HHT - Coblator/Avastin

Considerations

• • Overarching mindset: Avoid trauma by avoiding direct contact with the tissue

    • Trauma results in bleeding and the bleeding can be torrential, even life-threatening  

Preparation

• • Obtain preoperative Epistaxis Severity Score (ESS)

  • Link to ESS from Drexel here

  • Dr. L preferred method 

    • Coblator - Procise EZ view coblation sinus wand, Smith and Nephew (Settings 7 coblate, 5 coag)

  • Dr. R methods 

    • KTP laser on operative microscope 

      • Setting: 2 watts continuous

    • Silver glide bipolar 

    • Silastic splints - thinnest possible  

  • Avastin (Bevacizumab) - 8 ml (200 mg) of 25 mg/ml concentration prepared by pharmacy

  • Dr. R

    • Turn bed 180 degrees

    • Option: Microscope at top 

  • Afrin, topical spray only, not on pledgets 

  • Floseal, first line packing 

  • Merocel, last resort packing

  • pRBCs on standby, if needed 

Procedure

• • Dr. L

    • Use Coblator to address telengiectasias

  • Inject total of 100 mg (4 ml), with 50 mg (2 ml) on each side. Inject the following 4 sites:

    • Sphenopalatine area

    • Ascending process of maxilla (ie. maxillary line)

    • Bony part of superior nasal septum (plane of the anterior head of the MT)

    • Floor of the nose (plane of the IT)

  • Dr. R

    • Infiltrate 2 ml (50 mg) or Avastin distributed on either side at the following three locations: septum, floor of nose, inferior turbinate 

    • Option: KTP laser

      • Hold the laser away from the surface so that it results in blanching but not cutting of the tissue

      • Active the laser in a circumferential pattern around each telengectasia moving toward the center of the telengectasia until it completely blanches

    • Option: Silver glide bipolar, if bleeding results

      • Again, hover the tip just above the surface of the bleeding site (not in direct contact) 

      • May need to apply a thin layer of bone wax to prevent sticking 

    • Option: Place trimmed silastic splints bilaterally on septum and curving onto floor (if needed) 

      • Secure in standard fashion with a single 4-0 Prolene suture 

      • Leave in place as long as tolerated or until next procedure is needed 

Sample operative report

Post-op

• • Follow up

    • TAV 1-2 weeks 

  • Follow up in 2 months, obtain ESS score

  • Routine nasal care

  • Remember to counsel the patients on prevention and treatment

    • Moisture and lack of trauma are key 

    • Intermittent nasal rest for minor bleeds 

      • Apply Vasline coated cotton ball to occlude nostril on bleeding side x 24-48 hours 

    • If major bleed is treated in ED, Afrin and Floseal

      • Only place non-dissolving pack if absolutely needed 

      • Transfuse as needed 

Pearls & Pitfalls

High-Yield

Links