2017-18 HSC Section 3 Green Book

Reprinted by permission of Laryngoscope. 2017; 127(5):1017-1020.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Arterial Ligation Versus Embolization in Epistaxis Management: Counterintuitive National Trends

Michael J. Sylvester, AB; Sei Y. Chung, BS; Luis A. Guinand, BA; Aparna Govindan, BA; Soly Baredes, MD, FACS; Jean Anderson Eloy, MD, FACS

Objectives/Hypothesis: Arterial ligation and embolization are treatment modalities indicated in severe and refractory epistaxis. The purpose of this study was to examine temporal trends and compare outcomes in treatment of hospitalized epi- staxis patients with ligation or embolization. Methods: This retrospective cohort analysis utilized the 2008 to 2013 National Inpatient Sample to identify patients admitted with a primary diagnosis of epistaxis, and an associated procedure code for ligation or embolization. Results: A total of 1,813 cases met the inclusion criteria, with 57.1% undergoing ligation. During the study period, treat- ment with ligation has trended downward, whereas treatment with embolization has remained constant. Overall, ligated patients were older (64.1 vs. 62.4 years; P 5 0.027) and had higher rates of congestive heart failure (15.1% vs. 9.8%; P 5 0.001). No significant differences in rates of chronic pulmonary disease, coagulopathy, liver disease, or hereditary hemorrhag- ic telangiectasia were observed between cohorts. No differences were observed in rates of blood transfusion, stroke, blind- ness, or in-hospital mortality; however, ligated patients had lower rates of intubation/tracheostomy (2.8% vs. 5.3%; P 5 0.009). Ligated patients also experienced shorter hospital stays (3.6 vs. 4.0 days; P 5 0.014) and incurred lower hospital charges ($33,029 vs. $69,304; P < 0.001). Conclusion: Compared to embolization, ligation is associated with significantly decreased hospital charges and shorter hospital stay, without an increase in complication rates. Counterintuitively, ligation appears to be trending downward nation- ally in its use relative to embolization. Key Words: Epistaxis, embolization, ligation, national inpatient sample (NIS). Level of Evidence: 2C Laryngoscope , 127:1017–1020, 2017

INTRODUCTION Epistaxis is one of the most common emergencies treated by otolaryngologists. Epistaxis is typically sponta- neous in onset and idiopathic in etiology, although it is often associated with comorbidities such as hypertension and coagulopathy. Most episodes of epistaxis will resolve without treatment, or with conservative measures such as nasal packing. However, about 6% of patients will require From the Department of Otolaryngology–Head and Neck Surgery ( M . J . S ., S . Y . C ., L . A . G ., A . G ., S . B ., J . A . E .); the Center for Skull Base and Pitui- tary Surgery, Neurological Institute of New Jersey ( S . B ., J . A . E .); the Department of Neurological Surgery ( J . A . E .); and the Department of Oph- thalmology and Visual Science ( J . A . E .), Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 10, 2016. Presented as an oral presentation at the 2016 American Rhino- logic Society Annual Meeting, San Diego, CA, U.S.A., September 16–17, 2016. Financial Disclosure: The authors have no funding, financial rela- tionships, or conflicts of interest to disclose. Send correspondence to Jean Anderson Eloy, MD, FACS, Professor and Vice Chairman, Director, Rhinology and Sinus Surgery, Director, Otolaryngology Research, Co-Director, Endoscopic Skull Base Surgery Program, Department of Otolaryngology–Head and Neck Surgery, Pro- fessor of Neurological Surgery, Professor of Ophthalmology and Visual Science, Neurological Institute of New Jersey, Rutgers New Jersey Medi- cal School, 90 Bergen St., Suite 8100, Newark, NJ 07103. E-mail: jean.anderson.eloy@gmail.com

more aggressive management, including surgical arterial ligation and endovascular arterial embolization. 1–3 Success rates for both ligation and embolization are comparable and estimated to be greater than 90%. There are advantages and drawbacks associated with each modality. Arterial embolization is typically thought to carry a greater risk of serious complications, including stroke and blindness. 1,4 Although ligation may confer decreased rates of these major complications, emboliza- tion can be performed with local anesthesia, avoiding the risks associated with general anesthesia. Emboliza- tion also confers less trauma to the nasal mucosa and allows embolization of additional branches of the exter- nal carotid artery that may be contributing to recurrent episodes of epistaxis. 4 The current literature has suggested that surgical arterial ligation is more cost-effective than endovascular arterial embolization. 3–6 The purpose of the present study was to provide an updated cost analysis and com- parison of outcomes regarding these two treatment modalities, utilizing data from the 2008 to 2013 Nation- wide (National) Inpatient Sample (NIS).

MATERIALS AND METHODS This retrospective cross-sectional analysis was performed utilizing data from the 2008 to 2013 NIS. The NIS is the largest all-payer inpatient database in the United States and is part of

DOI: 10.1002/lary.26452

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