Etiology and Management of Nasopharyngeal Hemorrhage After Radiotherapy for Nasopharyngeal Carcinoma

Objective: To analyze the etiology of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and evaluate the relevant management and rescue approaches.

Methods: Seventeen cases of nasopharyngeal hemorrhage caused by radiotherapy of NPC, treated between January 2015 and March 2018, were retrospectively analyzed to study the etiology of nasopharyngeal hemorrhage. The management and rescue strategies, including anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization, were assessed for their effectiveness.

Results: Nasopharynx hemorrhage after radiotherapy of NPC was mainly associated with erosion of the internal carotid artery or maxillary artery by the tumor. Among the 17 cases, 11 patients were treated by digital subtraction arterial angiography embolization, and 3 were treated by endoscopic nasopharynx electrocoagulation. Overall, 13 patients survived, while 4 died.

Conclusion: Anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization are suitable for treating nasopharyngeal hemorrhage. However, effective hemostasis depends on early identification of the bleeding vessels.

Keywords: nasopharyngeal carcinoma (NPC), nasopharyngeal hemorrhage, radiotherapy, prognosis

INTRODUCTION

Nasopharyngeal carcinoma (NPC) is the most common head and neck cancer in southern China, affecting 30 out of 100,000 people. It is usually diagnosed with a high degree of malignancy and consequently leads to >34,000 deaths annually.¹ Currently, the primary treatment modality for NPC is radical radiation therapy, with chemotherapy as an auxiliary option. Although radiotherapy has evolved from two-dimensional radiotherapy to intensity-modulated radiation therapy (IMRT), which has improved local control rates and minimized adverse effects on surrounding healthy tissue, radiation complications are frequently observed. These include xerostomia, sinusitis, temporal lobe necrosis, cranial nerve palsy, and brainstem damage.² In addition, radiation arteritis with carotid stenosis, especially nasopharyngeal hemorrhage, also occurs often.³

The vascular injury resulting from radiation is believed to be a significant cause of bleeding after radiation treatment for NPC.⁴ Multiple factors may be involved, including local hypoxia, vascular remodeling, inflammatory infection, nasopharyngeal and nasal dysfunction, dry mucous membranes, tumor recurrence, and malnutrition.⁵ Nasopharyngeal hemorrhage represents a particular subtype of epistaxis after radiotherapy for NPC, described as a sudden hemorrhage of >100 mL or continuous bleeding of more than 300 mL in the nasopharyngeal area within a short period.⁶ The condition is usually dangerous and critical, with many complications, and the reported mortality rate has varied from 35.7% to 100%.⁷

There are no standard treatment methods for significant bleeding after radiotherapy, and bleeding-related factors should be avoided. Various hemostasis strategies are available, including packing of the anterior and posterior nostrils, applying the nasal cavity balloon, carotid artery ligation, and vascular interventional embolization. In the past five years, >800 new cases of NPC have been treated in our clinic every year. In the present study, we retrospectively analyzed the etiological factors of nasopharyngeal hemorrhage after radiotherapy for NPC and evaluated the management protocols to provide insight into improving the effectiveness of the treatments.

READ FULL ARTICLE From Dovepress