Massive Epistaxis Revealing a Post-Traumatic Aneurysm of the Internal Carotid Artery: A Clinical Case and Review of the Literature

Internal carotid artery (ICA) aneurysms are an unusual but serious cause of epistaxis. This epistaxis is massive and sometimes uncontrollable threatening the vital prognosis of patients. We report the case of a 16-year-old adolescent received in emergency with severe bilateral epistaxis, asthenia and grade-3 left exophthalmos. In his history, the subject had been the victim of an assault six months before consultation. He had received blows on the cephalic extremity with light but repeated epistaxis. The treatment consisted to blood products transfusion and local compression by sterile gazes. An ICA aneurysm in sphenoid sinus has been confirmed in a craniofacial CT scan coupled to vascular opacification. Although the ICA has a variable course in contact with the sphenoid sinus, massive epistaxis would be the consequence of a pronounced dehiscence of the ICA in the sphenoid sinus, particularly in a traumatic context. In front of this type of epistaxis in our context, general practitioners must be able to suspect a ruptured ICA aneurysm in the presence of exophthalmos and a notion of old or recent cranio-encephalic injury. Additionally, due to the high morbidity and mortality of this condition, a monitoring algorithm is necessary for patients with head trauma to facilitate early detection.

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany

BACKGROUND Reports of a decrease in hospital admissions during the coronavirus disease 2019(COVID-19)lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.AIM To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.METHODS A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period.This was done on a weekly basis before,during,and after the lockdown.An Interrupted Time Series was used as the analysis method.RESULTS In our analysis,we included 26183 patients.The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients(P<0.05).This effect was most pronounced in the age group of 0-39 years,where the decrease was highly significant(P<0.001).However,there was no change observed in patients aged 80 years and older(not significant).With the end of the lockdown period,the overall number of patients,especially in the youngest age group,increased abruptly and significantly(P<0.01).CONCLUSION During the lockdown period,there was a decrease in hospital admissions for younger patients with epistaxis,possibly due to the fear of COVID-19 exposure.We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Cost Effective Trend in Epistaxis Management

Background: Epistaxis affects much of the population and is a common medical complaint seen across a variety of medical settings. Current standard of care treatment includes a range of options from topical therapy to invasive intranasal device insertion in the absence of on-demand specialist involvement. Aim: The aim of this article is to not only highlight superior outcomes in patients with acute nontraumatic epistaxis that are treated with noninvasive nebulized tranexamic acid instead of more invasive options, but also monetary benefit to the community through reduced costs. Case Presentation: this case report highlights a successful epistaxis resolution with use of tranexamic acid in a 64-year-old female after she was subjected to intranasal device insertion that did not resolve bleeding. Conclusion: Nebulized tranexamic acid is a cost-effective medication that not only reduces rates of recurrence, but it also increases patient satisfaction while minimizing overall healthcare costs, and therefore should be the first choice therapy in uncomplicated epistaxis management.

Epistaxis in end stage liver disease masquerading as severe upper gastrointestinal hemorrhage

AIM: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH).

An Epistaxis Emergency Associated with Multiple Pollutants in Elementary Students

Emergencies of epistaxis in students caused by environmental pollution have rarely been reported to date. This study aimed to explore the cause of an emergency of epistaxis in elementary students by using a field epidemiological investigation. Twenty-two epistaxis cases from a single school with differences in gender, age, and classroom,were diagnosed within a period of 7 days. The air concentration of chromic acid mist （Cr6~） in the electroplating factory area, new campus, and residential area exceeded the limit of uncontrolled emissions. The emission of HCL and HzSO4was also observed. Formaldehyde levels in the classrooms exceeded the limits of indoor air quality. Abnormal nasal mucosa was significantly more frequent in the case group （93.3%） and control group 1 （of the same school） （66.7%） than in control group 2 （from a mountainous area with no industrial zone） （34.8%; P 〈 0.05 and P 〈 0.01, respectively）. On the basis of the pre-existing local nasal mucosal lesions, excessive chromic acid mist in the school＇s surrounding areas and formaldehyde in the classrooms were considered to have acutely irritated the nasal mucosa, causing epistaxis. Several lessons regarding factory site selection, eradication of chemical emissions, and indoor air quality in newly decorated classrooms, should be learned from this emergency.

Teachers’ Awareness Regarding Emergency Management of Epistaxis inside the School;Alahssa, Saudi Arabia

Background: Epistaxis is one of the commonest emergencies encountered by ENT physicians as well as to family and emergency physicians. It is common among school children as they are easily injured during different school activities. Objective: The aim of this study was to assess the level of knowledge and attitude regarding first aid management of epistaxis among school teachers in Al-Ahsa, Saudi Arabia. Method: A cross sectional study was conducted in November 2017 among Saudi school teachers in AlAhssa region, Kingdom of Saudi Arabia. The data were collected by a well-structured online questionnaire which was designed including questions about the biographical data of the teacher, questions about the past knowledge of the emergency management of epistaxis and questions assessing the awareness of the method applied as a management of epistaxis. Result: We received 485 valid responses. 76% of teachers were female, 93% worked in public and 40% were in primary schools. 54% of participants had received information about first aid to stop nose bleeding or hemorrhage. 67% said that their students experienced epistaxis before. Interestingly, 15% said they would not try to stop the bleeding, and only 25% said they would press on the cartilaginous part of nose. However, a higher percentage (57%) knew that they should tilt the head forward.

Angiographic embolization for refractory epistaxis

Objective:To assesstheroleof angiographicembolizationin treatmentof refractoryepistaxis.Methods:The diagnosticandtherapeuticroleof digitalsubtractionangiography(DSA)in13patientswithrefractoryepistaxiswereretro-spectivelystudied.Results:Pseudoaneurysmof carotidarterywasconfirmedin3of the13patientswithrefractoryepis-taxiswithangiography.Selectiveangiographicembolizationwasperformedin12/13patients.Thesuccessratewas91.67%(11/12).Patientsweretolerantto theuseof DSAwithoutseverecomplications.Conclusion:Selectiveangiographicem-bolizationis a safeandeffectivemethodintreatmentof refractoryepistaxis.In caseof traumaticepistaxiswithineffective conservativetreatmentor recurrentepistaxis,preoperativeangiographyshouldbe performedto ruleoutpseudoaneurysmof carotidartery.

Secondary Signs of Surgical Epistaxis Management

Severe epistaxis management remains a challenge to otolaryngologists. Despite the large choice of treatment strategies to control epistaxis, the method of regional haemostasis via edoscopic arterial ligation has become frequently used. Arterial supply occlusion is usually performed by electrocautery or application of titanium clips. After placement of titanium clips, they will remain in place forever and could surprisingly be rediscovered later on CT-scan. Most of otolaryngologists are familiar with this method and are able to identify these clips, however, it could be more difficult for radiologists and other practitioners. In order to draw the attention of other specialists to the existence of this method and to help them correctly interpret such CT-scans, the authors present an example of a case that troubled radiologists. In addition, the authors also discussed the vascular supply of the nasal fossa and methods of severe epistaxis management.

Clinico-Epidemiological Pattern and Treatment of Epistaxis in a Tertiary Hospital in South Western Nigeria

Background/Objectives: Epistaxis is a common presentation and may constitute a major challenge to the parents and the health care givers. This study aimed at determining the clinico-epidemiological pattern, presentation and etiology of epistaxis. Materials and Methods: This prospective study of all patients that presented with epistaxis via the Ear, Nose and Throat department of a tertiary institution in Nigeria. The study was carried out between June 2012 and July 2017. Data were obtained from patients who gave consent by using pre-tested interviewer assisted questionnaire. All the data obtained were analyzed using SPSS version 16.0. Results: The prevalence of epistaxis in this study was 12.2%. The peak age group was 1-10 years with epistaxis prevalence of 36.4%. The male to female ratio was 1.5:1. Anterior epistaxis was more common than posterior epistaxis accounted for 80.1% and 7.4% respectively. Single episode of epistaxis was seen in 78.4% of the patients while recurrent epistaxis occurred in 21.6%. Unilateral epistaxis was 62.5%, bilateral epistaxis was 37.5% while right nasal bleeding accounted for 35.8%. The main local causes of epistaxis were trauma 29.5%, infective rhinosinusitis 18.8% and sinonasal tumours 12.5%. Severe epistaxis requiring blood transfusion was seen in 2.8% of the patients and death was recorded in 2.3%. Majority 110 (62.5%) were managed by observation alone, 20 (11.4%) by conservative therapy and 22 (12.5%) had surgical excision. Blood transfusion was given in 5. The outcome of treatment was good recovery in 79.0% while patients’ satisfaction with treatment was noted in 84.1%. Conclusion: Epistaxis is a common sinonasal presentation with effect on quality of life. In our center commonest site of nose bleeds was local mainly from traumatic, inflammatory and neoplastic aetiology.

Propranolol-Induced Epistaxis in a Woman with Multiple Obstetric Complications: Case Report

Epistaxis is a common complaint which is rarely life-threatening, as most cases are self-limited and as such unreported. However, it may be a significant cause for concern if it becomes recurrent. Although a number of medications including topical antihistamines and non-steroidal anti-inflammatory drugs are known aetiological factors for epistaxis due to their antiplatelet effects, beta blockers are not being widely reported as a possible cause. This report presents the case of a 34-year-old G2P0+1, who was diagnosed with hyperthyroidism in pregnancy and subsequently reported epistaxis twice at different occasion and different hospital settings when propranolol was introduced for her treatment, with resolution of epistaxis after withdrawal of propranolol. The report aims to highlight and sensitize physicians to the possible risk of bleeding in patients placed on beta blockers especially propranolol for a wide range of medical condition due to its thrombocytopathic effect.

Traumatic Middle Meningeal Artery Pseudoaneurysms Presenting with Intractable Epistaxis: A Rare Case Report and Review of Literature

Middle meningeal artery (MMA) pseudoaneurysms are very rare and are most often traumatic. They may present as an epidural or intraparenchymal hematoma. This study reports a rare case in which a patient suffered from intractable epistaxis because of a pseudoaneurysm in middle meningeal artery and skull base fracture after craniocerebra trauma. Pseudoaneurysm and the feeding artery were embolized by using Onyx-18 liquid embolic system. Complete cessation of bleeding was achieved in this case immediately after the endovascular therapies. In this study, clinical manifestation, diagnostic imaging and endovascular treatment are described. Formation mechanisms and the treatment of traumatic pseudoaneurysm of middle meningeal artery are discussed.

Acute onset of massive epistaxis due to post-traumatic cavernous internal carotid artery pseudoaneurysm: A case report

Rationale:Cavernous internal carotid artery(ICA)pseudoaneurysm caused by non-penetrating head trauma is a rare cause of massive epistaxis.The sudden onset of epistaxis due to such a fatal aneurysm protruding into the sphenoid sinus is extremely rare in clinical practice.The management is often challenging because of anatomical inaccessibility of the bleeding point.Patient's concern:A 42-year-old man with a history of head trauma showing an ICA aneurysm eroding the sphenoid sinus followed by massive epistaxis.Diagnosis:A computerized tomography(CT)scan showed a fracture in the sphenoid sinus.CT angiogram revealed cavernous ICA pseudoaneurysm.Interventions:Endovascular coil embolization.Outcomes:The patient recovered well and was discharged without any neurological deficits Lessons:Cavernous ICA pseudoaneurysm may lead to a life-threatening situation.If a patient has a history of head trauma,post-traumatic cavernous ICA pseudoaneurysm should be considered a differential diagnosis of massive epistaxis.

Hereditary hemorrhagic telangiectasia presenting as a recurrent epistaxis in an adolescent:A case report

BACKGROUND Epistaxis can be an isolated finding or a manifestation of a systemic disease.Some of the potential etiologies are usage of anticoagulants,bleeding disorders,vascular aneurysms,nasal neoplasm,hypertension and nasal steroids.Hereditary hemorrhagic telangiectasia(HHT)as a cause of recurrent epistaxis is uncommon.CASE SUMMARY In this report,we describe an 18-year-old adolescent with recurrent epistaxis,mucocutaneous telangiectasia and family history of HHT,consistent with HHT.CONCLUSION Timely diagnosis is needed not only to treat the epistaxis but also to be vigilant for other serious manifestations of this condition.

Laser Treatment of Epistaxis and Oral Bleeding in Hereditary Hemorrhagic Telangiectasia

Background: Hereditary hemorrhagic telangiectasia (HHT) is a relatively common, albeit under-recognized autosomal-dominant multisystemic vascular disorder. Epistaxis due to telangiectases in the nasal mucosa is the most common and often the earliest symptom of HHT. As many as 90% of affected individuals eventually experience recurrent epistaxis, with a mean frequency of 18 episodes per month. Prompted by the limitations of invasive treatment, researchers have directed attention to laser photocoagulation as an alternative nonsurgical treatment modality with promising results. Purpose: The purpose of the present study was to describe our experience with the state-of-the-art 980 nm diode laser for the treatment of bleeding lesions of the skin, nasal and oral mucosa in patients with HHT. Methodology/Principal: We treated 16 HHT patients with intractable bleeding from telangiectasias using the 980-nm diode laser as an office procedure using local anesthesia. We recorded hemoglobin levels before and after treatment and used disability questionnaires. Results: All patients treated had an improvement in hemoglobin levels and disability scores. In patients with multiple lesions hemoglobin levels improved from a mean of 8.4 to 11.2 (p = 0.008). The disability index in this group improved from a mean of 5.3 to 2.8 (p = 0.007). Follow-up ranged between 4 and 12 months. Conclusions: The 980-nm diode laser is a good office based solution for bleeding in HHT.

Analysis of Endoscopic Sphenopalatine Artery Surgery for Refractory Epistaxis

Background: This study aimed to determine the safety and efficacy of sphenopalatine artery (SPA) surgery in patients with refractory epistaxis and to identify factors associated with the indications for surgery to assist clinicians in making prompt and appropriate decisions regarding SPA surgery for refractory epistaxis. Methods: We analyzed 97 consecutive patients with nasal bleeding hospitalized in our institution between April 2009 and March 2018. Clinicopathological characteristics and clinical outcomes were analyzed from retrospective chart reviews. Results: Of the 97 patients, 28 (29 sides) required SPA surgery. There were no differences in sex, anti-coagulant drug or antiplatelet use, hemoglobin concentration, or platelet count between Group A (patients who required surgery) and Group B (patients who did not require surgery). Age (58 vs. 67 years, p = 0.038) and severity of comorbidity (0 vs. 1, p = 0.039) were significantly lower in the surgery group. Patients who were younger and had lower Charlson Comorbidity Index (CCI) scores had more requirements for surgery than those who were older and had higher CCI scores. There was no significant difference between the groups with respect to the proportion of patients receiving blood transfusions;however, the length of hospitalization was significantly longer in Group A than in Group B (8.9 vs. 8 days, p = 0.038). Success rate (non-rebleeding rate) was 89%, comparable to that reported in previous studies. Conclusions: Endoscopic SPA surgery was found safe and effective method with few complications. Younger patients with lower CCI scores were found appropriate for SPA surgery for refractory epistaxis due in part to a lower risk of anesthesia.

The action mechanism of Rhizoma Imperatae for pediatric epistaxis management using a network pharmacology approach

Background:Pediatric epistaxis is one of the most common and frequently occurring diseases,while its pathogenesis is complicated and remains to be fully elucidated.Objective:This work aims to explore the therapeutic effect and action mechanism of Rhizoma Imperatae in the treatment of pediatric epistaxis in a network pharmacology approach and to provide a practical reference for treating epistaxis in children.Methods:The active ingredients of Chinese herb Rhizoma Imperatae were obtained from the TCMSP database,and the targets of chemical compounds were subsequently predicted using the Swisstargetprediction database;the disease targets of epistaxis were exported from the Genecards database;the obtained overlapped genes were applied for protein-protein interaction(PPI)analysis,Gene Ontology(GO)anlysis and KEGG analysis.Results:There were 128 targets of Rhizoma Imperatae were predicted,and 500 disease targets were collected,with 19 overlapped targets between the drug and the disease.The five genes matrix metallopeptidase 9(MMP9),EGFR,JUN,PTGS1,and ESR1 had the most connections based on the PPI analysis.The GO analysis indicated that positive regulation of vascular smooth muscle cell proliferation and positive regulation of smooth muscle cell proliferation were greatly associated with MMP9,EGFR,and JUN genes in biological processes(BP)and positive regulation of lipid kinase activity and nitric-oxide syntheses activity affected EGFR and ESR1 genes mostly in molecular function(MF).Conclusion:The present research results demonstrated that Rhizoma Imperatae might play a role in alleviating pediatric epistaxis using a network pharmacology technique,hoping to figure out its action mechanism of the drug against the disease.

舌下免疫治疗儿童变应性鼻炎伴鼻出血的疗效分析

目的:观察粉尘螨舌下免疫治疗变应性鼻炎所致儿童鼻出血的临床疗效。方法:回顾性分析2022年3月至2024年3月江阴市人民医院接受粉尘螨舌下免疫治疗的35例变应性鼻炎伴鼻出血儿童的相关资料,年龄4~12岁,观察舌下免疫治疗1年后的疗效。对比治疗前后患者鼻部症状改善的评分、药物使用评分及鼻出血症状评分。结果:治疗1年后,35例患儿与治疗前相比,鼻部症状评分(治疗前8.29±1.95;治疗后1.40±2.13)、药物使用评分(治疗前1.37±0.81;治疗后0.09±0.28)及鼻出血症状评分(治疗前4.89±1.95;治疗后0.31±0.90)都显著下降(P<0.001)。35例患儿有31例88.6%鼻出血不再发作,无严重不良反应发生。结论:粉尘螨舌下免疫治疗变应性鼻炎所致儿童鼻出血疗效显著,安全性高。

鼻中隔相关性鼻出血的临床特点和疗效分析

目的探讨鼻中隔相关性鼻出血的有效治疗方法和治疗效果。方法回顾分析本院2019年7月至2022年4月住院治疗的120例鼻出血患者,均经鼻内镜检查明确出血点且与鼻中隔相关,分别用鼻腔填塞(观察组)、电凝止血(对照组)和鼻中隔矫正及电凝止血术(试验组),比较分析三组治疗效果。结果试验组首次止血成功率100%,术后3个月随访无再出血者;对照组首次止血成功率80.95%,8例需再次出血,术后3个月随访再出血率13.51%;观察组首次止血成功率77.42%,7例需再次填塞后止血,术后3个月随访再出血率32.26%。三组比较差异具有统计学意义(P<0.05)。结论鼻中隔相关性鼻出血在全身麻醉鼻内镜下电凝止血联合鼻中隔矫正手术治疗鼻腔出血较单纯电凝止血和鼻腔填塞止血效果更佳,且降低鼻腔填塞物导致患者鼻面部胀痛不适感,且治愈率高,在患者条件允许情况下值得临床推广。

老年患者急性鼻出血内镜下电凝止血列线图预测模型的构建与验证

目的探讨老年患者急性鼻出血,需内镜下电凝止血术治疗的相关危险因素,建立列线图预测模型,并予以验证,以便治疗时能选择恰当的止血方式。方法收集2018年1月-2022年12月该科228例单侧急性鼻出血老年患者的临床资料。根据是否接受内镜下电凝止血术,分为电凝止血组(n=112)和保守填塞组(n=116),探讨内镜下电凝止血术的独立危险因素,建立列线图预测模型,绘制受试者操作特征曲线(ROC curve),使用校正曲线和临床决策曲线分析(DCA),评价模型的预测性能和一致性。结果单因素分析结果显示,年龄、高血压、心脑血管疾病、服用抗凝药物和出血部位与内镜下电凝止血有关(P<0.05);多因素二元Logistic回归分析显示,年龄增大、存在高血压、长期服用抗凝药物,以及出血部位位于后鼻区或位置不明的患者,接受内镜下电凝止血术的可能性更高(P<0.05);基于上述独立危险因素,建立预测老年患者急性鼻出血内镜下电凝止血风险的列线图模型,曲线下面积(AUC)为0.856(95%CI:0.805~0.907)。校正曲线和DCA显示,该列线图干预收益的阈值范围大。结论基于年龄、高血压、服用抗凝药物和出血部位建立的老年患者急性鼻出血内镜下电凝止血的列线图模型,预测能力和区分度好,对临床有一定的指导意义。