EArly surgical intervention versus conventional treatment in posterior epistaxis: A systematic review

Background: Traditionally the posterior epistaxis is managed with nasal packing and prolonged hospital stay. However, the patient may undergo a cycle of nasal packing, repacking and eventual surgical intervention. This protocol could subject the patient to significant morbidity and may not be the cost effective strategy either. On the other hand, endoscopic sphenopalatine artery ligation (ESPAL) is increasingly employed and it has got an established role in the posterior epistaxis management. The proponents claim minimal morbidity associated with ESPAL, and regard it as an efficient, safe and cost effective treatment option compared to the traditional approach. Aim: To compare the safety, efficacy and cost effectiveness of early surgical intervention with traditional treatment (packing with or without subsequent surgical intervention) in the management of posterior epistaxis. Methods: Potentially eligible articles were identified from the following electronic databases: MEDLINE, EMBASE, The Cochrane Library including the Cochrane Central Register of Controlled Trials, Database of Abstracts and Reviews (DARE), and Google scholar. They were included if they fulfilled pre specified criteria. Data were extracted from the eligible studies according to a protocol developed for the purpose this study. Results: Two RCTs and four retrospective reviews were included. Among the included studies, both RCTs were prospective trials. Both studies have reported reduced re-bleed rates with early surgical intervention compared to the traditional management. But these differences were not statistically significant. However, there was a statistically significant reduction in cost and the total hospital stay with early surgical intervention in both RCTs. The findings from RCTs were supported by all retrospective reviews. Conclusion: Despite limited evidence, this systematic review favours early surgical intervention as opposed to traditional treatment with nasal packing. The duration of hospital stay and cost involved influence the choice of surgical intervention. However, further well designed multicentre randomised controlled clinical trials are required for a more definitive conclusion