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Review
The expanding role of interventional radiology in head and neck surgery
Stephen Broomfield1 Iain Bruce1 Andrew Birzgalis1 Amit Herwadkar2
1 Department of Otolaryngology, Head and Neck Surgery, University Hospital of South Manchester NHS Foundation Trust Manchester, UK
2 Department of Neuroradiology, Salford Royal NHS Foundation Trust Manchester, UK
Correspondence to: Stephen Broomfield [Ссылки доступны только зарегистрированным пользователям ]
Introduction
Interventional radiology is defined by the Society of Interventional Radiology as ‘the delivery of minimally invasive, targeted treatments, performed using imaging for guidance’. Although the principles of angiography for diagnosis have existed since the 1920s, and today remain a well-established modality for the diagnosis of many common conditions, it was not until the 1960s that the American Charles Dotter, and other pioneers, extended these techniques from diagnosis to treatment.1 Their foresight, together with ever-increasing technological capability, allowed the use of transluminal angioplasty for the treatment of peripheral vascular disease and led Dotter to say, in 1964, that ‘it should be evident that the vascular catheter can be more than a tool for passive means for diagnostic observations: used with imagination it can become an important surgical instrument’.2,3 Thus, interventional radiology as a specialty was born. Work on the cerebral vasculature began in the 1970s, largely for neurosurgical conditions. It is perhaps not surprising that the initial, and still best known, uses of interventional radiology were for the highly accessible vascular system, and for the type of non-vascular conditions that offered poor surgical access, such as in neurosurgery. More recently, interventional radiology techniques have been applied to head and neck cancer patients, initially with the use of detachable balloon occlusion in patients with laryngeal cancer and impending carotid artery rupture. From this, the range of applications of interventional radiology in the extra-cranial head and neck has continued to evolve and expand. These applications include line placement, foreign body removal, placement of feeding tubes (primary gastrostomy, gastrojejunostomy or jejunostomy tubes), and oesophageal or bronchial dilatation and stenting. The main focus of this review is on the vascular applications of interventional radiology in the head and neck, which can be divided into three main categories: management of acute haemorrhage (e.g. epistaxis, carotid blowout); management of vascular lesions (e.g. tumours, arterio-venous malformations); and venous sampling.
Management of acute haemorrhage
Epistaxis
Epistaxis is one of the most common complaints presenting to the otolaryngologist, the majority being from an anterior nasal vessel, and dealt with using simple techniques such as cautery and nasal packing. There is, however, significant controversy about the best management for intractable posterior epistaxis when posterior nasal packing has failed. Traditional open surgical treatment includes ligation of the anterior ethmoidal artery via a Lynch-Howarth (peri-orbital) incision, or neck exploration with ligation of the external carotid artery or internal maxillary artery. The widespread use of endoscopes has meant that such open techniques are now reserved for the most refractory of cases, with most surgeons advocating endoscopic trans-nasal or trans-antral sphenopalatine artery ligation or endoscopic anterior ethmoidal artery ligation as a first line approach.4–6 Selective embolization of bleeding vessels with particles or coils is an increasingly used treatment for such cases of refractory epistaxis, and has been shown by many to be safe and effective.7–12 Figure 1 shows how bleeding was managed using embolization in a patient with intractable epistaxis who was not considered fit for general anaesthesia.
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Figure 1. (a) Digital subtraction angiogram showing nasal vasculature with bleeding point (black arrow) and catheter (white arrow); (b) after selective embolization there is no blood flow to the bleeding point (black arrow). Blood flow to the anterior part of the nose has been preserved (white arrow)
At present, there is little consensus as to which treatment modality is preferable or most cost effective, as both surgery and embolization carry similarly acceptable complication rates. Each patient is therefore managed on an individual basis, taking into account the experience of the surgeon, the fitness of the patient for general anaesthesia and the availability of interventional radiology services.