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PubMed2004

Post-transplant lymphoproliferative disorder presenting as epistaxis.

An unusual case of epistaxis resulting from post-transplant lymphoproliferative disorder is described. A 30-year-old woman who had undergone renal transplantation 12 years previously presented with profuse, posterior, unilateral epistaxis. The initial findings, workup and treatment are presented. A post-nasal space (PNS) mass was detected and biopsy showed this to be an Epstein-Barr virus-positive polymorphous B-cell post-transplant lymphoproliferative disorder. Computed tomography findings showed a polypoid lesion protruding from the sphenoethmoidal recess and filling the left PNS. Post-transplant lymphoproliferative disorder is well known to involve tonsil tissue. Commonly, this is the first presentation of the disease in children. However, until now post-transplant lymphoproliferative disorder has not been described in the PNS or nasal cavity presenting as epistaxis. We conclude that all transplant patients presenting with epistaxis should be followed up for an accurate examination of the PNS and nasal cavity after the acute episode.

Adult↗

PubMed1987

Embolization of epistaxis and juvenile nasopharyngeal angiofibromas.

This article reviews arterial embolization of epistaxis and juvenile nasopharyngeal angiofibromas. A protocol for the complete and rapid exploration of epistaxis is suggested that is based upon which arteries providing blood to the nasal fossa may be responsible for the bleeding and the most optimal way for their demonstration and evaluation. The relevant anatomy of the major arteries, their branches, and important anastomoses are described. The goals of embolization are to control severe or recurrent epistaxis, prevent recurrence if possible, and avoid occlusion of any vessels not responsible for the hemorrhage. The most appropriate embolic material is chosen, realizing that recurrence can be caused by the use of resorbable embolic material or by a very proximal or too complete embolization. Embolization may be used for specific causes of epistaxis including idiopathic, hereditary hemorraghic telangiectasia, hemorrhagic tumors, vascular malformations, trauma, disorders of hemostasis, and postsurgical problems. Juvenile nasopharyngeal angiofibromas are discussed with respect to their clinical presentation, classification, computed tomographic, MR imaging, and angiographic evaluation, treatment, future trends in treatment, and precautions and complications.

Adolescent↗

PubMedDate not supplied

Endoscopic sphenopalatine artery ligation is an effective method of treatment for posterior epistaxis.

Transantral ligation of the internal maxillary artery is the most widely used surgical technique for control of intractable epistaxis. Although this technique is highly efficacious, significant complications may occur, including oroantral fistula, damage to the infraorbital nerve, and recurrent bleeding. An endoscopic transnasal approach for ligation of the terminal branch of the internal maxillary artery, the sphenopalatine artery, provides an alternative to transantral ligation. We have used endoscopic ligation of the sphenopalatine artery to treat 38 patients requiring surgical therapy for epistaxis. These cases were retrospectively reviewed to analyze the efficacy and morbidity of our technique. Five patients (13%) had significant recurrence of their epistaxis, of whom two required further surgical intervention. There were no major complications in this series. There were some minor sequelae including nasal crusting (34%) and paresthesia of the palate and nose (13%). The median hospital stay was 3 days (range 1 to 10). Endoscopic transnasal sphenopalatine artery ligation seems to be a safe and effective technique for management of posterior epistaxis.

Aged↗

PubMed2004

[A statistical analysis of epistaxis between outpatients and inpatients].

Although we found several statistical studies on epistaxis, we found no reports discussing clinical differences in nasal bleeding between outpatients and inpatients. We therefore examined 103 inpatients (1998-2001) and 337 outpatients (2001) with epistaxis for gender, age, season, bleeding points, and blood pressure. We then compared these parameters statistically in both groups using Mann-Whitney's U test. The incidence of epistaxis in inpatients was statistically higher in winter than in any other season, and most had uncontrolled borderline hypertension. We concluded that borderline hypertension worsens in winter and that patients with borderline hypertension should be medicated to prevent severe epistaxis.

Adolescent↗

PubMed1998

Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation.

BACKGROUND: Many complications were reported to be related with nasotracheal intubation. Various chemical or mechanical techniques have been proposed to decrease hemorrhage and trauma associated with nasotracheal intubation but the results remain controversial. We conducted a prospective, randomized, single-blind study to elucidate the effect of an endotracheal tube softened with warm water before use on the incidence and severity of epistaxis following nasotracheal intubation. METHODS: Sixty-two healthy, (ASA class I or II) patients scheduled for elective surgery were randomly assigned into two groups. Patients in the treatment group were intubated with a softened endotracheal tube made possible by heating it in warm water while those in the control group were intubated with unsoftened (intact) tube. Epistaxis was evaluated immediately after intubation and its severity was graded as none, mild, moderate and severe. The use of Magill forceps and postoperative nasal morbidity were also recorded. RESULTS: The total incidence of epistaxis in the "unsoftened" group was significantly higher than that of "softened" group (76.7% vs. 43.8%, P = 0.0002). The severity of nasal hemorrhage was also significantly lightened in the "softened" group. No technical difficulty was encountered in intubation with a softened endotracheal tube by prewarming. The morbidity referable to nasal intubation, however, did not differ in both groups. CONCLUSIONS: In conclusion, our study shows that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during the act of nasotracheal intubation. It is an effective way and worth a try.

Adolescent↗

PubMed1999

Non-traumatic aneurysms of the cavernous sinus causing massive epistaxis--report of three cases.

Three cases of non-traumatic intracavernous aneurysms that gave rise to massive epistaxis and required operative intervention, are reported. This is a rare but serious cause of epistaxis, because delayed diagnosis and management can lead to repeated bleedings and even to death. It is important, therefore, to diagnose the source of epistaxis and treat it as soon as possible. In our three patients, an emergency angiography enabled us to diagnose an aneurysm in the cavernous sinus. These aneurysms were located in the C3 or C4 portion of the internal carotid artery and were 3-5 mm in diameter. The projections of these aneurysms were infero-medial, antero-inferior, and lateral, respectively. All three patients underwent emergent surgery. Neck clipping of the aneurysm was performed in two patients, and gradual occlusion of the internal carotid artery in the third patient. Emergency surgery successfully prevented further episodes of epistaxis in all three patients.

Aneurysm↗

PubMed2000

[Indications for selective arterial embolization in the treatment of epistaxis].

After posterior packing has failed, the treatment of choice for severe, recurrent posterior epistaxis is arterial ligature, usually through a transantral approach to the Internal Maxillary artery (LTA) or selective percutaneous embolization (EP). The advantages and disadvantages of each technique are discussed by various Authors. A critical review of the literature brings to light the discrepancies between the results of various studies: in a series by Strong et al. and in a review of the literature EP proved more effective than LTA (90-94% vs. 85-89%). On the contrary, using personal data Cullen and Tami reported that the results are analogous. As regards complications, these proved slightly more frequent, but minor, with LTA while the rare complications with EP were more serious. The per-patient costs fundamentally depend on the type of hospital management and the availability of a treatment center; the results of the various studies are not analogous in this regard. The specific indications for the choice of which technique to use include: LTA: ethmoid artery hemorrhage, severe arteriosclerosis of the carotid compartment and allergy to the contrast medium; EP: cardiovascular instability, severe anemia and all conditions which are contraindications for general anesthesia. In the cases studied by the Authors, of the total 203 patients admitted to hospital for posterior epistaxis between May 1995 and November 1999, 12 (5.9%; on the average 2.6 pt/yr) showed values lower than those found at other Centers. A total of 13 EP procedures were performed and the result was positive (stopping the hemorrhage) in 11 (91.7%). In one post-traumatic case there was a recurrence which could not be controlled by EP and thus the Authors resorted to surgical ligature. All the patients underwent fibroscopy after the posterior packing was removed and before establishing the indications for EP. A full 50% of the patients treated showed arterial hypertension and in all patients except the one with multiple traumas, the pre-embolization angiography showed the presence of submucosal teleangiectasia in the site of the epistaxis. This report supports the hypothesis that, in the presence of triggering factors (hypertension, pregnancy), untreatable epistaxis is sustained by a submucosal vascular malformation. On the other hand, it also asserts that although the patient evaluation to determine the EP treatment was less invasive than that used in other Centers, it was able to identify the patients with this malformation, thus validating the clinical criteria used.

Adult↗

PubMed2000

[Epistaxis: emergency treatment approach].

After a brief summary of the causes of severe epistaxis and the surgical choices available for treatment, the authors present their own cases study. Starting from a brief description of the anatomy involved in the system of arterial irrigation of the nasal cavities, they focus on two fundamental concepts: the basis for a proper topographic picture of the site of bleeding and the success of surgery. First and foremost is the emergence of two arterial branches from the sphenopalatine formen; this differs from what is asserted in the classical treatise on anatomy and in line with what has been stated in the Nomina Anatomica, approved during the X World Congress on Anatomy (Tokyo 1975). Secondly, focus is placed on the existence of two important anastomotic systems in the arterial circulation of the nasal cavities: the one between nasal septum and anterior-posterior ethmoid arteries and the one between the lateral-posterior nasal and nasoseptal arteries. In the literature the failure of surgery in treating severe epistaxis is explained by the onset of supplementary anastomotic circulation. The indications for surgical treatment of epixstaxes are: copious bleeding in hospital or after the packing has been removed; underlying pathology or general status which has been aggravated by the packing; patient which has already been staunched several times. The results of 31 epistaxis procedures are presented: 8 (25.81%) upper and 23 (74.19%) posterior. The upper epistaxes were treated as follows: 3 cases with anterior ethmoid ligature, two of which failed; 2 cases with combined ligature of the anterior and posterior ethmoid; 3 cases of successful septoplasty. The posterior epistaxes were treated as follows: 11 cases of ligature of the lateral-posterior nasal artery, 2 of which failed; 12 cases of successful combined ligature of lateral-posterior nasal and nasoseptal arteries. These results confirm that it is possible to effectively resolve surgically severe epistaxis using microsurgery or transnasal endoscopy based on in depth knowledge of the complex architecture of the arterial circulation within the district of the paranasal sinuses, possible anatomic variations and collateral circulation.

Adult↗

PubMed2002

Management pitfalls in the use of embolization for the treatment of severe epistaxis.

Angiographic embolization for the treatment of severe recurrent epistaxis was added to the traditional treatment options--nasal packing, cauterization, and surgical vessel ligation--in 1974. Since then, clinical experience has shown that this procedure is safe and effective. When epistaxis cannot be controlled with cautery, nasal packing is the most common next step. As such, it is often performed by emergency physicians and other clinicians who are not otolaryngologists. We report two cases in which intranasal neoplasms were obscured as a result of a significant distortion of the normal anatomy. This distortion was secondary to emergency-room treatment of severe epistaxis by repeated nasal packing followed by angiographic embolization. Pre-embolization angiographic studies and subsequent postembolization endoscopic evaluations did not reveal the presence of the occult neoplasms because of the presence of inflammation and edema after treatment. Clinicians should be aware that nasal packing and embolization can obscure the underlying source of epistaxis, and follow-up radiologic studies and endoscopic evaluations are essential to avoid delays in diagnosis.

Adult↗

PubMed2002

Fibrin glue treatment for epistaxis.

Our study was made to prove the second-generation surgical fibrin sealant Quixil to be an effective substitute for nasal packing, chemical coagulation and cautery in management of patients with epistaxis. Our series includes 204 patients with anterior epistaxis (186), and with posterior epistaxis (18) as results of trauma, clotting disorders, chronic and/or atrophic rhinitis and upper respiratory infections, and hypertension. Patients were randomly divided into four groups: with fibrin glue (67) (Quixil), with electric cautery (61), with silver nitrate coagulation (60), and with foam nasal packing (16). For the fibrin glue group, hemostasis was achieved by spraying with 0.3 ml Quixil fibrin glue to each bleeding nostril. The results were excellent in all of the 62 (92.5%) patients of the fibrin glue group with complete and immediate hemostasis. We found good healing of bleeding sites, no swelling and secondary bleeding, no inflammation, no plaque or crists. Three months monitoring of atrophic changes of the nasal mucosa proved absence of atrophy of the nasal mucosa. In this group, the bleeding time averaged 2 min 30 sec since the moment of admittance. In the groups where cautery, coagulation, or nasal packing was used, we found local swelling, pain, and slow healing of the bleeding site with accidental atrophy of the nasal mucosa. The rates of these side effects were significantly higher in comparison with the fibrin glue group. The bleeding time was also longer. We found that the fibrin glue is more effective hemostatic in comparison with foam nasal packing, cautery and coagulation, and provides no complications usual for these types of treatment of epistaxis.

Adolescent↗

PubMed2002

Management of epistaxis in general practice.

BACKGROUND: The vast majority of cases of epistaxis can be managed successfully within general practice. OBJECTIVE: To describe a range of clinical interventions in the management of epistaxis appropriate to general practice. DISCUSSION: A number of relatively simple treatments and procedures may provide relief for anterior nasal bleeding, which is the site for over 80% of cases of epistaxis. Where more procedural interventions are necessary, adequate preparation and appropriate tools are required to perform these processes safely. Initial identification of the site of bleeding before commencement of treatment may be difficult but allows the correct treatment to be applied with minimal discomfort to the patient. More copious bleeding which constitutes less than 5-10% of cases, is usually the result of posterior nasal bleeding and is best treated in a facility well set up to handle such an eventuality. In cases of chronic epistaxis, a number of interventions, medical and surgical have been trialled with variable success, and should be used with caution in general practice.

Anesthesia↗

PubMed1975

The frequency of epistaxis in a male population sample.

In a population sample consisting of 507 males aged between 50 and 60 years and 120 thirty-year-old sons of these males the frequency of epistaxis and predisposing factors of epistaxis were studied. Only one-third of the subjects had never had epistaxis. One out of ten subjects had been treated for epistaxis by a doctor at least once in his life. About 3 per cent had had nose-bleeds during the previous week. Statistically it was shown that a history of upper respiratory infection and intake of acetylsalicylic acid separately might predispose to expistaxis.

Adult↗

PubMed2003

The value of coagulation profiles in epistaxis management.

A prospective pilot study was conducted to investigate the role and relevance of clotting profiles in the management of epistaxis patients. Forty-eight per cent of the study patients had abnormal clotting profiles. Half of the abnormal clotting profiles could have been predicted from a routine history, but half could not. The coagulation screens on this group were repeated and 5% of the initial study group were found to have a persistent abnormality. The authors suggest that although coagulation screens will not predict the potential management problems associated with the epistaxis patient, they remain an important part of the clinical investigation. An epistaxis may be the only indication of an underlying coagulation disorder. The diagnosis of such a disorder following an epistaxis may lead to the treatment of an otherwise unknown condition and prevention of more serious sequelae.

Adult↗

PubMed2005

Management of epistaxis.

Family physicians frequently encounter patients with epistaxis (nasal bleeding). In rare cases, this condition may lead to massive bleeding and even death. Although epistaxis can have an anterior or posterior source, it most often originates in the anterior nasal cavity. A directed history and physical examination generally determine the cause of the bleeding. Both local and systemic processes can play a role in epistaxis. Nasal bleeding usually responds to first-aid measures such as compression. When epistaxis does not respond to simple measures, the source of the bleeding should be located and treated appropriately. Treatments to be considered include topical vasoconstriction, chemical cautery, electrocautery, nasal packing (nasal tampon or gauze impregnated with petroleum jelly), posterior gauze packing, use of a balloon system (including a modified Foley catheter), and arterial ligation or embolization. Topical or systemic antibiotics should be used in selected patients. Hospital admission should be considered for patients with significant comorbid conditions or complications of blood loss. Referral to an otolaryngologist is appropriate when bleeding is refractory, complications are present, or specialized treatment (balloon placement, arterial ligation, angiographic arterial embolization) is required.

Embolization, Therapeutic↗

PubMedDate not supplied

Economic analysis of the treatment of posterior epistaxis.

BACKGROUND: The aim of this study was to compare the economic impact of controlling posterior epistaxis by transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular embolization. METHODS: We conducted a retrospective chart review of patients undergoing treatment of posterior epistaxis by either TESPAL or embolization. International Classification of Diseases 9 code 784.7 (epistaxis) was the initial screen followed by common procedural terminology codes for TESPAL and angiography with embolization. The total charges and direct costs for TESPAL and endovascular embolization were determined. An unpaired Student's t-test was used to evaluate statistical significance. RESULTS: Analysis revealed 25 patients that met inclusion criteria. The mean total charge was $14,088 for embolization and $7561 for TESPAL. The differences were statistically significant (p < 0.00006). Costs, defined as reimbursement by third-party payers and direct payments, varied widely and their difference did not reach statistical significance in this sample. CONCLUSION: Our data established no economic advantage for angiography and, in fact, show a trend toward this treatment being more expensive than TESPAL. TESPAL is a procedure that can be performed quickly and on an outpatient basis without the need for angiography equipment or expertise. Additionally, the procedure provides the advantage of a comprehensive endoscopic nasal evaluation for ruling out tumors or other intranasal lesions. With equal efficacy, at least equal costs and equal risk, and additional diagnostic advantages, TESPAL is a more rational treatment for posterior epistaxis.

Adolescent↗

PubMed2006

Epistaxis and its management: an observational pilot study carried out in 23 hospital centres in France.

OBJECTIVE: The purpose of this study is to describe the treatment of epistaxis in hospital emergency departments and to identify the principal risk factors for more severe episodes of bleeding. STUDY PROTOCOL: Prospective cross-sectional epidemiological study MATERIAL AND METHODS: This study was carried out in 23 hospital centres in France, most of them teaching hospitals. Every patient presenting non-traumatic epistaxis or else associated with hereditary hemangioma during two consecutive and separate 24-hour periods were included. RESULTS: Fifty patients were included in the study. Nasal bleeding was stopped within 30 minutes for 47 patients. Fourteen patients were hospitalized. The risk factors for severe epistaxis included either copious bleeding or else bleeding for more than 6 hours or patients aged 65 and over. A history of repeated nasal packing and/or taking medication with a known hemorrhagic risk was associated with the amount and duration of bleeding (p < 0.05). CONCLUSION: Risk factors for severe epistaxis should be identified as to improve patient care and avoid treatment failure or useless hospitalization.

Aged↗

PubMed1991

Transantral ligation of the maxillary artery for refractory epistaxis. A case report.

A case of severe arterial epistaxis treated by transantral ligation of the maxillary artery is reported. A 66-year-old woman had recurrent left sided epistaxis from the posterior nasal cavity which was difficult to control by conventional nasal packing methods. Selective angiography was performed to identify the arterial flow patterns and site of bleeding which was confirmed to be the descending palatine artery. Following radiographical examination, ligation and clipping of the maxillary artery and its branches was performed with transantral approach under general anesthesia. No further epistaxis occurred after the ligation. This surgical procedure seems to be relatively simple and highly effective in the management of refractory epistaxis.

Aged↗

PubMed1989

[Epistaxis caused by leeches].

Among the conditions which can cause epistaxis are intranasal or nasopharyngeal foreign bodies. A living foreign body, or parasite, in the nose or nasopharynx is rare in western countries, but in other parts of the world is a fairly common cause of epistaxis. In the past 5 years 17 cases of epistaxis due to infestation with leeches were treated in our 2 departments. In 14 patients, 9-27 years old, the complaint was of recurrent episodes of mild epistaxis and blood-spitting several days before admission. 3 patients were admitted hemorrhaging profusely from the nose and mouth. Examination showed a green-brown mass protruding from the nasopharynx behind the soft palate, which is every case was a blood-engorged leech. Treatment consisted of removing the leech by applying a forceps to the middle of the leech's body and giving a quick pull. Bleeding ceased immediately after removal of the leech. All the patients had drunk water from brooks, streams or fresh water lakes. Therefore, in areas in which leeches are present only boiled or filtered water should be drunk.

Adolescent↗