrinth [6-10]. However, other studies report significant complications after a partial middle turbinectomy (PMT) as anosmia,

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Fig. 1. Extensive nasal polyposis involving middle turbinate.

hyposmia, frontal sinusitis, crusting, atrophic rhinitis, and epistaxis [11-13]. The advances of endoscopic procedures have also brought along the possibility of a surgical solution to nasal bleeding by using very precise hemostatic techniques. These procedures include endoscopic cautery of bleeding points and more difficult techniques of endoscopic ligation of the sphenopalatine artery (SPAL) or of the anterior ethmoidal artery [3,14-16]. We initiated this retrospective study to evaluate (1) the effect of PMT on postoperative epistaxis in patients without nasal packing and (2) the possibility that SPAL could reduce the risk of bleeding in these patients.

2. Materials and methods In this retrospective study, we reviewed the cases of extended nasal polyposis (graded as stage III according to the Lund-MacKay classification) that underwent primary FESS with PMT at the Ospedali Riuniti University Hospital, Foggia. For all patients, each surgical side was evaluated independently. We then selected the last consecutive 27 patients (15 women and 12 men; age range, 2261 years; mean, 39.1 years) who underwent PMT on 40 sides (13 patients bilateral). Functional endoscopic sinus surgery with PMT was planned in all sides with evidence of concha bullosa and/or polypoid degeneration of the middle turbinate (Fig. 1), and/or flail turbinate, and/or obstruction of access to the middle meatus. The study group was compared with a control group of 27 patients (13 women and 14 men; age range, 2254 years; mean, 34.4 years) with extended bilateral nasal polyposis who underwent FESS with middle turbinate preservation on 40 sides (13 bilateral and 14 unilateral with PMT on the other side, belonging to the study group).

Patients with other systemic diseases involving nasal structures (primary ciliary dyskinesia, cystic fibrosis, Wegener granulomatosis, etc) or coagulation problems treated with anticoagulants or submitted to additional nasal procedures (septoplasty, inferior turbinoplasty, etc) were excluded from the study. All patients underwent a preoperative fiber endoscopic examination and a computed tomography scan of paranasal sinuses to evaluate the extension of the nasal polyposis. The surgical procedure was determined by the extent and location of the disease. In the study group, PMT was performed as described by LaMear et al [6], after injecting the middle turbinate with 2 mL of 2% lidocaine solution with 1:80 000 epinephrine. During surgery, discrete bleeding was controlled positioning 2 intranasal cotton pads with naphazoline for a few minutes or using a bipolar cautery. The study group was further divided into 2 subgroups based on the SPAL: 21 patients (52.5%) were submitted to this procedure, whereas 19 (47.5%) were not. Sphenopalatine artery ligation was executed according to the technique described by Budrovich and Saetti [17]. After surgery, 2 intranasal cottonoid pads are left in each nostril until the trachea is extubated to minimize bleeding that could be brought on by coughing or by other Valsalva maneuvers. They are generally removed in the postanesthesia care unit. Only if diffused bleeding occurs that cannot be controlled with cauterization of the bleeding points, we use anterior nasal packing done with open cell foam polymer of hydroxylated polyvinyl acetyl (Merocell sinus pack from Medtronic Xomed, Jacksonville, FL). The same treatment is expected in cases of epistaxis in the following period of hospitalization during recovery. It is also advisable for the patients to avoid blowing their nose or to do unnecessary efforts, which can augment the pressure (contraction of the abdominal wall, coughing, sneezing). Patients are told that they may expect to see many tissues spotted with blood for several days after surgery. Antibiotic therapy is prescribed with amoxicillin and clavulanic acid (1 g twice a day orally) and tranexamic acid (1 g twice a day orally) starting the night of the surgery. Starting the next day, nasal lavages are frequently performed with lukewarm sterile saline solution. Upon discharge, the patient receives a written list of rules to prevent eventual bleeding (sneeze with open mouth, avoid blowing nose, washing with warm water, avoid eating very hot foods, and avoid drugs that have anticoagulatory effects such as aspirin and its derivatives). If significant bleeding occurs, the patient is instructed to return to the hospital immediately. A postoperative checkup is performed a week after surgery, in particular, to remove the scabs or the clots and to evaluate the postoperative healing and the eventual postoperative bleeding. Subsequent checkups are performed weekly until the full integrity of the mucosa is restored. In each visit, patients are questioned regarding nasal bleeding and symptoms of acute sinusitis, frontal headache, nasal

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Table 1 Type of PMT in study group Middle turbinate Polypoid degeneration Flail turbinate Obstruction of access to middle meatus Concha bullosa Anterior resection 3 1 1 Anterior-inferior resection 5 6 5 Posterior-inferior resection 15 1 Medial half resection 3 Total n (%) 23 8 6 3 (57.5%) (20%) (15%) (7.5%)

dryness, or nasal obstruction. The patients are followed for a minimum of 1 year after surgery, recording endoscopic findings of mucosal disease, synechiae, lateralization of middle turbinate, and stenosis of frontal recess. Patients submitted to FESS with PMT and without PMT were compared in relation to the risk of bleeding using the Fisher exact test. The same test was used to compare the study group patients submitted to SPAL and patients who did not undergo this procedure, in relation to the risk of postoperative bleeding. A P value of less than .05 was considered significant.

3. Results In the study group, an anterior ethmoidectomy with PMT was performed on all sides. In 36 (90%) sides, the procedure was associated with maxillary antrostomy; 32 (80%), with posterior ethmoidectomy; and 26 (65%), with frontal sinusectomy. Partial middle turbinectomy was performed due to a polypoid degeneration of middle turbinate in 23 (57.5%) cases, flail turbinate in 8 (20%), obstruction of access to the middle meatus in 6 (15%), and concha bullosa in 3 (7.5%). The involvement of turbinate resection has been described in Table 1. In the control group, an anterior ethmoidectomy was performed in all patients, whereas maxillary antrostomy was performed in 35 (87.5%), posterior ethmoidectomy in 29 (72.5%), and frontal sinusectomy in 22 (55%). A SPAL was necessary to stop intraoperative bleeding in 21 (52.5%) sides of the study group and in 7 (17.5%) of the control group. This procedure has been more frequently necessary when a posterior-inferior resection of middle

turbinate (with tail involvement) has been performed (Fig. 2). Other intraoperative complications included a liquor fistula in 1 case (study group) and lesion of the papyracea lamina in 1 case (control group) Postoperative bleeding occurred in 8 cases (20%) of the PMT group (1 case was submitted to SPAL) and in 2 (5%) patients of the control group (Fig. 3). In the postoperative period, 2 (5%) patients of the PMT group referred nasal dryness for the 3 months after surgery (both had been submitted to SPAL), and 1 (2.5%) referred a frontal headache for 1 month. In the control group, just 1 (2.5%) patient (who had also been submitted to SPAL) showed symptoms of nasal dryness for the 2 months after surgery. At 3-month follow-up, in the study group, no case had remnants of lateralization of middle turbinate, 2 (5%) surgical sides showed narrowing of middle meatus antrostomy, and 12 (30%) sides had evidence of nonobstructing nasal polyps in the anterior ethmoidectomy cavity and/or frontal recess. In the control group, lateralization of middle turbinate that obscured visualization of the middle meatus was evident in 6 sides (15%), with a synechiae in 3 (7.5%). Moreover, 3 sides (7.5%) showed narrowing of maxillary antrostomy, and 15 (37.5%) showed nonobstructive nasal polyps in middle meatus. In comparison of the 2 groups using the Fisher test, a higher tendency of bleeding showed up in the PMT group with a significant statistical difference compared with the control group (P b .05; odds ratio [OR], 4.75). Also, analyzing only the study group, the probability of bleeding appears to be higher in the patients not subjected to SPAL,

Fig. 2. Cases of SPAL related to the type of middle turbinate resection.

Fig. 3. Postoperative bleeding in PMT group and control group.

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with a significant statistical difference compared with the patients that did undergo this procedure (P b .5; OR, 0.09).

4. Discussion Partial resection of middle turbinate is a controversial procedure. Many surgeons prefer to perform this procedure, reporting (1) the better visualization of intranasal anatomy during and after surgery with consequential precocious visualization of a polyposis relapse, (2) the improvement of the long-term patency of the middle meatus antrostomy, (3) the small percentage of related complications (crusting, atrophic rhinitis, drying, infections), (4) the improvement of nasal airflow and decrease of nasal resistance, and (5) the lower rate of frontal sinusitis, a complication reported in the case of turbinate preservation as a consequence of turbinolateral postoperative synechiae with a blockage of the ostiomeatal complex [6-10]. On the contrary, other rhinologists refuse PMT due to the reported complications of anosmia/hyposmia, frontal or sphenoidal sinusitis (due to hypertrophy of turbinate remnants) bleeding, drying, and atrophic rhinitis [11-13]. No other study, however, has analyzed the specific hemorrhagic complications of the partial resection of the middle turbinate on the patients affected by nasal polyposis [10,12]. One study done by Brescia et al [18] did not demonstrate any significant differences in terms of postoperative bleeding between patients with nasal polyposis who underwent FESS with and without PMT. However, the authors analyzed the hemorrhagic tendency only after unpacking. The actual tendency of nasal surgery is to avoid nasal packing because the procedure is annoying and is usually not necessary in a FESS surgery [2-5]. To prove such theory, we wanted to analyze the effective risk of bleeding in a patient who underwent FESS with PMT without nasal packing and compare it with those patients who were not packed, in which the resection had not been done. From our data emerged, in fact, a higher risk of bleeding in the group of patients who underwent PMT as opposed to the control group (P b .05; OR, 4.75). The bleeding can be justified both by the vascular coagulation of the mucosa in patients with nasal polyposis and the rich vascularization of the turbinate. In fact, some histopathologic studies done on the patients with rhinosinusitis showed that inflammation of the ethmoid is always accompanied by inflammation of the mucosa of the middle turbinate [19]. These data could justify, in the cases of polyposis, a higher hyperemia and vascular congestion that could be the cause of the bleeding when resection, even partial, is done. Moreover, the rich vessels of the middle turbinate branch originate from the proximal portion of the posterior lateral nasal artery just after exiting the sphenopalatine foramen [20].Therefore, this rich arterious vascularization of the middle turbinate and the proximity of the posterior portion of the sphenopalatine foramen can justify

the significant bleeding caused by even minimal vessel lesions. From our data, in fact, it is evident that SPAL has been more frequently performed when the tail of the middle turbinate was involved in the PMT (Fig. 2), being that this region receives the principle branch that originates from the posterior lateral nasal artery and is therefore situated only a few millimeters from the sphenopalatine foramen. This is the reason why some authors suggest to limit the PMT to only one third or one half of the anteroinferior part of the turbinate preserving the tail and the posterior third [10], but this is not possible when the polypoid degeneration involves a significant area of this region. In such a case, it seems careless to leave a patient unpacked, exposing them therefore to a high hemorrhagic risk. However, the advances of endoscopic procedures has also brought along the possibility of a surgical solution to nasal bleeding by the use of very precise hemostatic techniques. The endoscopic ligation of the sphenopalatine artery is considered by many authors a good option for the patients with refractory posterior bleeding because it has shown in different studies percentages of success, on average, higher than 95%, with major complications practically absent [3,14-16]. In our study, however, such a technique has allowed a significant reduction on our study group of hemorrhagic risk as opposed to patients who did not undergo such procedure (P b .05; OR, 0.09). Such a procedure results to be also particularly simple in the course of an FESS because the retrieval of the sphenopalatine peduncle is assured by detaching the mucosa of the edge of the posterior maxillary antrostomy done during the course of the surgery. Our results might probably underestimate the hemorrhagic risk being that 52.5% of the study group underwent simultaneous ligation of the sphenopalatine artery, which, as proven by the study, reduced the risk of bleeding (limiting a postoperative bleed to only 1 patient). However, this limit determined by the retrospectiveness of the study does not hinder the statistical demonstration of the higher tendency of bleeding in the patients with nasal polyposis who underwent PMT. On the other hand, the execution of a randomized prospective study of the issue would expose ethical problems being that it would presume that SPAL not be executed in part of the patients even if it was necessary during surgery due to an intraoperative bleeding. We preferred, therefore, to evaluate this retrospectively in patients who underwent PTM regardless of the treatment given to control bleeding. Hemorrhage complication risk is obviously lower in PMT in comparison with inferior turbinate surgery because the middle turbinate is smaller and contains less vascular and erectile tissue, and in PMT, only a small area of the turbinate is denuded [6]. In fact, our recent work pointed out that the surgery that was most burdened by hemorrhagic postoperative complications is inferior turbinate surgery [3]. The other complications described hereafter of the execution of the PMT were rarely found in our study. Nasal dryness was found only in 2 patients in the study group

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and 1 in the control group. In all these cases, the patients also underwent ligation of the sphenopalatine peduncle, because dissecting the fibers of the posterior nasal nerve reduces parasympathetic innervation of the nasal mucosa. The consequential reduction of the glandular secretion had, however, a transient effect (23 months) possibly because of the vicarious function on the mucosal secretion caused by the globet cells of the nasal mucosa. Therefore, the risk of atrophic rhinitis after PMT seemed to be extremely rare, as already proven by Lawson [7] in an ample study. Endoscopic signs of frontal rhinitis did not accompany frontal headache found in just 1 patient of the study group, and it resolved itself spontaneously barely 1 month after surgery. These data diverge from that found by other authors who found percentages of frontal sinus pathology after turbinectomies to be between 10% and 75% [11,12]. Our results could be explained by the extremely limited dissection of the anterior portion of the inferior turbinate with a careful conservation and minimum trauma to the mucosa of the recess of the frontal sinus. Such precautions were proven by the absence of synechiae or of stenosis of the frontal recess in the study group. In the control group, 6 cases of lateralization of the middle turbinate were observed with synechiae in 3 cases. This situation can be explained by the instability of the whole middle turbinate after an ethmoidectomy, regardless of the routine execution of controlled synechiae between the septum and the middle turbinate in the case of obvious instability of itself. In none of the cases that we studied, we observed the onset of anosmia or hyposmia, commonly found by other authors [12,13]. 5. Conclusion Partial middle turbinectomy is a safe procedure that presents a low percentage of complications and that allows more postoperative control of the surgical cavity with an early access to evaluating and treating relapse of polyposis. However, it is characterized by a higher incidence of postoperative hemorrhagic complications in patients who are not packed during the FESS operation. The execution of the SPAL significantly reduces this risk. It would therefore be auspicious, if packing is not intended, to add this procedure to the FESS surgery, especially when a PMT is performed, which also includes the tail of the middle turbinate. Acknowledgment A special thanks goes to Emily Fiocca Matthews for the precise and punctual translation of the text into English.

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