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. 2018 May-Jun;84(3):290-297.
doi: 10.1016/j.bjorl.2017.12.007. Epub 2018 Jan 20.

Breaking paradigms in severe epistaxis: the importance of looking for the S-point

Eduardo Macoto Kosugi  1 , Leonardo Balsalobre  2 , João Mangussi-Gomes  2 , Miguel Soares Tepedino  3 , Daniel Marcus San-da-Silva  4 , Erika Mucciolo Cabernite  4 , Diego Hermann  5 , Aldo Cassol Stamm  5
Affiliations

Breaking paradigms in severe epistaxis: the importance of looking for the S-point

Eduardo Macoto Kosugi et al. Braz J Otorhinolaryngol. 2018 May-Jun.

Abstract
in English, Portuguese

Introduction: Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point.

Objective: The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it.

Methods: A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017.

Results: Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis.

Conclusion: The Stamm's S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Introdução: Desde a introdução da endoscopia nasal no campo de Otorrinolaringologia, o paradigma de tratamento para casos graves de epistaxe voltou-se para a identificação precoce e correta do local de sangramento. Embora a epistaxe grave seja geralmente considerada uma hemorragia posterior, um pedículo vascular arterial tem sido frequentemente observado na porção superior do septo nasal, ao redor da projeção da axila da concha média, posterior ao tubérculo septal. Esse pedículo vascular foi chamado de Stamm's S-point.

Objetivo: O objetivo deste estudo foi descrever o S-point e relatar casos graves de epistaxe originando-se neste local.

Método: Um estudo retrospectivo de série de casos foi conduzido. Nove pacientes com epistaxe grave espontânea, onde o S-point foi identificado como a fonte do sangramento, foram tratados no período de março de 2016 a março de 2017.

Resultados: Houve predominância do sexo masculino (77,8%) com idade média de 59,3 anos. A maioria dos casos apresentava comorbidades (88,9%), mas sem uso de ácido acetilsalicílico (66,7%). Observou-se predominância do lado esquerdo (55,6%) com sangramento anteroposterior como a principal apresentação inicial (77,8%). Seis pacientes (66,7%) apresentaram níveis de hemoglobina inferiores a 10 g/dL e quatro (44,4%) necessitaram de transfusão sanguínea. Cauterização do S-point foi realizada em todos os pacientes, com resolução completa do sangramento. Nenhum paciente apresentou recorrência de epistaxe grave.

Conclusão: O Stamm's S-point é relatado como uma nova região de origem de epistaxe grave espontânea, e o tratamento realizado com cauterização foi eficaz e seguro. Os otorrinolaringologistas devem buscar ativamente este local de sangramento em casos de epistaxe grave.

Keywords: Cirurgia endoscópica por orifício natural; Endoscopia; Endoscopy; Epistaxe; Epistaxis; Nasal septum; Natural orifice endoscopic surgery; Recorrência; Recurrence; Septo nasal.

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Figures

Figure 1
Figure 1
Microscopic cauterization of the branches of the anterior ethmoidal artery (AEA, anterior ethmoidal artery; PEA, posterior ethmoidal artery; S, septum).
Figure 2
Figure 2
Left nasal cavity, upper endoscopic view, above the axilla of the middle turbinate (A). The S-point (black arrow) is a vascular pedicle in the upper portion of the nasal septum (S). Note that the blood pulsation can be strong enough to reach the lateral nasal wall, with a posterior flow, simulating posterior epistaxis (MT, middle turbinate).
Figure 3
Figure 3
Left nasal cavity, anatomical dissection (1) and endoscopic view (2). The black circle and the yellow area show the region where the S-point (a branch of the anterior ethmoidal artery) can be found, superior to the middle meatus, in a region that is normally not assessed in nasal endoscopic surgeries (Ant, anterior; Pos, posterior; AEA, anterior ethmoidal artery; NSA, nasoseptal artery; SS, sphenoidal sinus; S, nasal septum; A, middle turbinate axilla; MT, middle turbinate).
Figure 4
Figure 4
Right nasal cavity. S-point (yellow circle) before (1) and after (2) the use of cotton pledgets with topical decongestant. After vasoconstriction, the S-point vascular pedicle practically disappears (A, axilla of the middle turbinate; MT, middle turbinate; S, nasal septum).
Figure 5
Figure 5
Identification of the S-point in nine cases (1–9). The S-point was identified with a yellow circle (S, nasal septum; A, axilla of the middle turbinate; MT, middle turbinate).
See this image and copyright information in PMC

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