: General Applicability in a Teaching Unit
, Nigel K. F. Koo Ng, MA, FRCS (ORL-HNS), DO-HNS, Gerald W. McGarry, MD, FRCS (ORL-HNS), FRCSEd, FFSTEd
Article Information
Shi Ying Hey, MRCS, DO-HNS1, Nigel K. F. Koo Ng, MA, FRCS (ORL-HNS), DO-HNS1, Gerald W. McGarry, MD, FRCS (ORL-HNS), FRCSEd, FFSTEd1Endoscopic sphenopalatine artery ligation (ESPAL) is the intervention of choice for refractory epistaxis in specialist ear, nose and throat (ENT)units and should be within the repertoire of competencies for all ENT trainees. Following its recent incorporation within the United Kingdom competency–based training syllabus as an explicit outcome standard, the ESPAL is not uncommonly being delivered by trainees under appropriate supervision. We assessed the efficacy and outcome of ESPAL in epistaxis management within our teaching hospitals.
Retrospective, structured review of all ESPAL procedures performed for epistaxis between December 2005 and December 2013. The techniques of ligation, operator grade, and outcome were studied.
Sixty-five patients (41 male:24 female; average age of 58.2 years) were identified in whom 67 artery ligations were performed (63 unilateral; 2 bilateral). Overall, success rate of ESPAL was 92.3% (60/65), with 5 rebleed cases recorded within 30 days of the primary procedure. Sixteen (24.6%) underwent "clipping," 26 (40.0%) had diathermy ligation, 18 (27.7%) had both clipping and diathermy, and in 5 (7.7%) patients, the ligation technique was not recorded. In 31 (47.7%) of 65 cases, a consultant was the principal surgeon. The remaining 34 (52.3%) of 65 cases were performed by trainees with (24, 70.6%) or without (10, 29.4%) supervision. There was no correlation between rebleed and operators' grade, level of supervision, or ligation technique.
Epistaxis is the commonest emergency in ear, nose and throat (ENT), with an estimated incidence of 108 in 100 000 population per year.1 In Scotland, this accounts for 1 in 3 of all ENT emergency admissions.2Effective initial management consists of localization of and direct therapy to the bleeding source (eg, silver nitrate cautery or bipolar diathermy) or application of localized pressure at the bleeding point with targeted, nasal packing. Despite being a common presentation, the management of epistaxis can be challenging due to its varying severity. The current lack of national guidelines results in management being dictated by the availability of local resources and personnel.3,4 While the majority of cases are conservatively managed, intractable epistaxis results in significant morbidity and even mortality, avoidance of which necessitates early surgical intervention in the form of artery ligation or embolization. With increasing refinements in endoscopic techniques and anatomical understanding of the locoregional nasal vasculature, endoscopic sphenopalatine artery ligation (ESPAL) has gradually emerged as the surgical intervention of choice for refractory epistaxis in specialist ENT units. Due to it being the most distal blood supply to the nasal cavity, ligation of sphenopalatine artery has gained popularity over the conventional approaches of external carotid and maxillary artery ligation, providing an inherently effective and localized control of epistaxis achievable endonasally with minimal access and minimal morbidity. Current evidence which comprises mainly of cohort studies has demonstrated that ESPAL benefits from both clinical and cost-effectiveness superiority, indicated by a high success rate of up to 100% in expert hands as well as shorter hospital stay.5–7
Not only in the expert hands, being the intervention of choice for intractable epistaxis, ESPAL should also be within the repertoire of competencies for all ENT surgeons. Following its recent incorporation within the United Kingdom competency-based training syllabus as an explicit outcome standard upon the completion of training to becoming an independent practitioner, the trainee must be able to demonstrate ability to perform ESPAL with minimum supervision. Due to the engendered training appetite, it is therefore not uncommon for the ESPAL being increasingly delivered by trainees under appropriate supervision, especially in teaching units. The aim of this study was to assess the efficacy and outcome of ESPAL in epistaxis management as it is used by all grades of operator within our teaching hospitals.
Study approval was obtained from NHS Greater Glasgow and Clyde clinical governance committee for surgery. A retrospective and structured review of records of ESPALs performed within all NHS North Glasgow hospitals over an 8-year period between December 2005 and December 2013 was conducted. All patients who underwent ESPAL were identified and indications for ESPAL were studied. Those patients in whom ESPAL was used for management of epistaxis were included in the study, while those who underwent ESPAL as an elective procedure in assisting the endoscopic excision of sinonasal tumors were excluded. Information on the techniques of ligation, operative details, and operator grade were extracted from operation notes. The efficacy of ESPAL and any related complications were specifically recorded.
Success measure for an ESPAL procedure was defined as no further epistaxis or rebleed within 30 days of the index procedure, whereas any presentation of epistaxis out with this period of time was classified as a late rebleed and was recalled but not included in the primary failure rate. Where appropriate, statistical analysis was performed using Fisher exact or χ2 (GraphPad Prism, LaJolla, California).
A total of 65 patients (41 male:24 female) underwent ESPAL for epistaxis management during the study period, in whom 67 artery ligations were performed (63 unilateral; 2 bilateral). The mean age of the study population was 58.2 years (range: 21-87 years). Overall, the follow-up period ranged from 1 to 8 years.
Efficacy
The overall success rate of ESPAL was 92.3% (60/65). Within 30 days of the primary procedure, a total of 5 (7.7%) rebleed cases were identified in which 2/5 had occurred within 24 hours and 3/5 were within 30 days. All 5 rebleed cases were recorded from the ipsilateral side of the initial presentation and among these, 4/5 had required readmission while 1/5 had occurred during the index admission. The outcome of the rebleed patients are summarized in Table 1.
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Table 1. Outcome of Patients With Rebleed Following the ESPAL Procedure.a
Of these 5 patients who had an unsuccessful primary procedure, there was only 1 case in which repeat ESPAL was performed. This was at 2-week interval from the index procedure requiring a readmission. Intraoperative findings confirmed division of the inferior turbinate branch of the sphenopalatine artery but intact posterior septal branches. Further diathermy and division was therefore carried out on the residual branches of the sphenopalatine artery and there was no subsequent epistaxis.
Surgical Techniques
The technique used for sphenopalatine artery ligation was analyzed. Of all 65 patients, 16 (24.6%) underwent "clipping" of the artery, 26 (40.0%) underwent diathermy, 18 (27.7%) had both clipping and diathermy, and in 5 (7.7%) patients, the ligation technique was not recorded. Within the remit of available data, there was no demonstrable superiority of clip application or diathermy in securing the sphenopalatine artery (P = .1893).
Operator Grade
In 31 (47.7%) of 65 cases, a consultant was the principal operating surgeon. The remaining 34 (52.3%) of 65 cases were performed by trainees with (24, 70.6%) or without (10, 29.4%) supervision by a consultant. There was no specific correlation observed between rebleed and operators' grade (P = 1.0000).
Late Rebleed Patients
In addition, a further 5 patients were identified during the follow-up study period where ipsilateral epistaxis had occurred beyond 30 days of the index procedure. These were recorded within a wide range of period from 6 weeks to 18 months. Of these 5 patients, 2 patients had spontaneous resolution following admission, 1 patient had nasal packing, 1 patient underwent examination under general anesthesia where generalized mucosal ooze was identified and managed with both diathermy and Floseal® (Baxter, Hayward, CA, US), while 1 patient had sphenopalatine foramen exploration which did not identify any remaining branches and an anterior ethmoidal ligation was subsequently performed.
Follow-Up
During the follow-up period, 4 patients died due to unrelated comorbidities at a period ranging between 6 and 38 months. In addition to rebleed cases, there were 2 postoperative complications recorded. One patient sustained an ipsilateral corneal abrasion due to the routine untaping of the eye and was reviewed postoperatively by ophthalmology. Topical antibiotics was commenced and there was no long-term sequelae. One patient developed dense postoperative adhesions requiring division both under local and general anesthesia; however, this was felt to be due to extensive and unsuccessful silver nitrate cautery prior to ESPAL.
Endoscopic sphenopalatine artery ligation represents an effective and safe treatment of choice in refractory epistaxis, as evidenced by a 92.3% success rate from our series. Notably, this can be achieved by varying grades of operators without significant reduction in outcome. While the method of securing the sphenopalatine vessels remains a contentious issue, our series has shown no demonstrable superiority from either clips or diathermy application. With no current national consensus on epistaxis management or the optimal timing for surgical intervention, ESPAL is usually indicated in common practice after a watchful waiting period of up to 48 hours for persistent epistaxis.8,9 The minimally invasive nature and high efficacy of ESPAL continue to support its preeminence in the management for refractory epistaxis and it should be considered as early definitive management of epistaxis not amenable to conservative measures. In practical terms, we therefore advocate for epistaxis not controlled within 12 hours of admission, that a senior member of the team (registrar grade or above) should be contacted with a view to consider an ESPAL procedure.
Our routine experience of ESPAL management of epistaxis has a success rate consistent with previously published cohort studies. This series of patients represents, to our knowledge, the largest group of epistaxis patients managed with ESPAL reported to date, also including multiple operators of varying grades.10–12
Being the current treatment of choice for refractory epistaxis, it is increasingly been recognized, particularly within the United Kingdom competency-based training syllabus, that ESPAL should be within the repertoire of competencies for all ENT trainees. Nevertheless, similar to most emergency operations, the acquisition of proficiency and training opportunities for ESPAL can be rendered ad hoc, for not uncommonly performed out of hours thus infrequently encountered by trainees. Furthermore, the on-going shaping and configuring of surgical training in the United Kingdom, in conjunction with the European Working Time Directive implementation, has shifted the paradigm toward competence-based training, which can inadvertently reduce the overall training time and operative experience in the emergency settings.
In parallel to these, the engendered training appetite has resulted in ESPAL increasingly being delivered by trainees, under appropriate supervision and guidance. Although ESPAL remains a procedure performed for over 20 years with outcomes published in various cohort studies, our series is novel in studying and comparing the operative outcomes by varying grades of surgeons. Interestingly, our study did not show less efficacious outcome with ESPAL performed by trainees with appropriate supervision (70.6%) or in capable trainees when operating unsupervised (29.4%). The favorable outcome by trainees is likely to be underpinned by transferable competencies acquired from the robust training within the elective settings in a range of endoscopic skills, prior to its applications in the emergency procedure. To further enhance the technical learning curve for ESPAL, the utility of simulation training could offer continuous development of skills in a longitudinal manner.
Our study has also highlighted the importance of appreciating variation in the sphenopalatine artery, which should prompt the surgeon to always actively search for all branches, including those posterior to the sphenopalatine foramen.13 Of note, a small group of late rebleed patients during the follow-up period were identified which occurred beyond 30 days of index procedure. This is unlikely to be attributed to the commonly perceived technical failure of clip dislodgement or incomplete division of vessels, but rather raises the possibility of subsequent neovascularization. As there is no known similar study with a prolonged follow-up post-ESPAL, the true incidence of this phenomenon can be difficult to ascertain. It, nevertheless, poses an interesting observation for studies in nasal vascular anatomy.
Although embolization has been shown to have equal efficacy to ESPAL in cessation of refractory epistaxis, in our practice, this tends to be reserved in patients with anesthetic concern or rebleed cases. This is, in part, due to the limited availability of embolization which has its own significant risks. Furthermore, ESPAL has been shown to be superior to embolization in terms of cost-effectiveness.14 In the current climate of an aging population with increasing comorbidities, patients' suitability for general anesthesia can often become the main drawback for performing ESPAL. A recent study, however, has reported performing ESPAL under local anesthesia,15 thereby circumventing the anesthetic fitness barrier and thus potentially extend the applicability of the procedure.
With an overall success rate of 92.3%, it would be appropriate to consider ESPAL as an early definitive management for intractable epistaxis. Endoscopic sphenopalatine artery ligation requires a sound understanding of the anatomical variation of sphenopalatine artery to ensure technical success. With appropriate training, there is no difference in outcome between ESPAL procedures performed by trainees compared to consultants. Thus, protocols should be developed that mandate the implementation of ESPAL in uncontrolled epistaxis.
Authors' Note
Oral presentation at 25th Congress of the European Rhinologic Society, on June 22-26, 2014; Scottish Otolaryngological Society (ENT Scotland) Summer Meeting, on May 13, 2016.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Shi Ying Hey, MRCS, DO-HNS 
https://orcid.org/0000-0003-3845-2566
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