Combination of a negative pressure suction device and endoscope can accurately locate the bleeding site of refractory epistaxis

Abstract Background Selective endoscopic coagulation of a nasal bleeding vessel is an effective means of treating epistaxis. Precisely locating the bleeding site(s) is critical. Objective To investigate the utility of combining a negative pressure suction device and endoscope in locating bleeding sites of refractory epistaxis. Methods A total of 116 patients with refractory epistaxis, who underwent systematic endoscopic exploration under local anesthesia in the absence of identifiable sites of bleeding were randomizely divided into two groups via negative pressure group (NPG) and control group (CG): The negative pressure suction device combined with an endoscope was used to re-explore the epistaxis. Nasal bleeding was induced using this method to help the operator locate the site of epistaxis accurately; the bleeding was then stopped using electrocoagulation with the suction electrode. The CG was treated with endoscopic re-exploration and selective tamponade. Results Compared with the CG, there were statistically significant differences in length of hospital stay, rebleeding, and postoperative pain and complications (all p < .05). Conclusion and significance Combining a negative pressure suction device and endoscope was a safe and effective technique for accurately locating bleeding sites in patients with refractory epistaxis.


Introduction
Nasal bleeding is an acute and frequently encountered emergency in Otolaryngological Departments and often requires immediately treatment. According to statistics, 60% of individuals will experience nosebleeds in their lifetime, of which 6% will require medical intervention [1][2][3][4]. After admission, patients and their families often experience different degrees of panic [5]. Before endoscopy was introduced to our department, the most common treatment for epistaxis was anterior-posterior nostril tamponade [3,6,7]. Although this yielded an adequate effect, it was also associated with significant pain, such as nasal pain, headach, dry sore throat, and nasal alar injury [7]. In addition, displacement of the packing material may lead to the risk for aspiration [7]. Selective endoscopic coagulation of the bleeding vessel is an effective means of treating epistaxis given the impressive evolution of nasal endoscopy [7][8][9]. Cautery haemostasis for posterior epistaxis under endoscopy is superior to posterior nostril tamponade and vascular embolization for reasons including pain, cost-effectiveness, risk, and overall control of bleeding [7,9]. Refractory epistaxis, however, is generally 'concealed' and known to originate from posterior bleeding [10]. In addition, its high recurrence rate often requires repeated nasal endoscopic surgeries and possible consequent complications such as panic asphyxia and upper airway obstruction, which may be life-threatening [7,8,11].
Emerging treatment options for refractory epistaxis have led major shifts in surgical approaches; more specifically, away from arterial ligation or radiological arterial embolization to electrocoagulation, which is not unresponsive to conventional nasal packing [12]. Electrocoagulation haemostasis under nasal endoscopy has advantages including accurate, rapid haemostasis, good effect, and minimal trauma [7,8]. Whether the site of bleeding can be quickly detected is the key issure for the success of electrocoagulation haemostasis under nasal endoscopy [13]. However, the bleeding site in 6-24% of cases of refractory epistaxis cannot be found using nasal endoscopy [1,3,6,13]. It has been reported that a considerable number of patients undergo selective nasal tamponade due to the inability to locate bleeding sites at the time, resulting in significant pain, and many complications including bradycardia and poor efficacy [12]. This suggests that there be still many cases of epistaxis requiring multiple endoscopic procedures to stop the bleeding, which is related to the ability of otolaryngologists to assess the sites of nasal bleeding under endoscopy due to inconsistent experience and standardized training [14]. During endoscopic exploration of refractory epistaxis, the inferior turbinate and middle turbinate sometimes need to be reversed, thus causing new bleeding; thus, repeated exploration and haemostasis causes more damage to the nasal mucosa, such as nasal adhesion, postoperative pain, and sinusitis. Moreover, it burdens the surgeon with mental pressure. Therefore, it is of high clinical significance to find a method that can assist in locating the site of nasal bleeding [7]. We used a negative pressure suction device to create negative pressure in the nasal cavity equivalent to raising the blood pressure of the bleeding point in the nasal cavity. This induces active bleeding, which, during the bleeding interval, helps the operator accurately locate the bleeding site.

Materials and methods
A total of 116 patients with refractory epistaxis, who were hospitalized between January 2019 and April 2021, were retrospectively enrolled. Due to the retrospective design of the study and the use of anonymized patient data, requirements for informed consent were waived. Inclusion criteria were as follows: (patients with) at least one nasal tamponade, with no bleeding spots found on systematic endoscopic examination by an otolaryngologist; able to tolerate local anesthesia and hold breath in conjunction with negative pressure devices; and no obvious contraindication to surgery. Individuals definitively diagnosed with coagulation dysfunction (blood system disease, liver and kidney dysfunction), those complicated by serious cardiovascular and cerebrovascular diseases, history of local trauma (including surgical trauma), refused local anesthesia, history of inflammation and tumors of the nasal cavity and sinuses, acute infectious diseases, history of radiotherapy for nasopharyngeal carcinoma and secretory otitis media, and hereditary haemorrhagic telangiectasia, were excluded. The Medical Ethics Committee of the authors' hospital approved this study.
Blood pressure, heart rate, electrocardiographic monitoring, and oxygen saturation were monitored in the local anesthesia operating room. With the patient supine, a conventional disinfectant towel was laid, nasal filler was removed, tetracaine and epinephrine cotton were used to anesthetize and contract the nasal cavity, and systemic examinations were performed under nasal endoscopy. The systematic search of the entire nasal cavity to detect bleeding was always performed in the same order: from anterior to posterior and from upper to lower, especially the following sites: junction of the nasal septum and nasal domain; nasal roof to the upper end of the nasal septum in the olfactory fissure area; junction of the middle nasal meatus and methyl plate of the middle turbinate (horizontal part and vertical part); upper margin of the inferior turbinate near the posterior fontanelle of maxillary sinus; front of the inferior meatus; posterior fornix of inferior meatus; and upper margin of the posterior nostril. Possible bleeding points were explored and, if none were found, the patients were randomly assigned to the negative pressure group (NPG) or control group (CG). For the CG, local selective tamponade was performed on suspected bleeding points during intraoperative exploration. In the NPG, the negative pressure device was applied, and negative pressure was adjusted to 40 kPa. The negative pressure football was placed into the anterior nostril of the affected side, and the patient was asked to press the other nasal alar with one hand to block the nasal cavity on the non-affected side and asked to hold their breath. The nasal cavity on the affected side connecting a negative pressure device form a closed space. then opening the negative pressure device, negative pressure in the nasal cavity is formed . Then, the bleeding site of the nasal cavity could be explored again under nasal endoscopy to accurately locate the bleeding site by following the blood flow at the time. Bleeding was stopped by electrocoagulation using an attractive haemostatic electrode, as shown in Figure 1. If nosebleed could not be induced, the patients underwent selective packing. The methodological protocol is illustrated in Figure 2.

Record of observation indexes
Epistaxis could be successfully induced in the NPG to locate the bleeding site. The length of hospital stay, number of rebleeding cases, postoperative pain, and postoperative complications (nasal adhesions, sinusitis, otitis media with secretions, septal perforation) were recorded in the two groups. Evaluation of the severity of postoperative pain after nasal packing was recorded using a visual analog scale (VAS). VAS scores were assessed using a ruler with two anchor points, with a score of 0 indicating the absence of pain and 10 indicating the worst pain (i.e. range, 0-10: 0 ¼ no pain, and 10 ¼ intolerable pain).

Evaluation of curative effect
After discharge, patients were advised to consume a balanced diet, devote attention to rest, not to blow their nose, control blood pressure, and keep the nasal cavity moist. If there was no recurrent nasal bleeding or bleeding on the affected side within one month, but the location of bleeding was significantly different from the previous site, the patient was considered to be cured.

Statistical processing
The recorded data were statistically analyzed using SPSS version 21 (IBM Corporation, Armonk, NY, USA). The ttest and chi-squared test were used for statistical comparisons and differences were considered to be statistically significant at level at p < .05.

Results
There was no statistically significant difference between the two groups in terms of sex, age, region of residence, and medical history. Demographic and clinical characteristics are summarized in Table 1. After the application of the negative pressure device in patients in the NPG, 56 sites of nasal bleeding were successfully found, accounting for 96.6% of all cases. Bleeding was not induced in 2 cases, as shown in Table 2.
After epinephrine and tetracaine cotton contraction, it was difficult to visualize obvious characteristic mucosal eminence, and some of the bleeding sites were difficult to find because they were in unusual locations. Results of the analysis revealed that the length of hospital stay in the NPG was shorter than that in the CG, and postoperative pain and complications (nasal adhesions, sinusitis, secretory otitis media, septal perforation) were better than those in the CG. Nasal bleeding recurred in 1 patient in the NPG after surgery (p < .05) ( Table 3).

Discussion
Recurrence of refractory epistaxis after nasal packing or surgery is a major problem for otolaryngologists due to the difficulty in identifying bleeding sites. Although ligation or arterial embolization of the external carotid artery and ethmoid artery by surgery can cure intractable epistaxis, they result in hemiplegic thrombosis and increase health costs [8,15]. Accurately locating bleeding sites during the operation is presently a 'hot topic' of discussion [6]. It has been reported that good efficacy in the treatment of epistaxis has been achieved by increasing target blood pressure during general surgery under anesthesia and locating the bleeding site of intractable epistaxis under nasal endoscopy [16]. However, we believe that this method increases surgical risk, especially in the middle-aged and elderly, thus increasing the incidence of cerebrovascular events in the operation theatre, and increasing the cost of surgery.
After combining a negative pressure suction device with an endoscope, given the severe bleeding induced by negative pressure in the nasal cavity, we used an electrode with negative pressure suction to perform electrocoagulation and haemostasis, which not only cleared the operative field but also shortened the duration of the procedure [9]. In this study, 116 patients with refractory epistaxis were enrolled and divided into two groups (i.e. NPG and CP). There were no statistically significant differences between the two groups in terms of clinical features or in age, sex, region of residence, and medical history. These results suggest that the efficacy of locating bleeding sites induced by the negative pressure device was high and recurrence was low in the NPG. Moreover, there was a significant difference in improvement in length of hospital stay, postoperative pain, and postoperative complications such as nasal adhesions and sinusitis. However, no statistical difference was found in secretory otitis media, septal perforation in the NPG compared with CG. We speculate that the low incidence of these two complications and the small sample size affected the statistical results. In the NPG, the largest number of bleeding sites was found in the upper nasal septum in the olfactory fissure area, accounting for approximately 39.7% [6,17,18]. The nasal cavity in the olfactory fissure area was the narrowest, and the patients were sensitive to pain, especially those with a high deviated nasal septum. Consequently, this made it difficult to observe the bleeding point behind the deviated septum; however, a 30 nasal endoscope was introduced when necessary [7,9]. Bleeding sites in the inferior meatus accounted for approximately 20.7%, especially in the anterior vault of the inferior meatus [19]. Bleeding in the anterior vault was easy to miss due to its narrowness and location in the front. Furthermore, using a rigid nasal endoscope facilitated entry to the inferior meatus from the middle part of the inferior meatus to observe the inferior meatus, especially during the bleeding interval. Finally, we found that this method was not only beneficial to locate the site of nasal bleeding, but also to test   whether the site of nasal bleeding was accurate or omitted, and can be used as a supplementary examination method after nasal endoscopic haemostasis.
In conclusion, the treatment of refractory epistaxis using a negative pressure suction device combined with an endoscope to accurately locate the bleeding site resulted in a better surgical effect and less intraoperative pain compared with traditional anterior-posterior nostril tamponade or selective endoscopic packing. Patients exhibited higher tolerance during the operation, which may be explained by the shortened duration of the procedure. Moreover, refractory epistaxis often requires repeated exploration, repeated fracture, and movement of the inferior turbinate, middle turbinate, and other structures, resulting in pain and discomfort. It can be used to quickly locate the bleeding point, shorten the duration of the operation, and reduce unnecessary injury. As such, the incidence of complications is lower and the patients recover quickly after the operation [20]. Ultimately, the length of hospital stay is shortened, which improves patient satisfaction, and can, to some extent, relieve mental pressure on the operator, which is worthy of clinical promotion [20].
Our study was limited by the small number of patients with refractory epistaxis. However, there are plans to collaborate with several other hospitals to conduct a multicentre clinical study with a larger sample size to further explore the safety of negative pressure devices in this procedure. It is anticipated that this technique will be widely used in the clinical treatment of refractory epistaxis in the future.

Disclosure statement
No potential conflict of interest was reported by the author(s).