Ethical statement and patient selection

This study was approved by the Ethics Committee of Hainan General Hospital, Haikou, China, and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from each patient. The 17 patients included in this study were treated for nasopharyngeal hemorrhage after radiation treatment for NPC in Hainan General Hospital, China, from January 2015 to March 2018.

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Management of nasopharyngeal hemorrhage

Upon the emergence of nasopharyngeal hemorrhage, the upper airway patency was ensured. The blood and blood clots in the throat were timely removed with a bedside mucus suction device to prevent tracheal obstruction. Meanwhile, single- or dual-chamber balloons, which were inflated with 10–15 mL of air or water, were used to fill the nasopharynx to control the bleeding. If the bleeding continued, nasal packing with Vaseline gauze was performed to fill the anterior nares. In cases with a large amount of blood loss, intravenous access was established to meet the potential needs for intravenous fluids and blood transfusion.

Rescue and management approaches were chosen appropriately to the clinical conditions and the bleeding rate. Patients with a small amount or continuous bleeding and bleeding point identified by nasal endoscopy were treated in the emergency with endoscopic nasopharynx electrocoagulation under general anesthesia. Patients with an unidentifiable bleeding point, due to an urgent medical condition or limited diagnostic options, underwent selective digital subtraction angiography (DSA) to identify the bleeding vessel. Hemorrhage in the external carotid artery was controlled by selective vascular embolization using a stainless steel coil, while bleeding from the internal carotid artery was managed using a stent. Endotracheal intubation was performed in an emergency that the patients presented respiratory abnormality, which might be caused by insufficient blood clot removal under conditions of restricted jaw opening and poor throat emission. A tracheotomy was performed when endotracheal intubation was infeasible. After the airway patency was ensured and bleeding controlled by using a single or double-lumen balloon tamponade, the patients were sent to the interventional room for DSA to further clarify the bleeding site and bleeding artery, which were eventually treated with selective vascular embolization. Endoscopic nasopharynx electrocoagulation hemostasis was generally not recommended for patients with nasopharyngeal hemorrhage after radiotherapy for NPC.

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The treatment was considered effective if the active bleeding decreased or stopped, and hemorrhage symptoms disappeared within 72 hours.

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