Question of the Week - November 2022

 

November 9th, 2022

A 24-year-old patient with no significant past medical history presents in the ED with a large nosebleed, and ENT is consulted for management. On physical exam, no definitive source of bleeding can be found. Despite many attempts of applying repeated pressure, nasal packing, oxymetazoline, and cautery, the bleed is persistent and continues to be significant. Surgical intervention is planned next.

Which of the following is true about the target vessel in the next-step surgical intervention?


A. The vessel can be localized endoscopically by visualizing the lamina papyracea.

B. The vessel originates from the external carotid artery.

C. Due to the lack of branches and anastomoses from this vessel, a common complication from its ligation is tissue necrosis.

D. The vessel arises from the ophthalmic artery.

  • Quiz Answer: B

    Explanation: In this patient’s case, since the bleed cannot be localized and continues to be significant, a posterior bleed is suspected. If conservative management (ie. nasal packing) fails to control bleeding, the next step is surgical intervention: usually endoscopic sphenopalatine ligation. The sphenopalatine artery (SPA) provides a majority of the blood supply to the nasal cavity and is one of the terminal branches of the internal maxillary artery, which originates from the external carotid artery. The SPA often has multiple branches and creates anastomoses with the ethmoidal arteries. Ligation of the SPA is done via endoscopic clipping or coagulation, and risk of localized hypoxia or necrosis is not common [C].

    Less commonly, ligation of the anterior ethmoidal artery (AEA) or posterior ethmoidal artery (PEA) is done. Both the AEA and PEA arise from the ophthalmic artery [D]. Clipping of the anterior ethmoidal artery is considered in cases where anterior epistaxis is difficult to control. In endoscopic procedures, after maxillary antrostomy, the anterior ethmoidal cells are excavated, and the lamina papyracea is visualized. Angled lenses are then used to locate the AEA adjacent to the lamina papyracea [A].

    In cases where surgical treatment fails or the patient has a high anesthetic risk, percutaneous embolization is a reasonable alternative.

    References: Beck R, Sorge M, Schneider A, Dietz A. Current Approaches to Epistaxis Treatment in Primary and Secondary Care. Dtsch Arztebl Int. 2018;115(1-02):12-22. doi:10.3238/arztebl.2018.0012

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778404/

November 23rd, 2022

Which statement regarding blepharoplasty is false?

A.  Skin, fat, and muscle can be removed during blepharoplasty
B.  Opening a patient’s mouth assists in determining how much skin to excise in lower blepharoplasty
C.  Blepharoplasty is not performed under local anesthesia
D.  Transconjunctival blepharoplasty does not require sutures for closing the incision

  • Quiz Answer: C

    A: While fat pads removal and skin tightening are commonly associated with blepharoplasty, muscle can also be trimmed during the procedure, since with age orbicularis oculi can become hypertrophied and result in fuller appearance of the eyelids. P.S. Excision of the muscle cannot be performed in the transconjunctival approach.

    B: Since opening of the mouth pulls the lower eyelid down, it is one of the methods, in conjunction with upward gaze, that is used during lower blepharoplasty procedures to prevent over excision of the skin and subsequent ectropion (outward turning of the lower eyelid).

    C: Blepharoplasty can be performed under general anesthesia or local anesthesia (1% lidocaine with 1:100,000 epinephrine) with IV sedation.

    D: In the transconjunctival blepharoplasty, the incision site can either be closed with sutures or left open. The latter approach does not impede wound closure while allowing for fluid drainage.

    Reference: https://www.ncbi.nlm.nih.gov/books/NBK538152/