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Fiorella2005 PDF
Fiorella2005 PDF
Objectives/Hypothesis: Septal dermoplasty has 7 (10%) had symptomatic liver disease, and 5 (7%) had
been recommended as the treatment of choice for life- cerebral arteriovenous malformation. During the
threatening epistaxis in patients with hereditary follow-up, 14 patients died of other complications of he-
hemorrhagic telangiectasia. The purpose of the study reditary hemorrhagic telangiectasia (11 patients) and
was to evaluate the effectiveness and outcomes of unrelated causes (3 patients). Conclusion: Septal dermo-
septal dermoplasty for management of transfusion- plasty remains an effective way of reducing transfusion
dependent epistaxis. Study Design: Retrospective requirements in patients with hereditary hemorrhagic
study. Methods: Between 1994 and 2004, septal dermo- telangiectasia and subjectively improves their quality
plasty was performed on 67 consecutive patients with of life. The otolaryngologist caring for patients with he-
severe epistaxis attributable to hereditary hemor- reditary hemorrhagic telangiectasia should be familiar
rhagic telangiectasia. The numbers of units of blood with other organ involvement by hereditary hemor-
received 1 year before and 1 year after septal dermo- rhagic telangiectasia to prevent complications during
plasty were obtained. A subjective appraisal of the surgery. Key Words: Septal dermoplasty, epistaxis, he-
results of the surgery as well as second procedures reditary hemorrhagic telangiectasia.
after septal dermoplasty was determined. Patients Laryngoscope, 115:301–305, 2005
were screened for pulmonary and cerebral arterio-
venous malformations, gastrointestinal tract bleed-
INTRODUCTION
ing, and symptomatic liver disease. Results: Data
were obtained in 66 of 67 (98%) patients with a mean Hereditary hemorrhagic telangiectasia (HHT) is an
age of 61.5 years (mean follow-up, 3.9 y). Accurate uncommon systemic autosomal dominant disorder of an-
transfusion requirements 1 year before and 1 year giogenesis characterized by the presence of vascular tel-
after septal dermoplasty were available in 32 of 66 angiectases in mucocutaneous tissues, visceral organs,
(48%) patients. In these 32 patients, the mean units of and the central nervous system.1 Epistaxis, caused by
blood received decreased from 21 units (range, 2–100 spontaneous bleeding from telangiectases of the nasal mu-
units) 1 year before septal dermoplasty to 1 unit cosa, is the most common manifestation of HHT. It may be
(range, 0 –10 units) in the year after septal dermo- so severe as to require multiple transfusions and intrave-
plasty (P < .001). Improved quality of life was claimed nous iron supplementation. Bleeding becomes more severe
in 57 patients. Second therapies, ranging from cau-
in later decades in approximately two-thirds of affected
tery to repeat partial septal dermoplasty, were re-
quired in 15 patients during follow-up. Among the 67 persons.2 Although nasal manifestations of HHT are well
patients, 31 (46%) had pulmonary arteriovenous mal- known to otolaryngologists, many of the other organ man-
formation, 14 (21%) had gastrointestinal tract bleeding, ifestations of this disorder are less well known and may
pose issues for the physician treating the patient with
HHT.
From the Department of Otolaryngology (M.L.F.) Universita‘ degli
Studi di Bari, Bari, Italy; and the Sections of Otolaryngology (D.R.), De- Mild and moderate epistaxis is treated by hormonal
partment of Surgery, and Interventional Radiology (K.J.H., R.I.W.), Depart- therapy with estrogens,3 chemical cautery and electrocau-
ment of Diagnostic Radiology, Yale University School of Medicine, New tery, and laser coagulation.4 Life-threatening epistaxis,
Haven, Connecticut, U.S.A.
Supported in part by March of Dimes grant HHT-FY04 – 677 and
which is associated with HHT, has been treated with
Josephine Lawrence Hopkins Foundation and General Clinical Research varying success using embolization,5 surgical ligation,6
Center NIH M01-RR-00125 grant (R.I.W. and K.J.H.). Young’s surgical closure of the nostrils by a skin flap,7 and
Editor’s Note: This Manuscript was accepted for publication August microvascular free flaps.8
3, 2004.
Send Correspondence to Douglas Ross, MD, Section of Otolaryngol-
William Saunders pioneered a skin grafting tech-
ogy, Department of Surgery, Yale University School of Medicine, Yale nique for severe epistaxis in 1958; since then, this tech-
Physician’s Building, 4th Floor, 800 Howard Avenue, New Haven, Con- nique has undergone modification.9 The principle of this
necticut 06519, U.S.A. E-mail: douglas.ross@yale.edu
procedure is to replace the fragile respiratory mucosa of
DOI: 10.1097/01.mlg.0000154754.39797.43 the nose with strong keratinized split-thickness skin
Surgical Technique
Surgical technique is shown in Figures 1 and 2. With the
patient under general endotracheal anesthesia, a 3 ⫻ 7-inch
split-thickness graft is taken from the lateral aspect of the right-
side thigh, using a Zimmer air dermatome on a setting of
141000of an inch. Xeroform and Telfa with Kerlex-wrapped
dressing are applied on completion of harvesting of the skin and
the graft, which is preserved in a saline-soaked sponge.
Bilateral inferior turbinectomies are performed in the fol-
lowing manner. Neo-Synephrine is placed into the nose for ade-
quate vasoconstriction; then the inferior turbinates are infil-
trated with 1% lidocaine and 1:100,000 epinephrine. The
turbinate is medialized and removed at its base using an anterior
straight scissor under endoscopic view, cutting anteroposteriorly,
as much as possible toward the lateral nasal wall. The free edge of
the remnant of the turbinate is then cut down using microderider. Fig. 1. (A and B) Sagittal views. (A) Nasal mucosa is removed with
a Faulkner curette (lateral wall). The nasal mucosa is resected, and
Meticulous hemostasis is achieved using Bovie electrocautery.
an inferior turbinectomy is performed. (B) The graft has been su-
The septal dermoplasty is performed. The nasal vestibule is tured anteriorly and applied to lateral wall.
injected with 1% lidocaine and 1:100,000 epinephrine. After 7
minutes a narrow circumferential strip of vestibular skin is ex-
cised from the septum and the floor and from the lateral wall of
both nostrils at the mucocutaneous junction. As much mucosa as 0.5 ⫻ 3-cm Neuropatties treated with mupirocin calcium oint-
possible is removed using a Faulkner curette, taking care to ment (Bactroban, Galaxo Smith Kline, Philadelphia, PA) are used
preserve the perichondrium of the septum that must nourish the for this task. The first pack is placed along the floor of the nose to
new grafts and the septal cartilage. anchor the graft inferiorly; then a second piece is placed superi-
Bleeding is controlled by the topical application of cotton orly, continuing in this alternate fashion until the nose is packed
soaked in epinephrine in one nostril and continuing the operation firmly. Packing is removed only after 5 days, when the grafts are
in the opposite side. Once the bleeding has slowed, the curetting well attached.
is continued until one is assured of adequate removal of mucosa. There is often “temporary” nasal obstruction after the packs
The skin graft is sutured in a U shape. A stitch is placed at are removed, because of excess skin at the posterior part of the
the inferior aspect of the rim incision with interrupted 3-0 chro- nose. This acts as an avascular small flap that eventually disin-
mic suture, and the skin graft is sutured circumferentially tegrates. When this occurs, the nasal airways improve.
around the rim incision of the nasal vestibule. The skin graft is
then inserted into the nose with a No. 2 bayonet forceps, and a Follow-Up Care
long nasal speculum is used to hold it in place for packing. Nothing more is performed for 10 to 14 days after surgery so
that the skin graft can become firmly attached to the nasal walls.
Packing and Removal During follow-up, cautious suctioning of crusts is performed to
An important aspect is careful nose packing, to avoid the facilitate breathing and success of graft take. Skin is not meant to
displacement of the skin graft while healing takes place. Multiple be in the nose, and crusting from desquamation frequently devel-
Outcomes
Our study is a large retrospective review of patients CONCLUSION
with severe epistaxis attributable to HHT that was The modified SD for transfusion-dependent epistaxis
treated by SD. To date, the data on SD reported in the in patients with HHT provides excellent palliation and
literature have been based on a small number of patients improves quality of life. The need for transfusions was
and the duration of follow-up has been short. Our out- significantly reduced in the subset of 32 patients with
comes are longer than previously reported and are based accurate blood transfusion records 1 year before and 1
on transfusion requirements before and after SD, as well year after SD. All patients with HHT who are undergoing
as subjective questioning of the patient or family. Cessa- SD should be seen 1 year after SD because in as many as
tion or marked reduction of epistaxis occurs in 90% of 25% of patients, laser or other secondary procedures will
patients with HHT during the first 2 years after SD. Four be necessary. The otolaryngologist treating patients with
patients did not benefit from SD. Our clinical experience HHT should be aware of other organ manifestations,
has demonstrated that, beyond the obvious health dam- which may influence management of the patient during
age, epistaxis of this magnitude seriously affects the qual- and after SD.
ity of life of the patient with HHT.
Limitations of our study include the retrospective
design and the recall bias associated with the quality-of- Acknowledgment
life assessment. Because some of our patients developed The authors thank James Dziura for his assistance
repeat bleeding attributable to new telangiectases or par- with data analysis.