title: Developing a laddered algorithm for the management of intractable epistaxis: a risk analysis.
abstract: OBJECTIVE
  For patients with epistaxis in whom initial interventions, such as anterior packing and cauterization, had failed, options including prolonged posterior packing, transnasal endoscopic sphenopalatine artery ligation (TESPAL), and embolization are available. However, it is unclear which interventions should be attempted and in which order. While cost-effectiveness analyses have suggested that TESPAL is the most responsible use of health care resources, physicians must also consider patient risk to maintain a patient-centered decision-making process.
  
  
  OBJECTIVE
  To quantify the risk associated with the management of intractable epistaxis.
  
  
  METHODS
  A risk analysis was performed using literature-reported probabilities of treatment failure and adverse event likelihoods in an emergency department and otolaryngology hospital admissions setting. The literature search included articles from 1980 to May 2014. The analysis was modeled for a 50-year-old man with no other medical comorbidities. Severities of complications were modeled based on Environmental Protection Agency recommendations, and health state utilities were monetized based on a willingness to pay $22 500 per quality-adjusted life-year. Six management strategies were developed using posterior packing, TESPAL, and embolization in various sequences (P, T, and E, respectively).
  
  
  METHODS
  Total risk associated with each algorithm quantified in US dollars.
  
  
  RESULTS
  Algorithms involving posterior packing and TESPAL as first-line interventions were found to be similarly low risk. The lowest-risk approaches were P-T-E ($2437.99 [range, $1482.83-$6976.40]), T-P-E ($2840.65 [range, $1136.89-$8604.97]), and T-E-P ($2867.82 [range, $1141.05-$9833.96]). Embolization as a first-line treatment raised the total risk significantly owing to the risk of cerebrovascular events (E-T-P, $11 945.42 [range, $3911.43-$31 847.00]; and E-P-T, $11 945.71 [range, $3919.91-$31 767.66]).
  
  
  CONCLUSIONS
  Laddered approaches using TESPAL and posterior packing appear to provide the lowest risk. Combining risk and cost-effectiveness perspectives, we recommend a laddered approach to intractable epistaxis with TESPAL first, followed by either embolization or posterior packing.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada.
authors.forename: Randy M
authors.initials: RM
authors.lastname: Leung
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland.
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Smith
authors.affiliation: Division of Otolaryngology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Luke
authors.initials: L
authors.lastname: Rudmik
mesh_terms: D000465:Algorithms; D015897:Comorbidity; D003362:Cost-Benefit Analysis; D004621:Embolization, Therapeutic / Q000191:economics; D004724:Endoscopy / Q000191:economics; D004844:Epistaxis / Q000191:economics* / Q000628:therapy*; D006801:Humans; D008026:Ligation / Q000191:economics; D011788:Quality of Life; D018570:Risk Assessment