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.

One Case of Primary Thrombocythemia with Concealed Hypokalemia Complicated by Acute Myocardial Infarction

Medical history summary: Male, 47 years old, was admitted to the hospital due to “dizziness accompanied by chest tightness and pain for more than 8 days”. One week ago, the patient experienced chest tightness, chest pain accompanied by profuse sweating for 3 hours and underwent emergency percutaneous coronary intervention (PCI) at a local hospital. The procedure revealed left main stem occlusion with subsequent left main stem to left anterior descending artery percutaneous transluminal coronary angioplasty (PTCA). After the procedure, the patient experienced hemodynamic instability, recurrent ventricular fibrillation, and critical condition, thus transferred to our hospital for further treatment. Symptoms and signs: The patient is in a comatose state, unresponsive to stimuli, with bilateral dilated pupils measuring 2.0 mm, exhibiting reduced sensitivity to light reflex, and recurrent fever. Coarse breath sounds can be heard in both lungs, with audible moist rales. Irregular breathing pattern is observed, and heart sounds vary in intensity. No pathological murmurs are auscultated in any valve auscultation area. Diagnostic methods: Coronary angiography results at the local hospital showed complete occlusion of the left main stem, and left main stem to left anterior descending artery percutaneous transluminal coronary angioplasty (PTCA) was performed. However, the distal guidewire did not pass through. After admission, blood tests showed a Troponin T level of 1.44 ng/ml and a Myoglobin level of 312 ng/ml. The platelet count was 1390 × 109/L. Von Willebrand factor (vWF) activity was measured at 201.9%. Bone marrow aspiration biopsy showed active bone marrow proliferation and platelet clustering. The peripheral blood smear also showed platelet clustering. JAK-2 gene testing was positive, confirming the diagnosis of primary thrombocytosis. Treatment methods: The patient is assisted with mechanical ventilation and intra-aortic balloon counterpulsation to improve coronary blood flow. Electrolyte levels are closely monitored, especially maintaining plasma potassium levels between 4.0 and 4.5 mmol/l. Hydroxyurea 500 mg is administered for platelet reduction. Anticoagulants and antiplatelet agents are used rationally to prevent further infarction or bleeding. Antiarrhythmic, lipid-lowering, gastroprotective, hepatoprotective, and heart failure treatment are also provided. Clinical outcome: The family members chose to withdraw treatment and signed for discharge due to a combination of reasons, including economic constraints and uncertainty about the prognosis due to the long disease course. Acute myocardial infarction has gradually become one of the leading causes of death in our country. As a “green channel” disease, corresponding diagnostic and treatment protocols have been established in China, and significant progress has been made in emergency care. There are strict regulations for the time taken from the catheterization lab to the cardiac intensive care unit, and standardized treatments are provided to patients once they enter the intensive care unit. Research results show that the incidence of acute myocardial infarction in patients with primary thrombocythemia within 10 years is 9.4%. This type of disease is rare and difficult to cure, posing significant challenges to medical and nursing professionals. In order to benefit future patients, we have documented individual cases of treatment and nursing care for these patients. The research results show that these patients exhibit resistance to traditional oral anticoagulant drugs and require alternative anticoagulants. Additionally, there are significant differences in serum and plasma potassium levels among patients. Therefore, when making clinical diagnoses, it is necessary to carefully distinguish between the two. Particularly, nursing personnel should possess dialectical thinking when supplementing potassium levels in patients in order to reduce the incidence of malignant arrhythmias and mortality rates.

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.

Reawakened Sexual Interest: The Result of Surgical Correction of Concealed Penis

Concealed penis (CP) is a developmental anomaly in which the penis is hidden in the skin of the abdomen, thigh or scrotum. As a result of this, the penis appears shortened in length. It was first described by Keyes Jr. E.L. in 1919. It can be associated with voiding problem and in adults, sexual issues, among others. Objective: To show that surgery can reverse celibacy induced by CP and highlight the need for an interdisciplinary approach to correction of this anomaly. Patient and Method: A thirty-one-year male patient who had a surgical release of his buried penis by two surgeons in 2019 in a private hospital. The case note was reviewed, the data obtained analyzed and the results including photographs, were presented. The patient was followed up. Result: A 10 cm length of penis and a hundred percent (100%) take of sheet of split skin graft used to resurface the denuded penis were achieved using combined spinal and epidural anesthesia. The patient, his mother and the surgeons were satisfied with the outcome. Consequently, he resolved to marry a wife after all. Conclusion: Concealed penis can now be regarded as a known cause of celibacy and surgical correction can reverse the celibate state.

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).METHODS:This observational single center study included all consecutive patients with ESLD and epistaxis identified from consecutive subjects hospitalized with suspected UGIH and prospectively enrolled in our databases of severe UGIH between 1998 and 2011.RESULTS:A total of 1249 patients were registered for severe UGIH in the data basis,461(36.9%) were cirrhotics. Epistaxis rather than UGIH was the bleeding source in 20 patients. All patients had severe coagulopathy. Epistaxis was initially controlled in all cases. Fifteen(75%) subjects required posterior nasal packing and 2(10%) embolization in addition to correction of coagulopathy. Five(25%) patients died in the hospital,12(60%) received orthotopic liver transplantation(OLT),and 3(15%) were discharged without OLT. The mortality rate was 63% in patients without OLT.CONCLUSION:Severe epistaxis in patients with ESLD is(1) a diagnosis of exclusion that requires upper endoscopy to exclude severe UGIH;and(2) associated with a high mortality rate in patients not receiving OLT.

Identification of the Concealed Structures in the Beiya Area of Western Yunnan

The interpretation of regional gravity and magnetic data, especially the extracted information about concealed targets and structures, provide important evidence for geological structure research, oil-gas resource assessment, mineral potential forecast and prospective area delineation. Several interpretation methods have been proposed to determine structural boundary, including vertical derivative, horizontal first-order derivative, total horizontal derivative, total gradient modulus, tilt derivative, and theta graph, and each have their advantages and disadvantages. This study used the tilt derivate method to obtain bouguer gravity anomalies in the Beya area, as shown in Fig. 1a.

Application of Tectono Geochemical Study in Deep Concealed Ore Body Exploration--As the Huize Super-Large Lead-Zinc Deposit an exemple

1 Geological Background of Minerlization or Geologic Setting The northeast of Yunnan1 Pb-Zn-Ag-Ge polymetallic ore district is an important part of the southwestern margin of the Yangtze block Sichuan-Yunnan-Guizhou

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.

Fuzzy Comprehensive Appraisal of Concealed Ore Deposits

In this paper, the transformation from the fuzzy to the accurate process is exemplified by the Jiaodong gold ore deposits concentrated region where the mathematical analysis is used to appraise and forecast regional concealed gold ore deposits. In this sense, this paper presents a new way to the appraisal of the non traditional mineral resources.

The Analysis Method of Time Reversal for Defect Diagnosis of Concealed Structure

本文基于结构声波检测技术及走时反演理论，提出了一种用于隐蔽结构缺陷诊断的走时反演分析方法，建立了联合高差异步测试的波速结构走时反演递推公式．该方法可以对隐蔽结构的波速结构进行网格化反演重建，实现了隐蔽结构的二维波速诊断．并以模型试验进行了验证．

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.

Metallogenic Prediction of the Peripheral Areas of the Xiyi Concealed Lead-Zinc Deposit in Baoshan City, Yunnan Province

The newly-discovered Xiyi lead-zinc deposit is a large deposit located in the north central Baoshan block of the southern Sanjiang metallogenic belt section, Southwest China.The surface of the deposit is mainly covered by eluvial-deluvial lateritic layer, without any mineralized outcrops. The main concealed orebody V3 is buffed in the depth of 300-500m. The orebodies are controlled by certain stratigraphic horizons, and most are cut by strata with a high angle, while a few occur along the strata. The direct wall rocks are calcisiltite, calclithite, bioclastic calcarenite,