[Otolaryngology Nasal Endoscopy] Methods and Precautions for Nasal Bleeding Control under Nasal Endoscopy

The wide popularization of nasal endoscopy has offered advanced, precise technical support for the examination, diagnosis and treatment of epistaxis, greatly lifting the overall standard of nasal bleeding management. Equipped with lighting, magnification and full-view observation functions, nasal endoscopy allows doctors to clearly identify the exact position and local pathological changes of bleeding sites. Meanwhile, a variety of targeted hemostatic approaches including micro-packing, laser therapy, microwave coagulation and high-frequency electrocoagulation can be carried out under direct endoscopic vision. Mastering the distribution of bleeding areas and common inducements of epistaxis is the foundation of standardized endoscopic hemostasis. In 1991, Mary conducted a comparative study between endoscopic intervention and traditional therapies for posterior nasal bleeding. She pointed out that nasal endoscopy can directly observe and treat posterior nasal bleeding points which are hard to detect with traditional methods, featuring short operation time and stable hemostatic results. In 1995, Wang Naya adopted microwave hemostasis guided by nasal endoscopy to treat 56 patients with ordinary epistaxis. Statistical data demonstrated that 58.9% of bleeding happened at the Kiesselbach's area of nasal septum (arterial or capillary hemorrhage), 26.8% took place in the posterior inferior nasal meatus, and the total hemostasis success rate hit 100%. In 1996, Zheng Jun reported 66 cases receiving endoscopic high-frequency electrocoagulation hemostasis, and all patients were fully cured, among which posterior nasal bleeding took up 42.86%.

Main Hemostatic Techniques Guided by Nasal Endoscopy

1. Distribution of Nasal Bleeding Sites

Sorted by the frequency of occurrence from high to low, nasal bleeding locations are listed as follows:

1. Kiesselbach's area of the nasal septum

2. Wu's venous plexus at the posterior inferior nasal meatus

3. Posteroinferior part of the nasal septum

4. Anterior wall of the sphenoid sinus (edge of posterior nasal aperture)

5. Nasal roof (olfactory cleft)

6. Other hidden areas

Apart from these high-incidence bleeding zones, clinicians need to watch out for easily overlooked hidden lesions and typical local signs. Mucous bulges similar to hemangiomas are common local manifestations, which are closely linked to repeated nasal bleeding and require careful inspection during endoscopic examination.

2. Applicable Scenarios and Specific Operation Methods of Endoscopic Hemostasis

Nasal endoscopic hemostasis fits all arterial and venous bleeding spots in the nasal cavity that can be clearly observed. The specific treatment methods are as follows:

1. Endoscopic micro-packing: Relying on the clear sight, sufficient light and precise positioning of nasal endoscopy, medical staff perform targeted micro-packing with petrolatum gauze, hemostatic gauze or hemostatic fiber after confirming bleeding foci. This method boasts high hemostasis efficiency, retains normal nasal ventilation, greatly reduces patients’ discomfort, and avoids redundant posterior nasal packing for posterior nasal bleeding.

2. Endoscopic high-frequency electrocoagulation: After pinpointing bleeding positions (especially broken small vascular stumps), the high-frequency electrode generates electric arcs to form local high temperature, carbonizing tissues and sealing broken blood vessels to achieve hemostasis.

3. Laser-assisted endoscopic hemostasis: Endoscopic laser carbonization and vascular closure are widely applied in clinical epistaxis treatment. Common laser devices include Nd:YAG laser, CO2 laser, KTP532 laser, semiconductor laser and holmium laser, among which Nd:YAG laser and KTP532 laser are most widely used in clinical practice.

4. Endoscopic microwave coagulation hemostasis: Microwaves belong to high-frequency electromagnetic waves, which can instantly raise local tissue temperature, lead to tissue denaturation and coagulation, and rapidly stop bleeding. The microwave probe can directly contact bleeding spots for quick hemostasis.

5. Low-temperature plasma radiofrequency ablation hemostasis: This technology follows the low-temperature coagulation principle. It uses plasma radiofrequency energy at 4–70°C to coagulate bleeding points and stop hemorrhage. Operators should control coagulation time properly and stop the operation once the nasal mucosa turns white or faint yellow. When treating nasal septum bleeding with this method, great attention should be paid to prevent the complication of nasal septum perforation.

3. Key Notes for Endoscopic Treatment of Nasal Bleeding

First, rational use of epinephrine cotton pads. Severe active bleeding will block the surgical field, making it impossible to locate bleeding spots or carry out electrocoagulation, laser or microwave hemostasis. On the premise of adequate nasal anesthesia, epinephrine-soaked cotton pads can be used to constrict blood vessels, control active bleeding and clear accumulated blood clots in the nasal cavity. Doctors can judge the possible bleeding positions according to bleeding features and high-frequency bleeding areas. After active bleeding is controlled by epinephrine, arterial bleeding sites may only show slight mucosal bulges; touching these bulges with a suction device will trigger minor bleeding to confirm the lesion.Second, select appropriate output power. When using laser, microwave and low-temperature plasma radiofrequency ablation, matching output power must be set. For Nd:YAG laser and KTP532 laser, the conventional power is about 30W with a working distance of 3–5 mm from bleeding spots; microwave power is set between 40W and 60W. Intermittent multi-point coagulation is recommended. All thermal coagulation techniques carry risks of deep tissue burns, especially when dealing with nasal septum bleeding, which may cause nasal septum perforation if operated improperly.

4. Unique Advantages of Nasal Endoscopic Hemostasis

1. It can accurately find active bleeding points in all parts of the nasal cavity, especially hard-to-detect lesions in the posterior nasal cavity.

2. It supports precise, intuitive and simple operations under direct vision, realizing fast, accurate and effective hemostasis with reliable curative effects.

3. It causes minimal tissue damage and pain for patients, avoids unnecessary anterior and posterior nasal packing, so it is especially suitable for epistaxis patients with hypertension, vascular diseases and blood system disorders.