Postoperative Epistaxis After Endoscopic Endonasal Skull Base Surgery: Incidence, Timing, and Clinical Implications.

Abstract

To determine the incidence, timing, bleeding sources, and associated factors of clinically significant postoperative epistaxis after endoscopic endonasal skull base surgery in a large single-center cohort. Retrospective cohort with a frequency-matched case-control analysis. Single tertiary center. Among 1070 adults who underwent endoscopic endonasal skull base surgery (2015-2025), patients who developed postoperative epistaxis requiring medical evaluation or surgical intervention (n = 13) were compared with 52 frequency-matched controls without bleeding. Bleeding timing, endoscopic bleeding sources, management, and exploratory univariable associations were evaluated. The incidence of clinically significant postoperative epistaxis was 1.2%. Bleeding occurred between postoperative Days 0 and 28 (mean ± SD, 13.1 ± 7.6 days; median, 14 days), and 76.9% occurred during Days 8 to 23. Identified bleeding sources included posterior septal branches of the sphenopalatine system (23%), flap donor site or inferior septal mucosal edge (15%), diffuse mucosal oozing (23%), and cerebrospinal fluid-mixed bleeding (15%). In exploratory univariable analyses, hypertension (odds ratio, 4.90; 95% CI, 1.35-17.80) and postoperative systemic steroid use (odds ratio, 3.60; 95% CI, 1.02-12.73) were associated with bleeding. Most patients (92.3%) required endoscopic surgical re-exploration for definitive hemostasis. Clinically significant postoperative epistaxis after endoscopic endonasal skull base surgery most often occurred during the second to third postoperative week and commonly originated from posterior septal branches or donor-site mucosa. These findings highlight the importance of careful postoperative monitoring and a low threshold for early endoscopic evaluation when clinically significant bleeding occurs.