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PubMed1994

Traumatic giant aneurysm of the intracavernous internal carotid artery causing fatal epistaxis: case report.

A patient with a giant intracavernous carotid aneurysm usually has symptoms and signs of a space-occupying lesion, producing one of a variety of types of cavernous sinus syndromes. Epistaxis is an unusual feature in these patients. A patient who noted the onset of repeated arterial epistaxis 2 years after a severe head injury was found to have a traumatic aneurysm of the cavernous portion of internal carotid artery. After angiography, he suddenly developed profuse, pulsatile, arterial epistaxis and had a cardiopulmonary arrest. This case and a review of previously reported cases emphasize the importance of early cerebral angiography in patients with posttraumatic recurrent epistaxis.

Adult↗
PubMed1998

Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy.

Posttraumatic pseudoaneurysm of the internal carotid artery (ICA) is an uncommon but potentially fatal cause of epistaxis. Because the onset of delayed bleeding from the time of injury is variable, prompt diagnosis of cavernous ICA pseudoaneurysm is often a clinical challenge. The relative urgency to evaluate for this disease is highlighted by the morbid nature of this entity. Optimal management demands rapid recognition and treatment to give the best functional outcome. The authors present a case series of six patients with skull base ICA pseudoaneurysm. A unifying feature in the majority of patients is the development of delayed, massive epistaxis. The time course for presentation of delayed life-threatening epistaxis ranged from 5 days to 9 weeks. Two patients exhibited the classic triad of unilateral blindness, orbital fractures, and massive epistaxis. All patients requiring intervention were successfully treated with endovascular embolization techniques that included detachable balloons and coils. The clinical and radiologic findings in this case series are presented. The relevant anatomy, diagnosis, and treatment of traumatic ICA pseudoaneurysm are reviewed. A contemporary treatment strategy is proposed.

Adolescent↗
PubMed1983

Severe epistaxis in facial fractures.

The incidence of epistaxis in 312 patients with facial fractures over a 5-year period is reviewed, finding the incidence of epistaxis to be 4 percent in all facial fractures and 11 percent (12 of 108) in midface fractures. Six of these required treatment with packing or transfusion, and two required surgery to control the epistaxis. The only other series reviewing epistaxis in facial fractures reported a similar incidence.

Adult↗
PubMed2006

Pediatric epistaxis.

OBJECTIVES/HYPOTHESIS: Otolaryngologists are frequently consulted for the evaluation and treatment of pediatric epistaxis. There is a lack of consensus as to the optimal approach to this problem. This study evaluated an approach used to evaluate and treat patients referred on an outpatient basis. STUDY DESIGN: Retrospective study. METHODS: Charts from 90 patients referred for the treatment of epistaxis were reviewed. RESULTS: Anemia was identified in 22% of patients. An abnormal coagulation study was identified in 7.8% of patients. Computed tomography (CT) imaging of the sinuses was obtained in nearly 90% of patients and revealed no suspicious masses. Opacification of the sinuses consistent with sinusitis was commonly seen. The majority of cases were resolved by the first follow-up visit with a topical nasal emollient. CONCLUSIONS: The outpatient evaluation of epistaxis should include a screen for anemia and coagulopathy. Routine CT imaging of the sinuses is unhelpful and is not recommended. The majority of cases are easily treated with rehydration of the nasal mucosa. Consideration should be given to rhinosinusitis as a co-existing factor in patients with epistaxis.

Administration, Topical↗
PubMed1995

Idiopathic epistaxis, haemostasis and alcohol.

Recent studies have suggested a link between antiplatelet medications and alcohol in the aetiology of acute adult epistaxis. The possibility that adult epistaxis may be associated with alcohol induced platelet dysfunction has not previously been investigated. This study evaluated primary haemostasis in 50 adult patients with idiopathic epistaxis. A detailed alcohol history was recorded and the Simplate bleeding time device was used to test haemostatic function. Forty-six per cent of patients were found to have an abnormality of primary haemostasis. Prolongation of the bleeding time was significantly associated with a history of alcohol use. The effect of alcohol on the bleeding time duration was significant (P < 0.001) even at low levels of intake of between 1 and 10 units per week. Although prevalent in the study group (42%) the use of non-steroidal anti-inflammatory drugs did not confer a significant additional risk of increased bleeding time. These findings support the importance of alcohol induced haemostatic abnormalities in the aetiology of adult epistaxis.

Adult↗
PubMedDate not supplied

Epistaxis.

Epistaxis is a frequent complaint, and may often cause great anxiety in patients and clinicians. Epistaxis results from the interaction of factors that damage the nasal mucosal lining, affect the vessel walls, or alter the coagulability of the blood, and which may be categorized into environmental, local, systemic and medication related. The knowledge of the first aid treatment of epistaxis is very poor, amongst not only the public, but also health professionals. Immediate emergency department management of epistaxis depends on prioritized assessment and treatment, including resuscitation if necessary, together with the application of relatively simple otolaryngological techniques. There is little high quality evidence regarding routine, alternative or adjunctive treatments.

Adult↗
PubMed1996

First aid treatment of epistaxis--are the patients well informed?

OBJECTIVE: To investigate the level of lay knowledge of first aid measures for epistaxis, and to determine the effectiveness of an ENT department policy of providing an advice sheet of first aid measures. METHODS: 50 patients presenting with epistaxis were questioned on the accuracy and level of their knowledge of the four basic procedures used to combat a nose-bleed. The results were correlated with the source of referral, previous treatment, and advice. RESULTS: A large proportion of patients who had previously been treated for epistaxis by their general practitioners and other non-ENT trained medical or nursing staff were unable to recall being given any first aid advice. For those who remembered being given advice, very few described all the steps correctly. In contrast, patients who had previously been seen by the ENT staff scored full points in every aspect. CONCLUSIONS: The results are a reflection of the departmental policy of supplying information sheets outlining the first aid measures to all patients presenting with epistaxis.

Epistaxis↗
PubMed2005

Look before you pack: key point in epistaxis management.

We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term "epistaxis management ladder" for easy understanding of the treatment of epistaxis.

Epistaxis↗
PubMed2001

Evaluation of the potential causes of epistaxis in dogs with natural visceral leishmaniasis.

Haemostasis was evaluated in 19 dogs with natural Leishmania infection, six of them with a history of epistaxis, and the results were compared with the results from 24 healthy dogs. In addition, the dogs' blood pressure was measured and biopsies were taken from the nasal mucosa. Buccal mucosa bleeding time was prolonged in the dogs with leishmaniasis (P < 0.002) and most significantly in those with epistaxis (P < 0.005). None of the Leishmania-infected dogs had thrombocytopenia, low levels of plasma von Willebrand factor antigen, a prolonged prothrombin time or activated partial thromboplastin time, a low plasma fibrinogen concentration or high serum fibrin degradation products. These results rule out defects of secondary haemostasis or disseminated intravascular coagulation as significant causes of epistaxis in non-complicated leishmaniasis. Histopathology of the nasal mucosa of 10 of the affected dogs, three of them with epistaxis, revealed ulcerative and inflammatory lesions in all of them.

Animals↗
PubMed2001

Endovascular particulate and alcohol embolization for near-fatal epistaxis from a skull base vascular malformation.

A three-year old girl who initially presented at 16 months with epistaxis from an anterior skull base vascular anomaly returned with near-fatal epistaxis despite embolization of the internal maxillary artery at the time of initial presentation. Repeat angiography demonstrated blood supply to the vascular lesion coming from branches of both the external and internal carotid arteries. The patient underwent four sessions of endovascular embolization with polyvinyl alcohol, alcohol, and gelatin microspheres. At the conclusion of treatment, her epistaxis had resolved and the only residual blood supply to the lesions came from bilateral ophthalmic arteries intentionally not sacrificed to prevent loss of vision. Endovascular embolization of both the internal and external carotid arteries is a challenging but important treatment option for life-threatening epistaxis resulting from vascular lesions of the skull base.

Carotid Artery, External↗
PubMed1987

Recurrent life-threatening epistaxis in a child with Bernard-Soulier syndrome controlled by bilateral ligation of external carotids and ethmoidal arteries.

Bilateral ligation of external carotids and ethmoidal arteries proved successful in controlling severe recurring epistaxis in a 13-year-old patient with Bernard-Soulier syndrome. In this child, epistaxis was the major bleeding symptom. Despite massive substitutive therapy, the patient suffered several life-threatening episodes of hypovolaemic shock. Although epistaxis is not reported as a cause of death in patients with haemostasis defect, our case might suggest that in selected cases with inherited platelet defect and intractable epistaxis so severe as to make normal or near-normal life impossible, surgical treatment could be considered.

Adolescent↗
PubMed1995

Use of oxymetazoline in the management of epistaxis.

The purpose of this study was to determine if use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing. The charts of 60 patients who presented to the emergency room with the diagnosis of epistaxis and who required medical management were reviewed. Sixty-five percent of these patients were successfully managed with oxymetazoline as their sole therapy. An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline. In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed. These data suggest that pharmacologic management may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications.

Adult↗
PubMed1990

Drug-induced epistaxis?

To assess the aetiological contribution made to spontaneous epistaxis in adults over the age of 50 years by various groups of drugs, a controlled study was designed. Fifty-three consecutive epistaxis patients were compared with 50 controls. Significant differences were found between the groups in their consumption of warfarin, dipyridamole and non-steroidal anti-inflammatory drugs. Hypertension was equally common in the two groups, but tended to be less well controlled in the epistaxis patients compared to the controls. It is thought that the link between the use of nonsteroidal anti-inflammatory drugs and the occurrence of epistaxis may be due to alteration of platelet function.

Aged↗
PubMed1988

Sleep apnea in epistaxis patients treated with nasal packs.

The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. This study demonstrates that nasal packs used for the treatment of epistaxis may induce obstructive sleep apnea or markedly exacerbate underlying obstructive sleep apnea and, therefore, contribute to the sudden deaths that have been reported in epistaxis patients.

Aged↗
PubMed1991

Control of epistaxis in patients with hereditary hemorrhagic telangiectasia.

Twenty-nine patients were admitted to Pennsylvania Hospital between March 1984 and July 1990 with a diagnosis of epistaxis and hereditary hemorrhagic telangiectasia. Data were obtained through a retrospective review of the charts of these patients. Patients were treated for epistaxis with the CO2 laser, neodymium:aluminum garnet laser with a wavelength of 1064 nm (Nd-Yag), Nd-Yag laser with a wavelength of 532 nm (KTP), septodermoplasty, or any combination of these procedures. Patients underwent an average of 2.5 procedures each. Overall, 25 of 29 patients reported their symptoms had greatly improved with therapy. The average length of time without the need for further surgical intervention was 16.3 months for the Nd-Yag laser and 11.7 months for the KTP laser. Septodermoplasty using buccal mucosal grafts allowed, patients to avoid additional procedures for 24.4 months, which was twice as long as for standard septodermoplasty using split-thickness skin grafts. Although no therapy completely resolves the epistaxis, laser therapy combined with septodermoplasty enables the patients to gain excellent control of the epistaxis for several years.

Adolescent↗
PubMed1994

Angiographic embolization for the treatment of epistaxis: a review of 108 cases.

Ninety-seven patients were referred to the Toronto Hospital (Western Division) between January 1984 and January 1992 for selective angiographic embolization (108 embolizations, including repeat procedures) to control intractable or recurrent severe epistaxis. Eighty-one patients (comprising 94 embolizations) were referred on an emergent basis because of failure of conventional conservative therapy, consisting of anterior and posterior packing. The remaining 16 patients (14 embolizations) were referred electively for recurrent epistaxis. A retrospective review of these cases was performed, with long-term telephone follow-up achieved in over 95% of cases. Embolization safely controlled active hemorrhage in 88% of the emergent cases. The success rate increased to 90% when two cases in which the source of epistaxis was found to be from the internal carotid artery were excluded (because these vessels could not be safely embolized). Of the patients whose epistaxis was initially controlled by embolization, 82% had no further nosebleeds (follow-up time ranged from 2 to 82 months; average, 26.8 months). More than half of the long-term failures were seen in patients with Osler-Weber-Rendu disease. Overall, the mortality rate was 0% and the long-term morbidity rate was 2% (one cerebral vascular accident and one case of skin slough in the territory of the superficial temporal artery.

Adolescent↗
PubMed1998

Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis.

OBJECTIVE: This study examined the advantages and disadvantages of internal maxillary artery (IMA) ligation versus embolization for the treatment of refractory posterior epistaxis. METHODS: Thirty-nine patients underwent 42 procedures for treatment of posterior epistaxis at the University of Cincinnati Medical Center between 1986 and 1994. Complication rates, failure rates, demographics, and the costs of IMA ligation and embolization were compared. A review of 20 studies published between 1973 and 1995 was done to determine the complication and failure rates of IMA ligation and embolization. Finally, a mail survey was used to determine the availability and use of IMA ligation and embolization by urban and rural otolaryngologists in Ohio. RESULTS: Complication and failure rates of IMA ligation and embolization were similar at our institution. In the literature review, IMA ligation had a higher complication rate, but fewer failures. Although the major complication rates were not significantly different, those associated with embolization were often more serious than those associated with IMA ligation. At our institution, the cost of IMA embolization was significantly lower than the cost of IMA ligation. Only 11% of Ohio otolaryngologists in nonurban areas have embolization available to treat posterior epistaxis. CONCLUSION: IMA ligation is more effective than IMA embolization but may be associated with a higher minor complication rate. The major complications that occur with IMA embolization are often more serious. Although IMA embolization was less expensive at our institution, it is unavailable in most nonurban regions in Ohio. Training in the use of IMA ligation for refractory posterior epistaxis should continue in otolaryngology residency training programs despite the increasing availability of embolization at university training centers.

Academic Medical Centers↗
PubMed2000

Endoscopic ligation of anterior ethmoidal artery in treatment of epistaxis.

Arterial ligation of the anterior ethmoidal artery may be required in cases of persistent epistaxis and conventional techniques involving open surgery carry a recognized morbidity. We describe an endoscopic, intranasal technique for ligation of the anterior ethmoidal artery. This technique was performed in a patient who had a severe epistaxis following nasal trauma. Her epistaxis persisted in spite of anterior and posterior nasal packing. Endoscopy showed the bleeding to originate high and lateral to the middle turbinate. Endoscopic exploration defined the frayed end of the anterior ethmoidal artery. A ligaclip was placed with immediate and persistent arrest of her epistaxis. No further nasal packs or treatment were required.

Adult↗