Delayed epistaxis after endoscopic pituitary surgery - possible cause, treatment and prevention

Abstract

INTRODUCTION: The endonasal endoscopic approach is a widely adopted, safe and effective technique in transsphenoidal pituitary surgery. Delayed post-operative epistaxis is an uncommon but recognized complication. MATERIAL AND METHOD: This is a report of two patients who underwent endonasal endoscopic resections of pituitary tumours. No bleeding was encountered initially, but both patients developed severe epistaxis in the early post-operative periods that required re-operations. The possible cause, surgical treatment and preventive measures were reviewed. RESULTS: Both patients received adrenaline injection of the nasal mucosa which would have caused vasoconstriction of the sphenopalantine artery during the initial operations. The author surmised that delayed haemorrhages may have occurred after the drug-effect had worn off. Re-operation was met with difficulties due to profuse bleeding and poor visibility. Control was achieved by blind coagulation of the arterial origin based on tactile tracing of anatomical landmarks, followed by precise coagulation of the bleeding branches. CONCLUSION: Delayed haemorrhages from the sphenopalantine artery is a potentially life-threatening complication of endoscopic pituitary surgery. The artery should be routinely and preemptively coagulated in the initial surgery to prevent this complication. Initial haemostasis under poor visibility can be achieved by following simple anatomical landmarks in order to regain surgical control.