The Journal of Laryngology & Otology (2012), 126, 228–235.

REVIEW ARTICLE
© JLO (1984) Limited, 2011
doi:10.1017/S0022215111003148

The role of embolisation in ENT: an update

J RISLEY, K MANN, N S JONES

Department of Otorhinolaryngology, University Hospital, Nottingham, UK

Abstract
Objective: To provide an update on the ever-increasing role that embolisation plays in the practice of
otolaryngology.
Method: A literature search was performed during November 2008. The Medline, Embase, PubMed and
Cochrane databases were searched. This resulted in 285 papers relevant for review.
Conclusion: The role of embolisation has expanded greatly to include the management of refractory epistaxis,
pre-operative preparation of vascular tumours, vascular injuries and as an adjunct in skull base surgery.

Key words: Radiology, Interventional; Angiography; Epistaxis; Angiofibroma; Paragangliomas

Introduction Pre-operative embolisation

Therapeutic embolisation was first used in the manage- Pre-operative tumour embolisation is undertaken via an
ment of acute gastrointestinal bleeding in 1972, by endovascular approach, although direct percutaneous
Rosch et al.,1 and has since become established in injection of an embolic agent into the tumour may be
the management of many clinical conditions. performed. Indications for embolisation include
Kingsley and O’Connor provided a review on the control of surgically inaccessible feeding vessels,
subject of embolisation in otolaryngology in 1982, which reduces blood loss and damage to adjacent struc-
noting its application in the management of acute tures, and that also allows better observation of the sur-
haemorrhage, vascular tumours and angiomatous gical field, reducing the risk of surgical complications.7
malformations.2
The aim of this review is to provide an update on the Juvenile nasopharyngeal angiofibroma
use of embolisation in the management of otorhinolar- These tumours have the potential to cause life-threaten-
yngological conditions (see Appendix 1 for our search ing bleeding during surgery.8 Recurrence is related to
strategy). incomplete excision. Angiography allows embolisation
of the feeding arteries pre-operatively, reducing intra-
operative blood loss by 60 per cent. Embolisation is
Epistaxis performed 24–72 hours before resection. Most
Sokoloff et al. first used embolisation successfully for vessels arise from the external carotid artery via the
refractory epistaxis in 1974.3 Local protocols have been internal maxillary artery and ascending pharyngeal
developed for epistaxis management and have achieved arteries, although the internal carotid artery can also
control in 95 per cent of patients.4 If sphenopalatine contribute to large tumours via the vidian and middle
artery ligation fails or the patient is unfit for general meningeal arteries.8
anaesthesia, angiographic embolisation is indicated. In the pre-embolisation era, the average blood loss
The embolic materials used include polyvinyl was 1136 ml. Studies have shown that this is greatly
alcohol particles, microcoils and Gelfoam® torpedoes.5 reduced with the use of embolisation (to 547 ml9 and
Success rates range between 71 and 100 per cent.6 677 ml,10 variously) enabling an almost bloodless
External carotid artery ligation should be avoided as operative field and enhancing tumour resection.9
it prevents later embolisation. Angiography normally However, when there is deep invasion of the sphe-
demonstrates a supply from large collaterals from the noid, embolisation may make complete excision more
greater palatine artery and infraorbital branches of the difficult, as it means that fingers of tissue that extend
internal maxillary artery, and it is uncommon to find down the vidian canal or behind the pterygoid plates
other responsible aberrant vessels. may remain undetected as they do not bleed.11,12

The radiographs in this article were presented as a poster at the ENT UK Annual Conference, 11 September 2009, London, UK
Accepted for publication 14 July 2011 First published online 15 December 2011
ROLE OF EMBOLISATION IN ENT 229

Tumour haemorrhage In cases of carotid body tumour resection, mean

This occurs frequently in patients with ulcerative blood replacements of 2.1 and 4 units have been
tumours, due to vessel erosion by malignancy. reported in cases in which embolisation was not per-
Management is initially conservative, with local formed, reduced to 200 ml with the use of pre-operative
packing, but transarterial embolisation has been used embolisation.18 This procedure can also reduce tumour
with success.13 Surgical treatment can be difficult, size by as much as 25 per cent, an important consider-
because of factors such as fistulae and radiation- ation as cranial nerves are easier to identify and pre-
induced necrosis, and is associated with a high mortality serve and it is thus uncommon to have to clamp or
and complication rate. Surgical ligation can leave the resect the internal or external carotid artery.20 Pre-
patient at risk of re-bleeding from a collateral circulation, operative embolisation of tumours larger than 2 cm
changing the vascular anatomy and making endovascu- has been advocated, and the operative procedure
lar management more difficult.14 Emergency ligation of should be performed within 48 hours of embolisation
the internal or common carotid artery results in a mor- (Figure 1).18
tality rate of 9–100 per cent, with neurological compli- Embolisation in cases of vagal paraganglioma has led
cations in 16–100 per cent of cases. to a reported reduction of mean blood loss from 990 to
Arterial embolisation offers an effective, safe, fast 425 ml, of operative time from 431 to 334 minutes, of
method for controlling bleeding from tumours.15 hospital stay from 18.3 to 7.4 days, and of post-operative
Transarterial embolisation has been reported to have a hypoglossal nerve paralysis incidence.21
success rate of 92 per cent,14 as well as producing an
average post-haemorrhage survival of 26 days, com- Carotid blow-out syndrome
pared with 8 days in patients receiving angiography Rupture of the extracranial carotid arteries or their
alone.13 major branches is life-threatening.22 Carotid blow-out
The haemostatic effect of embolisation is thought to syndrome is a pre-mortem event, and emergency surgi-
last longer than that of ligation, as the embolic materials cal ligation may be inappropriate due to the poor
can reach the peripheral vessels.14,16 Even if re-bleed- condition of the patient.23 Surgical management is dif-
ing occurs, repeated embolisation is relatively easy. ficult, due to previously irradiated or infected fields.
The recurrence rate of haemorrhage after embolisation The mortality rate for emergency ligation of the internal
is 0–33 per cent.14 or common carotid artery is 9–100 per cent, with major
The optimal timing and application of transarterial neurological morbidity rates of 9–84 per cent.24,25
embolisation is difficult in patients who are haemody- Recent developments in the use of covered stents
namically unstable due to massive bleeding, and the have decreased morbidity rates to 0–8 per cent and
mortality of the procedure is high in such patients. In mortality rates to 0 per cent, although the long-term
those with minor bleeding, it can be hard to identify sequelae have not been determined.24 When the
the source of the bleeding, and radiologists may hesi- internal, common or proximal external carotid artery
tate to use transarterial embolisation if no definite trunk is involved, the best approach is occlusion with
source can be found. detachable balloons. Branches of the external carotid
artery are best approached via superselective embolisa-
tion so the branches adjacent to the affected artery are
Palliative embolisation
preserved, reducing the risk of ischaemia involving
The use of palliative embolisation to control haemor-
the face and neck, and the risk of impairment of
rhage from terminal head and neck cancers has been
cranial nerve function (Figure 2).23
reported. Most bleeding arises from the oropharynx;
There is a 15–20 per cent incidence of delayed cer-
therefore, local packing is distressing and often
ebral ischaemic complications. Re-bleeding and com-
impractical.
plication rates can be high, due to infected wounds
Ligation of the carotid artery is an alternative,
and tumour progression.24 Intracranial complications
although it has significant mortality and morbidity.
can occur due to backflow of embolic material into
Pharyngocutaneous fistulae or tumour may make exter-
the internal carotid artery or vertebral artery.23
nal access to the carotid system difficult. Reports favour
However, immediate and long-term success has been
transarterial embolisation over open techniques due to
reported in up to 100 per cent of cases, with a major
its safety and efficacy, with low complication rates
complication rate of 7 per cent.26
and satisfactory survival rates being reported.17
It has been concluded that a combination of coil embo-
lisation and stent graft isolation of the common and
Paraganglioma internal carotid artery can control acute bleeding from
The first successful report of carotid body tumour vascular tumour invasion and prevent further carotid
embolisation was in 1983 by Shick et al.18 Blood bleeding episodes in patients with advanced tumours.25
loss has been shown to be significantly reduced with
the use of pre-operative embolisation. Direct puncture Other uses
therapeutic embolisation can be considered in the pal- Chylothorax secondary to injury to the thoracic duct or
liative management of these tumours.19 one of its branches has been treated by percutaneous
230 J RISLEY, K MANN, N S JONES

FIG. 1
(a) A lateral angiogram of the common carotid artery showing the typical appearance of a carotid body tumour splaying the carotids, supplied by
the ascending pharyngeal artery (red arrow). (b) Lateral angiogram showing pre-operative embolisation with particles and coils (blue arrows);
the catheter tip (white arrow) is seen in the common carotid.

FIG. 2
(a) A lateral angiogram of the common carotid artery in a patient with a laryngeal tumour treated with radiotherapy and neck dissection, who
presented with neck haemorrhage from a pseudo-aneurysm (red arrow) of the external carotid artery. (b) Lateral angiogram showing treatment
via occlusion of the external carotid artery with coils (blue arrow).
ROLE OF EMBOLISATION IN ENT 231

embolisation of the thoracic duct proximal to the tran- in cases of zone III trauma, in which haemorrhage
section, with subsequent normalisation of chylous can be difficult to access operatively. However,
output.27 Golueke demonstrated no difference between surgical
exploration and selective management, in terms of
Trauma length of stay, morbidity and mortality.29
Severe craniofacial injury may lead to significant oro- In cases of penetrating neck trauma, the liberal use of
nasal bleeding. The presumed location and lateralisa- cervical angiography and transarterial embolisation has
tion of bleeding is often misleading; therefore, been advocated due to its safety and reliability.29
bilateral internal carotid artery and external carotid Therapeutic embolisation has been shown to be effec-
artery angiography is helpful.28 tive in arterial neck trauma, and should be considered
In cases of ethmoid artery bleeding, embolisation a viable method of management when open access is
would be via the ophthalmic artery, which carries an not deemed essential (Figure 3).31
unacceptable risk of blindness due to occlusion of the
retinal and posterior ciliary branches; surgical clipping Hereditary haemorrhagic telangiectasia
is thus advocated.28 The treatment of epistaxis in patients with this con-
Many asymptomatic patients have significant vascu- dition is initially conservative. There is no definitive
lar injuries, and management of zone I or III injuries cure; rather, therapeutic measures aim to reduce the
can require extensive surgery. There is currently a severity and frequency of epistaxis, to improve
debate concerning the merits of mandatory neck quality of life.32 Increased vascularity due to aberrant
exploration versus the use of angiography and emboli- angiogenesis may make permanent treatment with
sation, since delayed management of vascular and aero- embolisation difficult.32 In one series utilising emboli-
digestive tract injuries is associated with a high sation, success rates of 80 per cent were reported in
morbidity rate. One study deemed interventional patients with idiopathic epistaxis, compared with
surgery to have been unnecessary in up to 63 per 20–25 per cent in those with hereditary haemorrhagic
cent of patients.29 In contrast, it has been demonstrated telangiectasia.24,33
that patients with a normal initial angiogram have a less The role of embolisation in hereditary haemorrhagic
than 2 per cent incidence of missed injuries.30 telangiectasia has not been established, because of high
Definitive control of haemorrhage can be achieved levels of recurrence and technical difficulties with
with the use of transarterial embolisation, especially embolisation of the anterior ethmoids.32

FIG. 3
(a) A right lateral upper cervical angiogram of an 18-year-old patient, attacked with a broken glass bottle, who subsequently presented with an
expanding submandibular mass, showing a pseudo-aneurysm (red arrow) in the region of the lingual artery. (b) The same right lateral upper
cervical angiogram view as illustrated in Fig 3 (a) showing subsequent embolisation of the pseudo-aneurysm (blue arrow).
232 J RISLEY, K MANN, N S JONES

Arteriovenous malformation resection and reconstruction may be worse than that

Angiography and selective embolisation is usually per- caused by the original lesion.35,36 Successful use of
formed prior to surgical excision of arteriovenous mal- embolisation to treat arteriovenous malformations has
formations, when this is indicated, to reduce the been reported in 60 per cent of cases.35
vascularity of the lesion and to define feeder vessels.
This aids long-term cure, since incomplete excision Carotid–cavernous fistula
leads to recurrence. Embolisation has been shown to Carotid–cavernous fistulae involve an abnormal arter-
decrease operative blood loss and lesion size and to iovenous anastomosis between the carotid artery and
decrease the extent of surgical excision.34 Due to the the cavernous sinus.37 They can be spontaneous, in
potential for rapid expansion in the period between patients with collagen vascular disease, fibromuscular
embolisation and resection, the time between pro- disease of the cerebral arteries, or rupture of intracaver-
cedures should be 24–48 hours.35 nous internal carotid artery aneurysms.37,38 Acquired
Treatment of external carotid artery arteriovenous cases occur as a result of trauma, transsphenoidal
malformations with embolisation alone is indicated if surgery, cavernous sinus meningioma embolisation
the lesion is deemed inoperable and surgical resection and rhinocerebral mucormycosis.
would increase morbidity, or the patient is unfit for This condition can present with epistaxis and, some-
surgery.34 times, signs of ophthalmic vein occlusion (i.e. dilated
Recommended indications for treatment with emboli- forehead veins, headache and raised intra-orbital
sation and resection are based on the clinical staging pressure). Patients may also develop pulsatile proptosis
according to the modified Schobinger classification, i.e. and visual disturbances.38,39
(1) quiescence, (2) expansion, (3) destruction and (4) Reviews of carotid–cavernous fistula management
decompensation.35 Early stage lesions (i.e. stages one have shown that angiography is the key to diagnosis
and two) can be resected and reconstructed easily. and management. Endovascular embolisation has
Painful or rapidly enlarging lesions (stages two and become an established treatment method. Stenting is
three) warrant early intervention owing to the high prob- also a feasible option due to its ability to maintain
ability of progression and the risk of serious haemorrhage. patency of the internal carotid artery (Figure 4).38
Intervention for extensive stage one lesions remains
controversial, for three reasons: (1) the risk of pro- Tonsillar haemorrhage
gression cannot be predicted, (2) resection of very Post-tonsillectomy haemorrhage due to a pseudo-
extensive stage one lesions is more likely to be incom- aneurysm of the lingual or facial artery usually presents
plete, and (3) the deformity produced by extensive hours or days after the surgery.40 Angiography should

FIG. 4
(a) A lateral angiogram of the skull base in a 70-year-old man who presented with a history of recent head trauma without fracture, with sub-
sequent proptosis and chemosis, showing a direct fistula between the cavernous sinus (blue arrow) and the internal carotid artery (red arrow). (b)
A later sequence of the lateral angiogram of the skull base post embolisation showing the first coil placed in the cavernous sinus (blue arrow).
ROLE OF EMBOLISATION IN ENT 233

be performed when an aneurysm or pseudo-aneurysm this is thought to be less than the risk incurred from sur-
is suspected in the tonsillar fossa, and can be treated gical packing.47
with embolisation.40
Functional endoscopic sinus surgery
Tracheostomy-related haemorrhage Bleeding is a recognised complication of endoscopic
This is a recognised complication, and the majority can sinus surgery.33 Iatrogenic injury of the internal
be managed conservatively. However, a tracheo-inno- carotid artery is rare; however, if this happens then
minate artery fistula has a high mortality rate if pressure to control bleeding, followed by angiography
untreated.41,42 Rates of 0.1–1 per cent have been and embolisation, is life-saving. Pepper and col-
reported after surgical tracheostomy, with a peak inci- leagues’ guidelines for internal carotid artery bleeding
dence at 7–14 days post-procedure.43 recommend the use of angiographic control (using tam-
If conservative measures fail, surgical management ponade balloons) to control bleeding, together with
is required. However, technical limitations include dif- emergency coil embolisation.48
ficulty in locating the bleeding vessels due to scarring
from prior procedures. Thus, angiography with emboli- Complications
sation has been advocated as the preferred method of Tseng et al. have classified the complications of embo-
management, and has been used with success.41,42 lisation into major and minor events.6 The commonest
minor side effect is fever and localised pain due to
Transsphenoidal surgery tissue necrosis.2 Minor complications are transient,
Delayed epistaxis resulting from damage to the spheno- and include facial pain, headaches, mental confusion,
palatine branches of the external carotid artery is an paraesthesia, jaw pain, groin pain, numbness and
infrequent but serious complication of transsphenoidal facial oedema.
surgery, which can be managed by sphenopalatine Major complications of embolisation include cer-
artery ligation or embolisation.44 False aneurysms of ebrovascular accident (CVA), blindness, ophthalmo-
the sphenopalatine artery can occur after transsphenoi- plegia, facial nerve palsy and soft tissue necrosis.6
dal surgery.45 The most serious risk is inadvertent embolisation of
Significant vascular complications related to internal the internal carotid artery, leading to a CVA. General
carotid artery injury during transsphenoidal surgery complications, such as sensitivity to the embolic or
include carotid laceration, carotid–cavernous fistula, contrast material, are rare.2
traumatic aneurysm, subarachnoid haemorrhage and Barlow et al. stated that the complication rate for
cerebral infarction. Arterial injuries that manifest embolisation in epistaxis resembles that of arterial lig-
during or after transsphenoidal surgery are rare (1 per ation, being 13–48 per cent.49 A literature review of the
cent), but they are associated with significant morbidity success rates and complications related to embolisation
(24 per cent) and mortality (14 per cent).44,45 for epistaxis found that, of 572 patients embolised for
Imaging of both the internal and external carotid cir- persistent epistaxis, five suffered significant long-
culations is important. Although internal carotid artery term morbidity (a prevalence of <1 per cent) and two
injuries are more common, negative findings on an suffered minor long-term morbidity (i.e. facial scar-
internal carotid artery angiogram do not necessarily ring). The risk of CVA was less than 1 per cent.50
rule out a vascular injury. Post-embolisation spasm of the accessory meningeal
artery may cause ischaemia and hypoaesthesia of the
Skull base tumours third branch of the trigeminal nerve, whereas occlusion
When a significant portion of a skull base tumour is of the petrosal artery may cause ischaemia of the hori-
supplied directly by the internal carotid artery, particle zontal segment of the facial nerve, resulting in paraly-
embolisation from within the carotid artery may be sis. Loss of vision can result from anastomosis between
performed. the internal maxillary artery and ophthalmic artery
For large, recurrent tumours, which may not be sup- branches, although pre-operative angiography should
plied directly by vessels typical of newly diagnosed demonstrate a choroidal ‘blush’ if this is the case.
lesions, direct percutaneous embolisation may help. Soft tissue necrosis is a rare complication, due to the
Pre-operative embolisation of a primary jugular extensive collateral blood supply of the head and neck.
foramen tumour should only be performed when it Unilateral necrosis of the mucosa overlying the hard
can reduce operative morbidity and blood loss.46 In palate has been reported in a patient following bilateral
skull base surgery involving the region of the jugular internal maxillary artery embolisation for epistaxis. The
foramen, the jugular bulb is opened. This can be associ- patient also received balloon tamponade and bilateral
ated with significant blood loss, prolonged operative nasal packs for two days post-procedure, and it was
time, and the risk of compression injury to cranial suggested that packing should be removed as soon as
nerves IX, X and XI from overpacking. Embolisation possible after embolisation.51
of feeder vessels to the jugular bulb before surgery Herdman suggested that if the stylomastoid artery is
reduces the risk of these complications. There is a occluded, the facial nerve is not usually in danger, due
theoretical risk of injury to lower cranial nerves, but to supply from the middle or accessory meningeal
234 J RISLEY, K MANN, N S JONES

artery (present in 90 per cent of the population). In the 4 Daudia A, Jaiswal V, Jones NS. Guidelines for the management
of idiopathic epistaxis in adults: how we do it. Clin Otolaryngol
remaining 10 per cent, as well as in cases of embolisa- 2008;33:618–20
tion of the middle meningeal artery, facial nerve dys- 5 Fukutsuji K, Nishiike S, Aihara T, Uno M, Harada T, Gyoten M
function should be expected. However, permanent et al. Superselective angiographic embolization for intractable
epistaxis. Acta Otolaryngol 2008;128:556–60
embolic agents are more likely to cause a permanent 6 Tseng EY, Narducci CA, Willing SJ, Sillers MJ. Angiographic
palsy; if these agents are needed (for example when embolization for epistaxis: a review of 114 cases.
surgery is not an option), the provocation test (invol- Laryngoscope 1998;108:615–19
7 Gupta AK, Purkayastha S, Bodhey NK, Kapilamoorthy TR,
ving pre-embolic injection of lidocaine) may assess Kesavadas C. Preoperative embolization of hypervascular head
the risk of a lasting palsy.52 and neck tumours. Australas Radiol 2007;51:446–52
The complications of embolisation for post-tonsil- 8 Yiotakis I, Eleftheriadou A, Davilis D, Giotakis E, Ferekidou E,
Korres S et al. Juvenile nasopharyngeal angiofibroma stages I
lectomy haemorrhage include: vessel perforations and II: a comparative study of surgical approaches. Int J
with subsequent extravasation of embolic material; Pediatr Otorhinolaryngol 2008;72:793–800
ischaemic injury to mucosal surfaces and cranial 9 Shenoy AM, Grover N, Janardhan N, Jayakumar PN, Hedge T,
Satish S. Juvenile nasopharyngeal angiofibromas: a study of
nerves; inadvertent involvement of the internal recurrent pattern and role of pre-operative embolization – ‘A
carotid artery; catheter-induced vasospasm; and post- decade’s experience’. Indian J Otolaryngol Head Neck Surg
procedure pain.53 2002;54:274–9
10 Li JR, Qian J, Shan XS, Wang L. Evaluation of the effectiveness
If hypovolaemic and vasoconstrictive drugs are used of preoperative embolization in surgery for nasopharyngeal
in the management of the trauma patient, there is the angiofibroma. Eur Arch Otorhinolaryngol 1998;255:430–2
possibility of external carotid artery territory vaso- 11 El-Banhawy OA, Ragab A, El-Sharnoby MM. Surgical resec-
tion of type III juvenile angiofibroma without preoperative
spasm. It is important to be aware that embolisation embolization. Int J Pediatr Otorhinolaryngol 2006;70:1715–23
into these vessels may cause reflux of embolic material 12 Carrillo JF, Albores O, Ramirez-Ortega MC, Aiello-Crocifoglio
into the internal carotid artery, resulting in intracerebral V, Onate-Ocana LF. An audit of nasopharyngeal fibromas. Eur J
Surg Oncol 2007;33:655–61
complications.28 13 Chou WC, Lu CH, Lin G, Hong YS, Chen PT, Hsu HC.
Transcutaneous arterial embolization to control massive tumor
Conclusion bleeding in head and neck cancer: 63 patients’ experiences
from a single medical center. Support Care Cancer 2007;15:
Embolisation has a significant role to play in many 1185–90
aspects of otolaryngological practice. It is well estab- 14 Kakizawa H, Toyota N, Naito A, Ito K. Endovascular therapy
lished in the management of intractable epistaxis, for management of oral hemorrhage in malignant head and
neck tumors. Cardiovasc Intervent Radiol 2005;28:722–9
being effective and having low complication rates. 15 Imai S, Kajihara Y, Kamei T, Komaki K, Tamada T. Arterial
Pre-operative embolisation of vascular tumours is embolization for control of bleeding in advanced head and
available in most centres. The benefits extend beyond neck malignancy. Int J Clin Oncol 1998;3:228–32
16 Bhansali S, Wilner H, Jacons JR. Arterial embolization for
a reduction in blood loss; embolisation also improves control of bleeding in advanced head and neck carcinoma.
visualisation of the surgical field, enabling greater J Laryngol Otol 1986;100:1289–93
ease of dissection, and reduces the duration of the oper- 17 Sesterhenn AM, Iwinska-Zelder J, Dalchow CV. Acute haemor-
rhage in patients with advanced head and neck cancer: value of
ative procedure. Embolisation plays an increasingly endovascular therapy as palliative treatment option. J Laryngol
important role in the palliation of advanced head and Otol 2006;120:117–24
neck tumours, and in the management of the sequelae 18 Schick PM, Hieshima AB, White RA. Arterial catheter embili-
zation followed by surgery for large Chemodectoma. Surgery
of these pathologies. 1980;87:459–64
In cases of head and neck trauma, bilateral angiogra- 19 Van Den Berg R. Imaging and management of head and neck
phy with a view to embolisation should be considered paragangliomas. Eur Radiol 2005;15:1310–18
20 Persky MS, Setton A, Niimi Y, Hartman J, Frank A, Bernstein A.
as a diagnostic and therapeutic intervention, especially Combined endovascular and surgical treatment of head and neck
if surgical management is being considered. paragangliomas – a team approach. Head Neck 2002;24:423–31
Embolisation has proved an important adjunct in the 21 Miller RB, Boon MS, Atkins JP, Lowry LD. Vagal paragan-
glioma: the Jefferson experience. Head Neck Surg 2000;122:
management of haemangiomas, arteriovenous malfor- 482–7
mations and telangiectatic conditions, and also of 22 Chang FC, Lirng JF, Luo CB, Wang SJ, Wu HM, Guo WY et al.
post-operative complications. Patients with head and neck cancers and associated postirra-
diated carotid blowout syndrome: endovascular therapeutic
In experienced units, embolisation is a safe, effective methods and outcomes. J Vasc Surg 2008;47:936–45
and important therapeutic adjunct in the management 23 Luo CB, Teng MM, Chang FC, Chang CY. Transarterial embo-
of a wide variety of otolaryngological conditions, and lization of acute external carotid blowout syndrome with profuse
oronasal bleeding by N-butyl-cyanoacrylate. Am J Emerg Med
could have an important role to play in most areas of 2006;24:702–8
ENT practice. 24 Roh JL, Suh DC, Kim MR, Lee JH, Choi JW, Choi SH et al.
Endovascular management of carotid blowout syndrome in
References patients with head and neck cancers. Oral Oncol 2008;44:
844–50
1 Rosch J, Dotter CT, Brown MJ. Selective arterial embolisation: a
25 Bates MC, Shamsham FM. Endovascular management of
new method for control of acute gastrointestinal bleeding.
impending carotid rupture in a patient with advanced head and
Radiology 1972;102:303–6
neck cancer. J Endovasc Ther 2003;10:54–7
2 Kingsley D, O’Connor AF. Embolization in otolaryngology.
26 Luo CB, Teng MM, Chang FC, Chang CY, Guo WY. Radiation
J Laryngol Otol 1982;96:439–50
carotid blowout syndrome in nasopharyngeal carcinoma: angio-
3 Sokoloff J, Wickbom I, McDonald D. Therapeutic percutaneous
graphic features and endovascular management. Otolaryngol
embolization in intractable epistaxis. Radiology 1974;111:
Head Neck Surg 2008;138:86–91
285–7
ROLE OF EMBOLISATION IN ENT 235
27 Patel N, Lewandowski RJ, Bove M, Nemcek AA Jr, Salem R. 49 Barlow DW, Deleyiannis FWB, Pinczower EF. Effectiveness of
Thoracic duct embolization: a new treatment for massive leak surgical management of epistaxis at a tertiary care centre.
after neck dissection. Laryngoscope 2008;118:680–3 Laryngoscope 1997;107:21–24
28 Komiyama M, Nishikawa M, Kan M, Shigemoto T, Kaji A. 50 Sadri M, Midwinter K, Ahmed A, Parker A. Assessment of safety
Endovascular treatment of intractable oronasal bleeding and efficacy of arterial embolisation in the management of intract-
associated with severe craniofacial injury. J Trauma 1998;44: able epistaxis. Eur Arch Otorhinolaryngol 2006;263:560–6
330–4 51 Guss J, Cohen MA, Mirza N. Hard palate necrosis after bilateral
29 Golueke PJ, Goldstein AS, Scalafani SJA. Routine versus selec- internal maxillary artery embolization for epistaxis.
tive exploration of penetrating neck injuries: a randomisied pro- Laryngoscope 2007;117:1683–4
spective study. J Trauma 1984;24:1010–1014 52 Marangos N, Schumacher M. Facial palsy after glomus jugulare
30 Germiller JA, Myers LL, Harris MO, Bradford CR. tumour embolization. J Laryngol Otol 1999;113:268–70
Pseudoaneurysm of the proximal facial artery presenting as oro- 53 Opatowsky MJ, Browne JD, McGuirt WF, Morris PP.
pharyngeal hemorrhage. Head Neck 2001;23:259–63 Endovascular treatment of hemorrhage after tonsillectomy in
31 Sclafani S, Panetta T, Goldstein A, Phillips T, Hotson G. The children. Am J Neuroradiol 2001;22:713–16
management of arterial injuries caused by penetration of zone
III of the neck. J Trauma 1985;25:871–81
32 Layton KF, Kallmes, Gray L, Cloft HJ. Endovascular treatment Appendix 1. Search strategy
of epistaxis in patients with hereditary haemorrhagic telangiec- The search strategy used encompassed the Medline,
tasia. Am J Neuroradiol 2007;28:855–88 Embase, PubMed and Cochrane databases. The
33 Roland NJ, McRae RDR, McCombe AW. Key Topics in
Otolaryngology, 2nd edn. London: Taylor and Francis, 2001 search was performed in November 2008, with the
34 Righi PD, Bade MA, Coleman JJ, Allen M. Arteriovenous mal- strategy outlined below. All types of study were con-
formation of the base of tongue: case report and literature sidered, and no language or publication date restric-
review. Microsurg 1996;17:706–9
35 Kohout MP, Hansen M, Pribaz JJ, Mulliken JB. Arteriovenous tions were applied. Results were discounted if not
malformations of the head and neck: natural history and man- related to ENT (e.g. embolisation of uterine fibroids).
agement. Plast Reconstr Surg 1998;102:643–54 The number of articles retrieved is shown below
36 Aslan S, Yavuz H, Cagici AC, Kizilkilic O. Embolisation of an
extensive arteriovenous malformation of the temporal region as
an alternate treatment: case report. J Laryngol Otol 2008;122: Embase
737–40
37 Bizri AR, Al-Ajam M, Zaytoun G, al-Kutoubi A. Direct carotid
Otolaryngology plus embolisation: 0
cavernous fistula after submucous resection of the nasal septum. Otolaryngology: 484 081
ORL J Otorhinolaryngol Relat Spec 2000;62:49–52 Embolisation: 20 286
38 Yu JS, Lei T, Chen JC, He Y, Chen J, Li L. Diagnosis and endo-
vascular treatment of spontaneous direct carotid-cavernous
Combined: 3002
fistula. Chin Med J 2008;121:1558–62 Applicable: 107
39 Pothula VB, Reddy KTV, Nixon TE. Carotico-cavernous
fistula following septorhinoplasty. J Laryngol Otol 1999;113: Medline
844–6
40 Walshe P, Ramos E, Low C, Thomas L, McWilliams R, Hone S. Otolaryngology embolisation: 529
An unusual complication of tonsillectomy. Surgeon 2005;3: Applicable: 27
296–8
41 Johnson PE, Tabee A, Fitz-James IA, Pass RH, Serres LM.
Major aorto-pulmonary collateral arteries (MAPCAs)–Bronchial PubMed
fistula presenting as tracheotomy bleed. Int J Pediatr Embolisation otolaryngology (plus related articles):
Otorhinolaryngol 2006;70:1109–13
42 Takasakia K, Enatsua K, Hasus MA. A case with tracheo-inno- 147
minate artery fistula. Successful management of endovascular
embolization of innominate artery. Larynx 2005;32:195–8 Cochrane
43 Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate
artery fistula after percutaneous tracheostomy: three case reports Library search for embolisation and otolaryngology: 0
and a clinical review. Br J Anaesthesia 2006;96:127–31 A–Z search: 0
44 Cockroft KM, Carew JF, Trost D, Fraser RA. Delayed epistaxis
resulting from external carotid artery injury requiring emboliza-
Search by topic ‘ENT disorders’: malignant disease =
tion: a rare complication of transsphenoidal surgery: case report. 0, non-malignant disease = 4
Neurosurgery 2000;47:236–9
45 Nishioka H, Ohno S, Ikeda Y, Ohashi T, Haraoka J. Delayed Address for correspondence:
massive epistaxis following endonasal transsphenoidal Professor N S Jones,
surgery. Acta Neurochir (Wien) 2007;149:523–6 Department of Otorhinolaryngology,
46 Noonan PT, Choi IS. Diagnostic imaging, angiography, and University Hospital,
interventional techniques for jugular foramen tumors. Oper Nottingham NG7 2UH, UK
Techol Neurosurg 2005;8:13–18
47 Carrier DA, Arriaga MA, Gorum MJ, Dahlen RT, Johnson SP. Fax: +44 (0)115 970 9748
Preoperative embolization of anastomoses of the jugular bulb: E-mail: Nick.Jones@nottingham.ac.uk
an adjuvant in jugular foramen surgery. Am J Neurorad 1997;
18:1252–6
Professor N S Jones takes responsibility for the integrity
48 Pepper JP, Wadwa AK, Tsai F, Shibuya T, Wong BJ. Cavernous
of the content of the paper
carotid injury during FESS: case presentations and guidelines
Competing interests: None declared
for optimal management. Am J Rhinol 2007;21:105–9
Copyright of Journal of Laryngology & Otology is the property of Cambridge University Press and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.