Laser‐Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review

Abstract

Background and Objectives Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT‐related epistaxis. Study Design/Materials and Methods A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium‐doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ2 and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates. Results Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild‐moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild‐moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients. Conclusions HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

In‐Office KTP Laser for Treating Hereditary Hemorrhagic Telangiectasia–Associated Epistaxis

“…Various surgical treatment methods for epistaxis in HHT patients have been described, including laser photocoagulation, cauterization, septodermoplasty, embolization, and Young's procedure 4 . Specifically, for laser photocoagulation, previous studies have established its efficaciousness in managing and decreasing the severity of epistaxis associated with HHT, while maintaining a strong safety profile 13,17–19 …”

“…These findings compliment results of a study by Hunter et al, who reported a significant decrease of ESS by 0.72 from baseline of 7.1 after KTP laser coagulation treatment 18 . A systematic review by Abiri et al noted that intranasal laser photocoagulation was able to reduce both epistaxis intensity and frequency in more than 70% of patients 13 . Together, there exists an important role for laser photocoagulation in the management of epistaxis in HHT, with in‐office therapy being a viable and efficacious option.…”

“…These include medical therapy such as hormonal manipulation and antifibrinolytic agents, along with surgical interventions such as photocoagulation, electrocautery, coblation, septodermoplasty, and nasal closure with Young's procedure 3,4,9–12 . Specifically for laser photocoagulation therapy, the use of potassium titanyl phosphate (KTP), argon, neodymium: yttrium aluminum garnet (Nd: YAG) lasers have all been described 4,13 . Laser treatment has been shown to be effective in the management of epistaxis in HHT patients, with significant decrease in the frequency and intensity of bleeds 13,14 .…”

“…Specifically for laser photocoagulation therapy, the use of potassium titanyl phosphate (KTP), argon, neodymium: yttrium aluminum garnet (Nd: YAG) lasers have all been described 4,13 . Laser treatment has been shown to be effective in the management of epistaxis in HHT patients, with significant decrease in the frequency and intensity of bleeds 13,14 . Laser procedures traditionally have been performed within the operating room, but come with it added costs associated with operating room use, and are also limited by the availability of healthcare resources.…”

Flexible laser Sphenopalatine artery ligation: An alternative to the classic approach

“…Diode laser is a commonly used flexible laser in the nose and face and is an excellent haemostatic tool for telangiectasia, arteriovenous malformations and endoscopic laser‐assisted resections of vascular tumours etc . Other types of fibre laser that can be potentially used for the same purpose are Nd: YAG laser therapy and thulium laser, the first already an established tool in haemorrhagic diseases such as Rendu‐Osler‐Weber syndrome and the second more recently tried in flap preparation for anterior skull base surgery…”