Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 5 Issue: 5

Efficacy of KTP Laser Photocoagulation Combined with Cautery as Treatment for Epistaxis in HHT

Hunter BN1*, McDonald J2, Wilson KF3 and Ward PD3
1Southern Illinois University Division of Otolaryngology Head and Neck Surgery, USA
2University of Utah School Departments of Pathology and Radiology, USA
3University of Utah Division of Otolaryngology Head and Neck Surgery, USA
Corresponding author : Hunter BN, MD
Southern Illinois University Division of Otolaryngology, Head and Neck Surgery, PO Box 19662, Springfield, IL, USA
Tel: 62794-9662
Fax:
217-545-8000
E-mail: [email protected]
Received: September 29, 2016 Accepted: October 20, 2016 Published: October 27, 2016
Citation: Hunter BN, McDonald J, Wilson KF, Ward PD (2016) Efficacy of KTP Laser Photocoagulation Combined with Cautery as Treatment for Epistaxis in HHT. J Otol Rhinol 5:5. doi:10.4172/2324-8785.1000294

Abstract

Background: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia characterized by spontaneous, recurrent epistaxis. Epistaxis ranges from sporadic, low volume bleeds to frequent hemorrhages causing anemia. In moderate-severe cases, KTP laser photocoagulation and/or electrocautery are commonly utilized to control epistaxis.

Objective: This observational cohort study aims to evaluate the efficacy of laser therapy combined with cautery as treatment for epistaxis in HHT.

Methods: Chart review and telephone interviews were conducted for all HHT patients at our center who had undergone laser therapy with or without concurrent electrocautery for intranasal lesions from 08/2011 – 12/2014. Data collected from chart included patient demographics, epistaxis severity score (ESS) at time of intervention, and any ESS recorded in the interim. Telephone interviews were conducted at two time points 18 months apart to collect ESS on subjects.

Results: 35 subjects were included in the final analysis, 10 of which had >1 procedure during the time frame. The average pre-operative ESS was 7.1. Post-operative ESS were an average of 2.93 units lower than the pre-operative scores (p<0.05). On average, for each 1-unit increase in pre-operative ESS, the improvement in postoperative ESS increased by 0.72 units (p<0.05). There was no significant difference when comparing age with time between procedures (p=0.38).

Conclusion: Laser therapy combined with cautery reduces epistaxis severity in HHT and provides greater improvement of symptoms in patients who present with more severe epistaxis.

Keywords: Hereditary hemorrhagic telangiectasia; HHT; Osler-weber-rendu disease; Osler-weber-rendu syndrome; KTP laser photocoagulation; Laser photocoagulation; Cautery; Bipolar cautery; Epistaxis; Epistaxis treatment; Epistaxis severity score; ESS

Keywords

Hereditary hemorrhagic telangiectasia; Osler-weber-rendu disease; Osler-weber-rendu syndrome; KTP laser photocoagulation; Laser photocoagulation; Cautery; Bipolar cautery; Epistaxis; Epistaxis treatment; Epistaxis severity score; ESS

Introduction

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectases, including the nasal mucosa. Nasal telangiectases are particularly prone to rupture, causing spontaneous, recurrent epistaxis. Epistaxis ranges from sporadic, low volume bleeds to frequent hemorrhages causing anemia [1]. Epistaxis in patients with HHT can cause social interference on a daily basis and have a negative impact on quality of life [2,3]. Mild cases are typically managed with conservative therapy, including humidification, topical nasal lubricants and creams, saline treatments, and other topical medications [1,4,5]. In moderate-severe cases, cautery and/or laser photocoagulation are commonly utilized to better control epistaxis.
Electrical or chemical cautery and laser photocoagulation are common minimally invasive therapies utilized to provide temporary epistaxis relief. Chemical cautery is used less frequently, in part, due to its greater likelihood to result in intraoperative and postoperative complications [6,7]. Electrocautery and laser therapy can be used separately, but are often used in conjunction. It has been suggested that electrocautery may be more helpful for larger lesions, and laser more appropriate for smaller lesions [8]. There are no published studies comparing electrocautery to laser therapy in the treatment of HHT-associated epistaxis. The types of lasers described in the literature for the treatment of epistaxis are neodymium-doped yttrium aluminium garnet (Nd:YAG), argon plasma coagulation (APC), and potassium titanyl phosphate (KTP). Studies to date that evaluate the efficacy of these therapies suggest these interventions are safe and may be temporarily effective; but have been limited by small sample sizes and poor objective metrics for assessment of outcome [6,8-16].
The Hoag epistaxis severity score (ESS), published in 2010, is a statistically validated tool for estimating epistaxis severity. A score of 0-10 is calculated based on a patient’s answers to six questions relating to typical nosebleed frequency, duration, amount of flow, presence of anemia, whether medical attention has been sought and transfusion history. Part of the value of the ESS is that it provides a uniform means of evaluating epistaxis for all clinicians [17]. Studies are only beginning to utilize this objective metric in HHT patients with severe epistaxis [18]. Prior to this study, no group has used a comprehensive, validated tool such as the ESS for measuring response to laser and cautery.
The purpose of this study was to employ the ESS to evaluate the efficacy of laser therapy and cautery as dual treatments for epistaxis in HHT.

Materials and Methods

Data collection and evaluation
Observational data was gathered on all HHT patients seen at the University of Utah HHT Center who had undergone laser photocoagulation therapy for epistaxis, with or without concurrent electrocautery, between August 2011 and December 2014 (University of Utah IRB 00039582). Patients were excluded if they had a history of septal dermoplasty or if they underwent nasal closure in the follow up period. Data collected on these subjects included age at time of procedure(s), gender, date of laser procedure(s), and pre-operative ESS. At least one postoperative ESS was collected for all patients and for some patients multiple postoperative ESS values were collected. In July 2013, all patients who had undergone laser photocoagulation in the 24 months prior were interviewed over telephone to administer an ESS survey. In January 2015, all patients who had undergone said therapy from August 2011 through December 2014 were interviewed over telephone to administer an ESS survey. In addition, at our multidisciplinary HHT Center, clinicians routinely administer the ESS survey to HHT patients as part of any clinical encounter. As a result, some patients in this cohort had several post-operative epistaxis severity scores recorded across time, while some had only a single post-operative ESS that was obtained via telephone interview.
Description of procedure
Procedures were performed (or supervised) by one of two otolaryngologists at our institution. Each procedure was done in the operating room under general anesthesia. During a typical procedure, topical intranasal vasoconstrictor (cocaine or oxymetazoline) is placed in the nose after adequate anesthesia has been induced. An endoscope is used to visualize the lesion(s). The KTP laser is then used at a setting of 2 watts, for 0.1-second duration and 0.1 second interval to photocoagulate the lesion(s). Considerable time is spent in carefully treating each lesion. The lesions that cannot be controlled with a laser are controlled with bipolar or monopolar electrocautery until hemostasis is achieved. Care is taken to avoid treating both sides of the septum to help minimize the risk of septal perforation. Bactroban ointment is then applied intranasally.
Data analysis
Descriptive statistics of both the patients’ characteristics and preas well as post-operative ESS were performed. For patients who had multiple post-operative scores, an average of all their scores was used for this analysis to determine the post-operative ESS. For patients who underwent >1 procedure, only scores prior to the second procedure were used in calculation of average postoperative score of the first operation. The distribution of epistaxis severity scores was examined and diagnostic pairwise plots relating each variable to the baseline ESS were plotted. ESS was divided into three ranges of severity: <3 (mild), 3-7 (moderate), and >7 (severe). The distribution of age by the time out from procedures as well as whether the patient had single or multiple procedures was compared using summary statistics.
Since some patients had multiple procedures, we used a generalized estimating equations (GEE) regression model with an unstructured correlation matrix. The difference between preoperative ESS and post-operative ESS (hereon will be referred to as “change in ESS”), a continuous variable, was used as the outcome. The following variables were used to build our regression model: age, sex, pre-operative ESS, post-operative ESS, time out from procedure and how many procedures the patients had during the follow up time (1, >1). Patient identification numbers (ID) were used as the clustering variable in the GEE model. Univariate as well as multivariate analyses were performed.
Age was separately compared with the time out from surgery (categorized as 0-6 months, >6months) and the number of procedures (1, >1) using generalized estimating equations (GEE) linear regression model with an unstructured correlation matrix (with age as the outcome) to account for correlated values within patients. Statistical analysis was performed using R 3.1.2 statistical language.

Results

The study cohort consists of 35 patients [originally 46 patients:11 were excluded (8 due to incomplete information and 3 due to previous septal dermoplasty)]. The mean age was 52.5 years, range 23 to 81 years. 20 of the patients were females (57%). Approximately two thirds had one procedure recorded during the period of follow up. 15 patients (43%) had >1 post-operative ESS recorded. Average followup time was 18 months from the date of the first laser procedure. The average pre-operative ESS was 7.1. There were no patients with mild pre-operative ESS (ESS <3). The average post-operative ESS (irrespective of time out from procedure) was 4.2 (Table 1).
Table 1: Demographics and summary statistics.
Results of the multivariate GEE model using change in ESS as the outcome, with pre-operative ESS as the main predictor showed that on average, for each 1-unit increase in pre-operative ESS, the post-operative ESS improved by 0.57 units (p<0.001). Similarly, the univariate model using the same parameters showed that on average, for each 1-unit increase in pre-operative ESS, the change in ESS increased by 0.72 units (p<0.001). The amount of time after the procedure was also a significant factor in both models. The further out from surgery, the higher the ESS. For each 1-month in time out from procedure, the post-operative ESS increased by 0.04 (p=0.004) in the multivariate model and 0.064 (p<0.001) in the univariate model (Table 2).
Table 2: Regression analysis (GEE) results for change in ESS using the pre-operative ESS as the predictor and difference between pre-operative ESS and post-operative ESS as the outcome. On average, for each 1 unit increase in pre-operative ESS, the change in ESS increased by 0.57 units in the multivariate model. Also, time out from procedure was statistically significant, where for each 1-month increase in time, the change decreased by -0.04 (95% CI: -0.07, -0.01).
There was a significant decrease in ESS when comparing pre- to post-operative values (p<0.001) (Figure 1a). When comparing the change in ESS among patients with moderate pre-operative ESS versus those with severe pre-operative ESS, patients in the severe group appreciated a greater change in ESS after laser therapy (p<0.001) (Figure 1b). There was no significant effect of age on change in ESS (p=0.73) (Figure 2).
Figure 1a: Boxplot comparing distribution of pre and post-operative ESS.
Figure 1b: Boxplot depicting the change from pre to post-operative ESS comparing patients with moderate pre-operative epistaxis severity (preoperative ESS >3 and <7) vs. patients with severe pre-operative epistaxis severity (pre-operative ESS >7). Subjects with higher (more severe) preoperative ESS demonstrated greater reduction in ESS after laser therapy than subjects with less severe ESS.
Figure 2: Boxplot depicting change in pre-operative to post-operative ESS in tertile age groups.

Discussion

Quantifying the severity of epistaxis is a difficult task. Metrics used historically for measuring epistaxis severity had significant limitations and inherent weaknesses [9,19]. In 2010, the Hoag epistaxis severity score (ESS) was published and has become recognized as a validated, robust and useful tool for the systematic assessment of epistaxis severity [17]. One recent study effectively used the ESS in HHT patients with epistaxis refractory to laser therapy [18]. Prior to this study, no group has used a comprehensive, validated tool such as the ESS for measuring response to laser and cautery.
This study demonstrates that KTP laser therapy used with or without cautery for epistaxis in HHT patients is effective in reducing epistaxis severity as measured by the ESS (Figure 1). We found that the most useful predictor for improvement in one’s epistaxis is a preoperative ESS. Based on our regression analysis, we propose a model for predicting clinical outcomes from laser therapy and cautery based on pre-operative ESS (Table 2 and Figure 3). In particular, patients with a pre-operative ESS > 3.3 had a demonstrable improvement in epistaxis. As pre-operative ESS increases (representing more severe epistaxis), there is a direct correlation with increasing benefit provided by these therapies provide (Figure 3). The data from our univariate analysis suggests that as pre-operative ESS increases by 1 point, one can expect a reduction in post-operative ESS of 0.72 points.
Figure 3: Scatter plot with line of best fit to predict change in ESS based off pre-operative ESS. y=0.72x-2.36.
Our data suggests that, as has been previously reported, in the post-operative setting epistaxis severity will worsen over time [12,20].After an initial improvement in ESS, for each one-month out from surgery, on average a 0.064 rise in ESS was observed.
This study was an observational study. Excluding the scores that were obtained via phone interviews, the remainder of the data was collected as part of the routine clinical evaluation of HHT patients who present for management at a specialty center for HHT. As a result, the follow-up interval was variable. Our cohort was small, totaling 35 patients. The biggest limitation of this study may be that the use of cautery in addition to laser therapy, versus laser alone was not standardized. In general, cautery was used as an adjunct to KTP laser only in patients for whom laser failed to coagulate vascular lesions during a procedure. However, our approach of using KTP laser, and only adding cautery when necessary was the same for all patients. In clinical practice, our experienced otolaryngologists found this approach to be the most effective.

Conclusion

KTP laser, combined with cautery in select cases, provides effective temporary treatment for HHT-related epistaxis. Using the ESS routinely can help guide clinical decision making and may be useful in providing prognostic counseling for HHT patients with epistaxis. This study suggests that patients who have higher preoperative ESS’ can expect greater improvement from treatment than patients with lower pre-operative ESS’ (less severe epistaxis). The study suggests that while these therapies provide a significant initial improvement in epistaxis severity, the ESS will increase with time.

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