Northeast Florida Medicine
Vol. 66, No. 1 2015
45
Otolaryngology
persistent sinonasal symptoms, CT scan, nasal endoscopy
and allergy testing were recommended. Explicit recommen-
dations were made to encourage patients to stop smoking
and to use saline nasal irrigation.
10
Some changes at the point of care have occurred in the
diagnostic arena. Typically, treatment of chronic sinusitis
has been empiric, based on presenting symptoms such as
persistent nasal congestion, facial pressure and cough. Sinus
CT, the gold standard for diagnosis, is typically reserved for
persistent or refractory symptoms (as mentioned above).
Some practitioners have chosen to offer in-officeCT, allowing
them to quickly distinguish true sinusitis from other condi-
tions such as allergies, migraine or tension headache before
initiating therapy. This is far superior to in-office sinus x-ray,
which has a fairly low sensitivity and specificity. The cost of
this equipment is still prohibitive for many physicians so
that in-office CT remains limited in availability.
Nose-Bleeding
Stepping away from chronic sinonasal infection, another
problem whose treatment has seen significant innovation
is epistaxis (aka nosebleed). Nose-bleeding remains a com-
mon medical and surgical problem, particularly in this era
of therapeutic anticoagulation. “Old-school” intervention
with extensively layered packing gauze and Foley catheter
insufflation is rarely used today. Instead, we have shifted
toward newer techniques, facilitated by newmedical devices
and interventional techniques, which have greatly improved
outcomes and lessened morbidity.
Most nosebleeds emanate from the anterior septum in an
area known as Kiesselbach’s plexus, a confluence of blood
vessels from the internal and external carotid arterial system.
For minor anterior nose-bleeding, newer resorbable hemo-
static powders such as NasalCease (topical calcium alginate)
can be obtained over the counter and used at home. For
patients who present to an urgent care center or emergency
department with nose-bleeding, premanufactured and non-
absorbable packing such as Merocel* sponges or the newer
Rapid Rhino* inflatable nasal packing are now available and
play a useful role in treating nosebleeds. In addition to being
generally effective, they can also be placed easily and later
removed by trained, non-specialist providers.
13
Whenavailable, anteriornasal cauterizationmayhave several
advantages over nasal packing. Very anterior bleeding sites
can often be treated successfully with chemical cauterization
by nonspecialist providers. More difficult bleeding can often
be controlled by direct or endoscopic cauterization using
chemical or electrothermal cautery. This can be comfortably
performed in an office or outpatient setting with application
of topical anesthetic.Retrospective studies have confirmed that
this technique can result in decreased need for subsequent
intervention. Intranasal cauterization has also been shown to
result in shorter hospital stays versus treatment withpacking.
14
Continual epistaxis also warrants investigation and treat-
ment for variousmedical conditions.Hypertension, congenital
coagulopathies, Wegener’s granulomatosis, sarcoidosis and
hereditary hemorrhagic telangiectasia are all diagnostic possi-
bilities. Frequently, anticoagulated cardiac patients may need
to temporarily stop their warfarin or even consider reversal
if the epistaxis is profuse enough to cause an acute anemia.
Next-generation anticoagulants such as dabigatran,
rivaroxaban, and apixaban present additional challenges
in cases of epistaxis. Dabigatran is a thrombin inhibitor,
while rivaroxaban and apixaban are factor Xa inhibitors.
These novel anticoagulants have been popular because of
their shorter half-life and lack of necessary blood level
monitoring.When bleeding complications occur, however,
reversal of these agents is problematic. There is no role for
Vitamin K in reversal of these new oral anticoagulants, and
fresh frozen plasma administration is ineffective. Instead,
options include hemodialysis, recombinant factor VIIa,
prothrombin complex concentrate, and activated PCC.
Several promising reversal agents are currently under in-
vestigation, but none has been FDA-approved in humans
yet. To date, there has been no proven reversal agent or
antidote for these novel anticoagulants.
15
If bleedingpersists or continually recurs despite local cautery
or packing, further intervention is warranted. Typically, this
involves the use of surgical ligation or arterial embolization.
16
The technique for surgical ligation has been greatly enhanced
with the use of nasal endoscopes.
17
In the past, ligation
necessitated a Caldwell Luc surgical procedure through the
maxillary sinus anterior and posterior walls with resulting
postoperative hospitalization, pain, numbness, and swelling.
With use of the nasal endoscopes, the sphenopalatine artery
can be isolated intranasally as it exits from the sphenopalatine
foramen. Surgical clips can be applied directly to the artery.
The patient can be discharged postoperatively with little
associated morbidity. Statistical success from sphenopalatine
artery (SPA) ligation approaches 100 percent.
18
Percutaneous embolization is another alternative that
offers great success in treating recalcitrant nosebleeds.
Typically performed by an interventional radiologist, this
technique was developed in 1974 and involves selective
embolization of the internal maxillary artery as well as the
sphenopalatine artery. The procedure is performed with IV
sedation and involves the use of polyvinyl alcohol, gelfoam,
or more commonly, Embosphere* microspheres. Results are
permanent, approaching a 90 percent success rate. Risks
involved in this procedure, although quite rare, include
headache, soft tissue necrosis, facial paralysis and less than
one percent chance of stroke.
19
