Clin[ Otolaryn`ol[ 0888\ 24, 426Ð430

A new bipolar diathermy probe for the outpatient

management of adult acute epistaxis
M[ O|DONNELL\ G[ ROBERTSON + G[W[ M CGARRY
Department of Otolaryn`olo`y\ Glas`ow Royal In_rmary\ Glas`ow\ UK

Accepted for publication 07 August 0888

O|DONNELL M[\ ROBERTSON G[ + MCGARRY G[W[

"0888# Clin[ Otolaryn`ol[ 24, 426Ð430

A new bipolar diathermy probe for the outpatient management of adult acute
epistaxis
The _ndings of a prospective evaluation of the use of a newly!designed bipolar diathermy probe in the
outpatient management of adult acute epistaxis are presented[ Forty!four adult patients with acute
epistaxis were treated with bipolar diathermy after identi_cation of the bleeding point using a rod lens
endoscope[ The use of the nasal endoscope allowed diagnosis of the source of the bleeding point in all
patients[ In all 33 patients immediate control of the bleeding was achieved[ The use of the bipolar probe
obviated the need for hospital admission in 20 patients "69)#[ Three patients had recurrence of their
epistaxis after treatment "6)#[ The number of patients requiring admission to hospital with epistaxis was
signi_cantly reduced using the new bipolar strategy[ "3[3:month versus 0[1:month\ P ³ 9[991#
Keywords epistaxis endoscopy bipolar diathermy direct treatment

Epistaxis remains the most common otorhinolaryngology
emergency[ Despite considerable interest in the subject there
remains no agreement on the most appropriate primary thera!
peutic modality[ In particular\ no therapy has been proven to
be safe\ e}ective and of use in both simple anterior epistaxis
and in posterior bleeds that have proven refractory to other
methods[
In the UK most patients with epistaxis that cannot be
controlled by chemical or electrocautery are treated with
anterior or posterior nasal packing and are admitted to hospi!
tal[0
Nasal packing\ although e}ective\ requires hospital admis!
sion and may be associated with serious side!e}ects such as
hypoxia\ bacteraemia and even myocardial infarction[1Ð4
Despite inpatient treatment with nasal packing between 1)
and 7) of patients have persistent bleeding necessitating
operation[5\6 Numerous operations have been described for
refractory epistaxis including arterial ligation\ endoscopic
cautery under general anaesthesia and angiographic embol!
ization[ Failure rates of between 09) and 14) have been
reported for these procedures[ Complication rates of up to
39) have been reported for maxillary artery ligation3 and a
literature average major complication rate of 7) is reported
for embolization[7\8 These procedures require either access to
Correspondence] G[W[ McGarry\ Department of Otolaryngology\
Glasgow Royal In_rmary\ Glasgow G3 9SF\ UK[
an operating theatre and general anaesthesia or to expensive\
specialist imaging equipment for angiography[
Morgagni\09 in 0650\ remarked upon the necessity of an
instrument that would permit the visualisation and direct con!
trol of bleeding vessels in the posterior nasal cavity[ In 0871
Pearson00 advocated the use of direct visualisation and treat!
ment of posterior bleeding vessels but it was not until the
advent of the rod lens nasal endoscope that this could be done
without recourse to general anaesthesia[ In 0877 Wurman01
was able to treat eight patients with posterior epistaxis suc!
cessfully under local anaesthesia using electrocautery guided
by a rod lens endoscope[
The senior author has previously described the use of endo!
scopically guided electrocautery as a safe and e}ective treat!
ment for posterior epistaxis[02 The e.cacy of electrocautery
is limited by technical factors such as its requirement for
e}ective thermal insulation making the probe bulky and
in~exible[ It is often di.cult to achieve haemostasis using
electrocautery\ as the heated probe tends to adhere to the
tissue coagulum causing re!bleeding when the probe is
removed[
In the last few years our department has attempted to _nd
a safe and e}ective method of haemostasis for use in con!
junction with the nasal endoscope[ Monopolar diathermy
although an e}ective haemostat has a greater attendant risk
of burns\ interference with pacemaker circuits and induction

Þ 0888 Blackwell Science Ltd 426

427 M[ O|Donnell et al[

of arrythmias[ Monopolar diathermy is particularly risky in patients[ In those patients in whom access to the bleeding
endoscopic surgery as the capacitive coupling of stray high point was problematic a 1[6!mm 14> rod lens endoscope was
frequency current may cause major complications[03\04 Bipolar used[ In a previous paper the senior author has described the
devices eliminate this risk and in laparoscopy bipolar elec! routine use of the 1[6 mm endoscope in conjunction with an
trodes have been shown to result in minimal unintended tissue insulated nasal cautery unit[02 The decreased diameter of the
destruction[ After the trial of several prototypes we have new bipolar probe in comparison to the electro!cautery unit
designed a ~exible bipolar diathermy probe which we have allows its use in conjunction with a 3!mm telescope and a _ne
found e}ective in the management of epistaxis[ We describe Adson Frazier suction device[ The 3!mm scope is preferred
our use of the probe during a 8 month trial period in which it for reasons of increased clarity and wider _eld of view[ The
was used as the primary modality of therapy for adult acute Adson Frazier suction catheter is used to provide a clear _eld
epistaxis[ of view to allow identi_cation of the bleeding point[ The
bleeding point was sought using a systematic approach[ Once
identi_ed the bleeding point was in_ltrated using 9[4Ð0 ml of
Patients and methods lignocaine 0) with 0 ] 79 999 adrenaline[ This was performed
under endoscopic vision using a standard dental syringe and
The study group consisted of adult patients "×05 years#
needle[ The bleeding point was then cauterized using the insu!
referred to Glasgow Royal In_rmary\ Department of Oto!
lated bipolar diathermy probe[
laryngology\ with acute epistaxis over a 8!month period "Jan!
The bipolar unit consists of a ~exible insulated probe of
uary 0887ÐSeptember 0887#[ Patients not actively bleeding at
1[7 mm diameter with a hemispherical tip "Fig[ 0#[ The bipolar
the time of presentation "two patients# and patients with
plates\ spaced 9[4 mm apart\ were mounted on the probe tip[
lesions unsuitable for cautery "post nasal space mass\ one
Bipolar current was generated using a Wolf 1241 footplate
patient# were excluded from the study[ All other patients
operated bipolar current generator[ This is used at its
underwent a standard nasal examination using headlight
maximum power setting of 49 W to produce current at a
illumination\ nasal speculae\ topical vasoconstriction with
frequency of 249 kHz[
Cophenylcaine Forte spray and suction[ If a bleeding point
In order to ensure general handling capability the patients
was found on the initial examination it was treated under
managed with the bipolar probe were all treated by all levels
direct vision using the bipolar probe "anterior#[ If the bleeding
of trainee otolaryngologists[ These included 0 year three
point could not be visualized on anterior rhinoscopy then a
specialist registrar\ two senior house o.cers in otolaryngology
3!mm 29> rod lens endoscope was used to identify the bleeding
and two basic surgical trainees[
point "posterior#[ Haemostasis was achieved with this method
and the patient was allowed home and telephoned the next
day to assess their progress[ Patients with signi_cant blood Results
loss\ who lacked social support or whose general medical
During the 8!month study period 33 patients with spon!
condition required monitoring\ were admitted[ All patients
taneous epistaxis were treated with the new bipolar diathermy
were followed up by a telephone survey and in the outpatient
probe "06 men\ 16 women^ mean age 56 years^ range 07Ð78
clinic 0 month after discharge when they were interviewed
years#[
about further bleeding or readmission to hospital[
In order to assess the impact of the new outpatient!based
management strategy we carried out an audit of monthly SOURCE OF REFERRAL
admissions to the ENT unit with epistaxis during the study
The majority of patients were referred by the Accident and
period[ We compared these _gures to monthly admissions
Emergency department of Glasgow Royal In_rmary "30 pat!
data from 16 non!study months "January 0884ÐMarch 0885\
January 0886ÐDecember 0886#[ The change in admission rate
attributable to the use of the new bipolar probe was deter!
mined by comparing the rate of admission before and after
its introduction[

DESCRIPTION OF ENDOSCOPIC TECHNIQUE

All patients in the study group\ in whom a bleeding point
could not be seen at anterior rhinoscopy\ underwent nasal
endoscopy after topical Cophenylcaine spray had been
applied for vasoconstriction and local anaesthesia[ A 3!mm\
29> rod lens endoscope "STORZ# was used in the majority of Figure 0[ The new bipolar diathermy probe[

Þ 0888 Blackwell Science Ltd\ Clinical Otolaryn`olo`y\ 13\ 426Ð430


ients\ 82)#[ The remainder were inpatients in other depart!
ments referred with acute epistaxis[
BLEEDING POINT LOCATION
The source of epistaxis was identi_ed in all 33 patients studied[
Fifteen patients "23)# were found on anterior rhinoscopy
to be bleeding from the anterior nasal septum[ Twenty!nine
patients "55)# had a posterior bleeding point[ The posterior
nasal septum was the source of bleeding in 08 patients "32)#
and the lateral nasal wall accounted for the remaining 09 cases
"12)#[ No cases of bilateral epistaxis were seen[
Morphological data regarding the bleeding point was also
recorded[ The most common macroscopic lesion seen at the
site of bleeding was an arteriole with or without adherent clot
"07 patients\ 39)#[ A sentinel area of granulation tissue in
juxtaposition to the bleeding point was seen in 02 cases "29)#[
MANAGEMENT STRATEGY
Thirty!three patients "64)# with acute epistaxis were man!
aged as outpatients using the new bipolar diathermy probe[
In 00 patients "14)# outpatient management was inap!
propriate or unfeasible[ In two cases the bipolar probe was
unavailable at the time of presentation and these patients had
nasal packing inserted\ were admitted overnight and under!
went bipolar diathermy the following morning[ Two patients
were admitted overnight for observation after local anaes!
thetic procedures were carried out to facilitate access for
bipolar diathermy "0 SMR\ 0 polypectomy#[
A further two patients were too frail and socially isolated
to be managed as outpatients and were admitted overnight
for observation[ Three patients were treated who were inpa!
tients in other departments and two patients required admis!
sion to haematology after successful treatment of the epistaxis
for correction of thrombocytopenia[
OUTCOMES
Immediate haemostasis was achieved in all patients treated
with the bipolar diathermy probe[ Three of these patients
had recurrence of their bleeding "5[7)#[ All of the re!bleeds
occurred in the group treated as outpatients[ One of the re!
bleeds was controlled with further bipolar diathermy[ Two of
the re!bleeds were treated at other hospitals[ No patient in the
study group required blood transfusion\ a general anaesthetic
or any surgical intervention[
FOLLOW!UP
Patients were followed up by telephone and in the outpatient
department as previously described[ Only two complications
were identi_ed at the time of outpatient review[ These were
both asymptomatic\ minor adhesions in the nasal vault that
Þ 0888 Blackwell Science Ltd\ Clinical Otolaryn`olo`y\ 13\ 426Ð430
A new bipolar diathermy probe 428
had occurred after the diathermy probe had been applied to
this area[
EFFECT ON ADMISSIONS
In an analysis of 16 recent months admissions with epistaxis
"January 0884ÐMarch 0885\ January 0886ÐDecember 0886#
the mean monthly admission rate was 3[3 and the average
duration of hospital stay was 1[1 days[ In the 8!month study
period 00 adult patients "0[1 per month# required admission
with acute epistaxis[ The average duration of hospital stay
was 0[4 days during the study period "P × 9[94\ P  9[97# and
a statistically signi_cant fall in the average number of monthly
admissions was observed "3[3 versus 0[1 P ³ 9[91# "Fig[ 1#[
In order to identify any signi_cant fall in the incidence of
epistaxis presenting to the accident and emergency department
during the study period a retrospective audit of Accident and
Emergency attendances was carried out[ In the 8 months prior
to the trial a total of 043 patients "06[0:month# presented
to the accident and emergency department with a primary
diagnosis of epistaxis[ In the _rst 5 months of the study 000
patients "07[4:month# su}ering from epistaxis were seen[ No
statistical di}erence is noted between these two groups[
Discussion
This paper is the _rst description of the use of bipolar dia!
thermy in outpatient management of adult acute epistaxis[
The majority of patients treated were referred to us by the
Accident and Emergency department and undoubtedly many
patients with minor\ anterior bleeds will have been treated by
casualty o.cers using silver nitrate cautery without requiring
referral[ We would suggest that this is the reason for the
predominance of posterior bleeding sources in the study group
"55)#[ It is interesting to note that of those patients with
posterior epistaxis only 09 "23[4)# were found to be bleeding
from a source in the lateral nasal wall[ Other studies have
suggested that the lateral nasal wall is the prime site of pos!
terior bleeding but these _gures\ which correspond closely
to those previously reported by the senior author\02 support
Shaheens identi_cation of the nasal septum as a source of
posterior epistaxis[05 Three patients treated with bipolar cau!
tery required treatment for a further epistaxis[ All of these
re!bleeds occurred in the groups that were discharged after
treatment[ This gives a failure rate for the procedure of 8[5)
in the group of patients discharged or 5[7) considering the
study group as a whole[ This compares favourably with the
failure rates of between 09) and 15[1) reported in the litera!
ture for nasal packing[ In addition the use of bipolar dia!
thermy allows for the immediate discharge of patients from
hospital making it an attractive means of improving patient
care while simultaneously reducing the cost of treatment[ The
majority of patients studied would have required admission
439 M[ O|Donnell et al[
Figure 1[ Admissions with epistaxis to Glasgow Royal In_rmary\ January 0884ÐSeptember 0887[
and nasal packing had bipolar diathermy not been available
Although our study group is small we are pleased to report
that no patient in the study group required transfusion[ Small
et al[5 reported that 19) of patients admitted with epistaxis
required transfusion\ and in a large series described by Monux
et al[6 04[8) required transfusion[
This study was designed as a pilot study prior to a major
multicentre randomised prospective evaluation of the use of
bipolar diathermy in the management of adult epistaxis[ As a
result the number of patients and the lack of randomisation
allow only limited conclusions to be drawn regarding the
e.cacy of the bipolar probe in reducing the need for admis!
sion for nasal packing[ Nevertheless a signi_cant fall
"P ³ 9[91# in the number of admissions with epistaxis was
noted during the study period compared with a representative
sample taken prior to the use of the bipolar probe[ We found
that the average monthly admission rate prior to the use of
the bipolar probe to be 3[3[ Glasgow Royal In_rmary serves
a population of 199 999 and from these _gures we can cal!
culate a rate of admission with epistaxis of 15[3 per 099 999
per year[ This is similar to the incidence of 17[7 per 099 999
per year reported by Small et al[5 in Edinburgh[ We would
therefore conclude that the period that we have selected for
comparison is a fair representation of the expected rates of
admission in an urban teaching hospital and that the fall in
admissions we have observed cannot therefore be explained
as a fall from an abnormally high baseline[ We found no
signi_cant fall in the numbers attending the Accident and
Emergency department with acute epistaxis during the study
period and therefore do not believe that the fall in monthly
admissions can be explained by an overall fall in the incidence
of the disease[
We conclude that the majority of patients with adult acute
epistaxis can be managed e}ectively and safely as outpatients
using bipolar electrocautery[ As a result of this new strategy\
inpatient admission for epistaxis is now an uncommon event
in our department[
Acknowledgements
We would like to thank the engineers and management of
Wolf for their help in the design and modi_cation of the
probe[ No direct _nancial assistance was sought or received[
The engineering of the probe was carried out by Richard
Wolf\ UK[ Con~ict of interest] None[
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