An uncommon cause of epistaxis: cartoid cavernous fistula.
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We report on an uncommon cause of epistaxis presenting to the emergency room. Epistaxis is not an uncommon presentation to emergency rooms across the world. The majority are easily controlled and have low mortality. We present a case of a carotid-cavernous fistula presenting with massive epistaxis culmination in cardiovascular collapse and death. Awareness of this entity will reduce the frequency of this condition resulting in major morbidity and mortality. (+info)
Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia.
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BACKGROUND AND PURPOSE: The treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia can be very challenging. The purpose of our study was to evaluate our experience with endovascular epistaxis embolization in patients with hemorrhagic hereditary telangiectasia and to compare this with our experience in patients treated for idiopathic epistaxis. MATERIALS AND METHODS: Over a 6-year period, we treated 22 patients with epistaxis by using endovascular embolization. Twelve of 22 patients had hereditary hemorrhagic telangiectasia; 10 patients had idiopathic epistaxis. The angiographic findings, efficacy of treatment, and complications for both groups were compared. RESULTS: Patients with hereditary hemorrhagic telangiectasia had angiographic abnormalities in 92% of cases compared with only 30% in the idiopathic epistaxis group. Compared with a group of 10 patients treated for other causes of epistaxis, those with hereditary hemorrhagic telangiectasia required significantly more re-embolization treatments or additional surgical procedures because of continued or recurrent bleeding episodes after embolization (P=.03). Complications were rare; a single patient in the idiopathic epistaxis group had a self-limited groin hematoma and postembolization facial pain. CONCLUSION: Endovascular embolization of epistaxis is a safe procedure that can be useful for patients with severe acute epistaxis or chronic persistent bleeding. Patients who undergo endovascular embolization for epistaxis related to hereditary hemorrhagic telangiectasia require repeat embolization and subsequent surgical procedures more often than those with idiopathic epistaxis. (+info)
Hereditary hemorrhagic telangiectasia: a rare cause of severe anemia.
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Hereditary hemorrhagic telangiectasia is an autosomal dominant disease in which arteriovenous communications are typically seen in the skin, mucosal surfaces, lungs, brain and gastrointestinal tract. This disease typically presents as epistaxis, gastrointestinal bleeding and arteriovenous malformations (in the brain and lungs). Although the epistaxis and gastrointestinal bleeding can result in anemia, patients diagnosed with hereditary hemorrhagic telangiectasia rarely present severe anemia. Herein, we report the case of a 49-year-old man with severe anemia and undiagnosed hereditary hemorrhagic telangiectasia. (+info)
Osler-Weber-Rendu disease with esophageal varices and hepatic nodular change.
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A 72-year-old male visited our hospital for further evaluation of esophageal varices. Telangiectasias were present in the stomach. He had recurrent epistaxis, which was also confirmed in his family's medical history. We diagnosed this case as Osler-Weber-Rendu disease. He had concomitant with hepatic nodular change. Abdominal angiography showed arterio-portal (A-P) shunts, superior mesenteric artery (SMA)-superior mesenteric vein (SMV) shunt, extension of SMV, and dilated and meandering portal vein. Esophageal varices were treated by endoscopic variceral ligation (EVL) and argon plasma coagulation (APC) therapy for prophylaxis of bleeding. (+info)
The role of surgical audit in improving patient management; nasal haemorrhage: an audit study.
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BACKGROUND: Nasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified. The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit. Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care. METHODS: Retrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March). Prospective: 60 consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent. New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use. RESULTS: Previously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days. In the prospective audit the total number of admissions was significantly reduced, by over 70%, (chi2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (chi2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (chi2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over pound 50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work. CONCLUSION: Exclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care. (+info)
Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection.
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BACKGROUND: Epistaxis in childhood is common but unusual in the first years of life. Oronasal blood has been proposed as a marker of child abuse. METHODS: We performed a retrospective review of all hospital notes of children in the Lothian region of Scotland who were <2 years of age and in whom facial blood had been recorded over a 10-year period. RESULTS: There were 77,173 accident and emergency department attendances with 58,059 admissions during the 10-year study period in children <2 years of age; 16 cases of nose bleed and 3 cases of hemoptysis were recorded. All cases of hemoptysis were associated with significant bouts of coughing and respiratory infections. Epistaxis in 8 cases was associated with visible trauma and in 4 cases with thrombocytopenia (secondary to malignancy in 3). In 2 cases, an associated apparent life-threatening event was described, and in 2 cases there was a coincident upper respiratory tract infection. Review of previous and subsequent history suggested 7 cases of "accidental" injury that might have been caused by abuse. These cases are described here. All children who presented with this problem to the accident and emergency department had been admitted for observation or management. CONCLUSIONS: Epistaxis is rare in the accident and emergency department and hospital in the first 2 years of life and is often associated with injury or serious illness. The investigation of all cases should involve a pediatrician with expertise in child protection. (+info)
Leiomyoma of the nose.
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Leiomyomas are benign neoplasms that are thought to originate from the vascular smooth muscle. They have a propensity to arise from the gastrointestinal tract, female genital tract (uterus) and subcutaneous tissue. The nasal cavity is an uncommon site for a leiomyoma. We report a 24-year-old woman with a rare nasal leiomyoma. A brief review of the literature and histological variations are described. (+info)
Pathways through the nose for nasal intubation: a comparison of three endotracheal tubes.
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BACKGROUND: In nasotracheal intubation, there are two main pathways in the nostril through which the endotracheal tube may pass. The lower pathway lies along the floor of the nose underneath the inferior turbinate. The upper pathway lies above the inferior turbinate, just below the middle turbinate. The lower pathway may be considered to be the safer route as it is located away from the middle turbinate and cribiform plate. METHODS: We conducted a randomized controlled trial comparing the frequency with which preformed, reinforced, and thermosoftened preformed tubes pass through upper and lower pathways. Ninety-two maxillofacial patients requiring nasotracheal intubation as part of their anaesthetic management were studied. Two patients were excluded from the study at endoscopy because of atypical nasal anatomy. After the induction of general anaesthesia, a standardized traditional nasal intubation was performed with a Macintosh laryngoscope, the operators endeavouring to direct the tube along the floor of the nose. Fibreoptic nasendoscopy was then performed by passing the tip of the fibrescope 2-3 cm into the nasal cavity above and below the tube, to identify the pathway taken. RESULTS: Data were analysed on 30 patients in each group. Five (16.7%) preformed tubes, 17 (56.7%) reinforced tubes, and 6 (20%) thermosoftened preformed tubes passed through the lower pathway. Significantly more reinforced tubes took the preferred pathway (P=0.001). Tubes passing through the upper pathway caused significantly more epistaxis than tubes passing through the lower pathway (P=0.003). CONCLUSIONS: Endotracheal tubes, particularly preformed tubes, frequently take the less favourable pathway during nasotracheal intubation, in spite of specific attempts to avoid this. (+info)