2017-18 HSC Section 3 Green Book

embolization seem counterintuitive. Further research is necessary to investigate the reason for these trends.

Using NIS case weights, national estimates of total number of national inpatient epistaxis cases treated with arterial ligation or embolization were determined. Given the finding that treatment of epistaxis with embo- lization was associated with longer length of stay, increased total hospital charges, and higher rates of intubation/tracheostomy, we expected embolization use to be trending downward nationally and ligation to be trending upward nationally. Instead, our findings dem- onstrated that treatment with embolization remained flat, and treatment with ligation appeared to trend downward from 2008 to 2013. One possible explanation is that otolaryngologists tend to have elective practices and cannot generally easily accommodate emergencies in their schedule, whereas vascular interventionalists can more easily incorporate epistaxis patients in their practice, which mostly is geared toward neurologic emer- gencies. Another potential explanation is that increased financial compensation offered for embolization, despite apparent superior outcomes offered by ligation, may par- tially contribute to these trends; however, these explana- tions are purely speculative. Alternatively, it is possible that confounding variables, inaccuracies in cohort identi- fication, and use of retrospective data may be influenc- ing these results. Limitations of the present analysis include those that are inherent to utilizing NIS data, including reli- ance on ICD-9 coding for identification of diagnoses, pro- cedures, and comorbidities. Improper coding could adversely and unpredictably affect our findings. Success rates of embolization versus ligation were also unable to be determined because the NIS does not contain any information on patients after discharge. Additionally, reliance on ICD-9 codes prohibit analysis of certain interesting variables. For instance, patients on anticoa- gulation therapy are more likely to receive embolization because it is considered less traumatic to the nasal mucosa. However, use of anticoagulants and complemen- tary quantitative measures such as platelets, partial thromboplastin time, and international normalized ratio are not able to be determined using the NIS database. The NIS database codes data from individual hospital- izations, from admission to discharge; thus, one patient could potentially represent multiple cases in the NIS in the case of multiple readmissions. Additionally, compli- cations that occurred postdischarge are unable to be cap- tured. Still, the large sample size afforded by the NIS gives a high degree of external validity to the findings. Results of this analysis add to the growing body of literature suggesting that ligation offers similar but more cost-effective control of refractory epistaxis. Given these findings, national trends toward decreasing surgi- cal arterial ligation and leveled endovascular arterial

CONCLUSION Relative to surgical arterial ligation, the national use of endovascular arterial embolization has been increasing for the treatment of refractory epistaxis. Patients who undergo ligation are older, with more comorbid cardiac disease. Ligation is associated with proportionally fewer airway complications resulting in intubation/tracheostomy. In addition, no significant dif- ferences compared to embolization were observed in rates of blood transfusion, stroke, blindness, or in- hospital mortality. Even in the presence of an older pop- ulation with a higher rate of congestive heart failure, the current study supports surgical ligation as a safe and more cost-effective intervention compared to emboli- zation for the management of refractory epistaxis; how- ever, current trends appear to suggest a move away from ligation towards embolization. BIBLIOGRAPHY 1. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med 2009;360:784– 789. 2. Goljo E, Dang R, Iloreta AM, Govindaraj S. Cost of management in epi- staxis admission: impact of patient and hospital characteristics. Laryn- goscope 2015;125:2642–2647. 3. Brinjikji W, Kallmes DF, Cloft HJ. Trends in epistaxis embolization in the United States: a study of the nationwide inpatient sample 2003–2010. J Vasc Interv Radiol 2013;24:969–973. 4. Rudmik L, Leung R. Cost-effectiveness analysis of endoscopic sphenopala- tine artery ligation vs arterial embolization for intractable epistaxis. JAMA Otolaryngol Head Neck Surg 2014;140:802–808. 5. Villwock JA, Jones K. Recent trends in epistaxis management in the Unit- ed States: 2008–2010. JAMA Otolaryngol Head Neck Surg 2013;139: 1279–1284. 6. Goddard JC, Reiter ER. Inpatient management of epistaxis: outcomes and cost. Otolaryngol Head Neck Surg 2005;132:707–712. 7. Flint PW. Cummings Otolaryngology-Head & Neck Surgery. 6th ed. Phila- delphia, PA: Elsevier Mosby; 2015:678–690. 8. McClurg SW, Carrau R. Endoscopic management of posterior epistaxis: a review. Acta Otorhinolaryngol Ital 2014;34:1–8. 9. Villwock JA, Goyal P. Early versus delayed treatment of primary epistaxis in the United States. Int Forum Allergy Rhinol 2014;4:69–75. 10. Strong EB, Bell DA, Johnson LP, Jacobs JM. Intractable epistaxis: trans- antral ligation vs. embolization: efficacy review and cost analysis. Oto- laryngol Head Neck Surg 1995;113:674–678. 11. Willems PW, Farb RI, Agid R. Endovascular treatment of epistaxis. AJNR Am J Neuroradiol 2009;30:1637–1645. 12. Siniluoto TM, Leinonen AS, Karttunen AI, Karjalainen HK, Jokinen KE. Embolization for the treatment of posterior epistaxis. An analysis of 31 cases. Arch Otolaryngol Head Neck Surg 1993;119:837–841. 13. Wehrli M, Lieberherr U, Valavanis A. Superselective embolization for intractable epistaxis: experiences with 19 patients. Clin Otolaryngol Allied Sci 1988;13:415–420. 14. Seno S, Arikata M, Sakurai H, Owaki S, Fukui J, Suzuki M, Shimizu T. Endoscopic ligation of the sphenopalatine artery and the maxillary artery for the treatment of intractable posterior epistaxis. Am J Rhinol Allergy 2009;23:197–199. 15. Simmen DB, Raghavan U, Briner HR, Manestar M, Groscurth P, Jones NS. The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon. Am J Rhinol 2006;20:502–505. 16. Voegels RL, Thome DC, Iturralde PP, Butugan O. Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis. Otolaryngol Head Neck Surg 2001;124:464–467.

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