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Fiberoptic Bronchoscope and Nd-Yag Laser in Treatment of Severe Epistaxis from Nasal Hereditary Hemorrhagic Telangectasia and Hemangioma

1987; Elsevier BV; Volume: 91; Issue: 5 Linguagem: Inglês

10.1378/chest.91.5.791b

1931-3543

Atul C. Mehta, Douglas R. Livingston, Howard L. Levine,

Vascular Malformations and Hemangiomas

To the Editor:The Nd-YAG laser is widely used in treating endobronchial obstruction from benign and malignant causes. Another use of the Nd-YAG laser is in the treatment of epistaxis from hereditary hemorrhagic telangectasia (HHT) of the nasal mucosa. Shapshay and Oliver1Shapshay SM Oliver P Treatment of hereditary hemorrhagic telangectasia by Nd-YAG laser photocoagulation.Laryngoscopy. 1984; 94: 1554-1556Crossref PubMed Scopus (70) Google Scholar treated six patients by fashioning a plastic suction tip to house the Nd-YAG laser fiber and a surgical microscope to visualize the field. Parkin and Dixon2Parkin JL Dixon JA Laser photocoagulation in hereditary hemorrhagic telangectasia.Otolaryngol Head Neck Surg. 1981; 89: 204-208Crossref PubMed Google Scholar used a flexible nasopharyngoscope to photocoagulate the nasal mucosa of eight patients with HHT. Although they used the Nd-YAG laser in some patients, argon laser was used in most. Recently, we have used a fiberoptic bronchoscope in conjunction with the Nd-YAG laser to treat five patients with recurrent or massive epistaxis. Four of these patients had HHT and one had a nasal hemangioma.General anesthesia with endotracheal intubation was used in all but one patient. The referring otolaryngologist was present throughout the procedure. An Olympus BITR fiberoptic bronchoscope was used with a flexible quartz laser fiber to deliver the Nd-YAG laser photocoagulation. In each case, we used the lowest wattage which would allow satisfactory control of bleeding and sufficient cauterization of target tissue. Table 1 lists our results with this modality. Immediate results and follow-up from ten to 14 months were satisfactory in all but patient 3. In this patient, the procedure was terminated due to the inability to stop active right-sided epistaxis. The left side, however, was successfully lased. Most of the blood trickled into the posterior pharynx and was suctioned from the mouth. Unfortunately, simultaneous lasing and suctioning of blood is not possible with currently available fiberoptic bronchoscopes. A prototype bronchoscope with separate suction and biopsy (laser fiber) channels is presently being investigated by at least one major manufacturer. Patient 5 required repeat Nd-YAG laser photocoagulation (Fig 1). Although we experienced no unusual need to irrigate the bronchoscope or clean the lens, we were meticulous in maintaining a clean laser fiber.3 No other treatment has been necessary in the remaining patients during this follow-up period.Table 1Results of Nd-YAG Laser Treatment of Severe EpistaxisPtSexAgeDiagnosisReason for Nd-YAGTreatments (n)AnesthesiaTotal energy/power/duration (joules/watts/sec)OutcomeComplicationsNeed further treatment?1M55HHT, massive epitaxisArgon laser unsuccessful elsewhere1General13724/50/0.5GoodNoneNo2M61HHT, recurrent epitaxisConservative treatment unsuccessful1General3,549/40/0.4GoodNoneNo3M58HHT, massive epitaxisArgon laser unsuccessful elsewhere1General3,257/45/0.5-0.7Fair (only left side lased)NonePossible right-sided embolization needed4M34Nasal hemangioma, recurrent epistaxisConservative treatment, CO2 laser unsuccessful1Local1,638/20-25/0.4-0.6GoodNoneNo5M58HHTCO2 laser unsuccessful2General9,273/30-40/0.4GoodNoneRepeat Nd-YAG laser7,169/40/0.4GoodNoneNo Open table in a new tab We feel our experience extends the use of the fiberoptic bronchoscope with the Nd-YAG laser to include the control of epistaxis from HHT and nasal hemangioma in patients who have not responded to conventional therapy or other laser systems. We found the Nd-YAG laser provided good photocoagulation and without the excessive tissue destruction or bleeding experienced by Parkin and Dixon.2Parkin JL Dixon JA Laser photocoagulation in hereditary hemorrhagic telangectasia.Otolaryngol Head Neck Surg. 1981; 89: 204-208Crossref PubMed Google Scholar In addition, the maneuverability of this flexible system gave us considerable freedom of movement in the nasal area. Further investigation and experience are necessary before this modality can be recommended for other causes of recalcitrant epistaxis. To the Editor: The Nd-YAG laser is widely used in treating endobronchial obstruction from benign and malignant causes. Another use of the Nd-YAG laser is in the treatment of epistaxis from hereditary hemorrhagic telangectasia (HHT) of the nasal mucosa. Shapshay and Oliver1Shapshay SM Oliver P Treatment of hereditary hemorrhagic telangectasia by Nd-YAG laser photocoagulation.Laryngoscopy. 1984; 94: 1554-1556Crossref PubMed Scopus (70) Google Scholar treated six patients by fashioning a plastic suction tip to house the Nd-YAG laser fiber and a surgical microscope to visualize the field. Parkin and Dixon2Parkin JL Dixon JA Laser photocoagulation in hereditary hemorrhagic telangectasia.Otolaryngol Head Neck Surg. 1981; 89: 204-208Crossref PubMed Google Scholar used a flexible nasopharyngoscope to photocoagulate the nasal mucosa of eight patients with HHT. Although they used the Nd-YAG laser in some patients, argon laser was used in most. Recently, we have used a fiberoptic bronchoscope in conjunction with the Nd-YAG laser to treat five patients with recurrent or massive epistaxis. Four of these patients had HHT and one had a nasal hemangioma. General anesthesia with endotracheal intubation was used in all but one patient. The referring otolaryngologist was present throughout the procedure. An Olympus BITR fiberoptic bronchoscope was used with a flexible quartz laser fiber to deliver the Nd-YAG laser photocoagulation. In each case, we used the lowest wattage which would allow satisfactory control of bleeding and sufficient cauterization of target tissue. Table 1 lists our results with this modality. Immediate results and follow-up from ten to 14 months were satisfactory in all but patient 3. In this patient, the procedure was terminated due to the inability to stop active right-sided epistaxis. The left side, however, was successfully lased. Most of the blood trickled into the posterior pharynx and was suctioned from the mouth. Unfortunately, simultaneous lasing and suctioning of blood is not possible with currently available fiberoptic bronchoscopes. A prototype bronchoscope with separate suction and biopsy (laser fiber) channels is presently being investigated by at least one major manufacturer. Patient 5 required repeat Nd-YAG laser photocoagulation (Fig 1). Although we experienced no unusual need to irrigate the bronchoscope or clean the lens, we were meticulous in maintaining a clean laser fiber.3 No other treatment has been necessary in the remaining patients during this follow-up period. We feel our experience extends the use of the fiberoptic bronchoscope with the Nd-YAG laser to include the control of epistaxis from HHT and nasal hemangioma in patients who have not responded to conventional therapy or other laser systems. We found the Nd-YAG laser provided good photocoagulation and without the excessive tissue destruction or bleeding experienced by Parkin and Dixon.2Parkin JL Dixon JA Laser photocoagulation in hereditary hemorrhagic telangectasia.Otolaryngol Head Neck Surg. 1981; 89: 204-208Crossref PubMed Google Scholar In addition, the maneuverability of this flexible system gave us considerable freedom of movement in the nasal area. Further investigation and experience are necessary before this modality can be recommended for other causes of recalcitrant epistaxis.