Survival of a Blank Cartridge Gunshot Injury to the Soft Palate in a Soldier.

ABSTRACT: The authors report a case of a soldier who survived after shooting a blank round from a K2 rifle into the oral cavity.For committing suicide, a 22-year-old male soldier shot a K2 rifle into his oral cavity. Because the first shot was a blank fire, he received an injury to his oral cavity, especially to his palate. On arrival hospital via air evacuation, the patient's vital signs were relatively stable and Glasgow Coma Scale score was 15. Profound epistaxis was noted from both nostrils, and his mouth was filled with blood. Intubation was performed immediately, followed by tracheostomy. On computed tomography scan, the palate was injured and laryngeal edema was seen.On operative field, severe swelling of the larynx was observed. Gunpowder remained present throughout nearly the entire palate. His palate was burned, and there was a 3-cm-diameter mucosal defect. The bleeding point was cauterized, and bleeding was controlled using oral packing. The packing was changed every morning for the first 2 days, and finally removed on the third day of hospitalization. On the eighth day of hospitalization, the defect of his soft palate showed healing by secondary intention, and a planned reconstructive operation was not needed. Tracheostomy was removed on the 45th day. He was able to eat and speak at the time of discharge (93rd day).The authors cannot overemphasize the importance of the airway in oral injuries. Packing for bleeding control under a safe airway should be followed as a routine part of the protocol for similar cases.

Severe Delayed Hemorrhage After Cosmetic Rhinoplasty in the Setting of Maxillary Vascular Malformation.

Late epistaxis after rhinoplasty is a rare but potentially life-threatening occurrence. This case report concerns a 20-year-old woman who had severe epistaxis 5 and 10 days after a closed rhinoplasty with internal osteotomies and who ultimately required transcatheter arterial embolization for definitive control of the hemorrhagic source. Arterial hypervascularity, with signs of arteriovenous malformation, of the midface at the level of the piriform aperture and maxilla was seen on angiography.

Prevalence of postoperative secondary bleeding and its relationship with intraoperative massive bleeding in patients undergoing orthognathic surgery.

INTRODUCTION: Postoperative bleeding after orthognathic surgery is a rare but life-threatening complication. Maxillary surgery is the main cause of bleeding, after which excessive epistaxis can occur until the 10th postoperative day. Due to the risk of secondary bleeding, the patient discharge process may be complicated for both the patient and clinician. Thus far, no studies have explored massive intra- and postoperative bleeding in patients undergoing orthognathic surgery. Therefore, this study was performed to determine the prevalence of postoperative secondary bleeding and its correlation with intraoperative massive bleeding in patients undergoing orthognathic surgery. MATERIALS AND METHODS: A total of 206 orthognathic surgery patients were included in this retrospective study. Perioperative data was collected by determining the number of patients who referred to the clinic for treatment of secondary bleeding. The following parameters were recorded: occurrence of intraoperative massive bleeding, pre- and postoperative haemoglobin and haematocrit values, intraoperative projected bleeding, amount of intravenous liquid needed, and length of hospital stay. In addition, the association between secondary and intraoperative massive bleeding was investigated. RESULTS: Two of 206 patients (0.97%) experienced both massive intraoperative bleeding and massive postoperative bleeding. CONCLUSION: Intra- and postoperative massive bleeding occurred only in a small number of patients; thus, longer hospitalisation and strict follow-up of this small group of patients may be required.

Hemorrhagic tonsillitis in an infant: A case report.

This case report describes a case of severe hemorrhagic tonsillitis in a nine month-old child who suffered significant amount of blood loss and was emergently taken to operating room for control of hemorrhage. The child was brought to emergency room by mom after noticing blood around child's mouth and nose and a subsequent episode of hematemesis having awoken from sleep. Initial impression was bleeding secondary to epistaxis however a thorough bedside otolaryngology exam including flexible rhinolaryngoscopy ruled this out. Rapid pooling of blood in oropharynx, continued hemorrhage with significant blood loss and recent history of hematemesis prompted emergent intervention in operating room for endoscopy for control of hemorrhage including esophagogastroduodenoscopy (EGD). Bleeding was identified from a blood vessel at left lower tonsil pole. Although there is a description in literature of such cases, these are uncommon in the pediatric population and none has been described in a patient this young requiring emergent operative intervention. This case report discusses the diagnostic and decision making dilemma in an infant in setting of ongoing active hemorrhage and the role of multidisciplinary team management.

European Reference Network For Rare Vascular Diseases (VASCERN) Outcome Measures For Hereditary Haemorrhagic Telangiectasia (HHT).

Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia that leads to nosebleeds, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT is estimated to affect 85,000 European citizens, but most health care providers have limited prior HHT exposure or training.Outcome Measures were developed and implemented by the HHT Working Group of the European Reference Network for Rare Vascular Diseases (VASCERN), in order to maximise the number of patients receiving good care. The measures specifically target areas where optimal management reduces morbidity and mortality in HHT patients, and were designed to be robust to emerging new evidence. Thresholds are the percentage of patients in particular settings who have been recommended screening, or provided with written advice. The 5 Outcome Measures cover (1) pulmonary AVM screening; (2) written nosebleed advice, (3) assessment of iron deficiency; (4) antibiotic prophylaxis prior to dental and surgical procedures for patients with pulmonary AVMs, and (5) written advice on pregnancy. They are not a blueprint for detailed HHT management, but are suitable for all clinicians to be aware of and implement.In summary, these 5 Outcome Measures provide metrics to identify healthcare providers of good care, and encourage care improvement by all healthcare providers.

A case of epistaxis.

The authors report a case of epistaxis in a 74-year-old male patient. His recent medical history documented recurrent nasal bleeding and a Le Fort 1 osteosynthesis 3 weeks before admission to our unit. A CT scan revealed a left descending palatine artery pseudoaneurysm in the left maxillary sinus that was successfully embolized. Pseudoaneurysms of the internal maxillary artery and its branches are rare life-threatening complications. This diagnosis should be considered when confronted to recurrent head and neck bleeding, especially in a context of recent maxillo-facial trauma or surgery. Embolization should rapidly be implemented.

Pediatric ear, nose, and throat emergencies.

Acute otitis media is the most common infection for which antibiotics are prescribed in children, resulting in more than 20 million antibiotic prescriptions annually. New practice guidelines published by the American Academy of Pediatrics and the American Academy of Family Physicians call for the judicious use of antibiotics in view of increasing antibiotic resistance and the unclear necessity of the use of antibiotics in children with uncomplicated acute otitis media. This article reviews those guidelines, several other common ear, nose, and throat entities, including sinusitis and dental emergencies, and current strategies in diagnosis and treatment.

Clinical features of epistaxis in dogs: a retrospective study of 35 cases (1999-2002).

Epistaxis was retrospectively evaluated in 35 dogs. Systemic disease was diagnosed in seven dogs and intranasal disease in 29. Nineteen dogs with intranasal disease had neoplasia. Dogs with neoplasia were older (mean 10.0 years) than dogs with nonneoplastic intranasal disease (mean 5.6 years). Signs persisting for >1 month occurred more often in dogs with intranasal than systemic disease. Unilateral epistaxis did not distinguish intranasal from systemic disease. Only dogs with intranasal disease had facial deformity, decreased airflow, or regional sub-mandibular lymphadenopathy. Dogs with systemic disease had a lower packed cell volume (mean 31.8%) than dogs with intranasal disease (mean 42.7%).

Nasal mucosal headache presenting as orofacial pain: a review of the literature and a case report.

Headaches are a significant component of many facial pain syndromes. These facial pain/headache syndromes often have various etiologies, including neurologic, vascular, musculoskeletal, or combinations of vascular/musculoskeletal origins. Referred rhinologic headache, however, can be overlooked as a cause of facial pain in the dental literature. We report a case of nasal mucosal headache that presented as facial pain and include a review of the literature.

A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy.

An audit of the local practice of sphenopalatine artery (SPA) ligation/diathermy was undertaken following its introduction to the unit in April 1998. The authors looked to the literature for evidence of what was to be taken as a successful result and were surprised at the lack of published data on its efficacy or lack thereof. Fivehundredsixtythree patients were admitted for inpatient management of epistaxis over a two-year period. Ten of these patients required surgical control of epistaxis and went on to have either sphenopalatine artery ligation or diathermy. One had concomitant anterior ethmoidal artery diathermy. Postoperatively, the patients stayed between one to ten days (mean 3.3 days). The mean follow up in the clinic was 42.7 days. A recurrent bleed rate of 33% was found, which is higher than previously published results. Of these failures one had internal maxillary embolization followed by anterior ethmoidal artery ligation. The other two failures were successfully corrected with anterior ethmoidal ligation. The authors discuss and illustrate the possible reasons for failure.

Otolaryngologic manifestations of pregnancy.

A unique group of ear, nose, and throat disorders are associated with pregnancy. While most are benign and reverse after parturition, some do not. These disorders may be classified categorically by site into cutaneous, otologic, rhinologic, oral, pharyngeal, and laryngeal manifestations. The etiology and pathogenesis of these disorders are discussed, making every attempt to separate fact from conjecture. Therapeutic recommendations are made based on available information.

Recurrent epistaxis caused by an intranasal supernumerary tooth in a young adult.

PATIENT: Male, 27. FINAL DIAGNOSIS: Recurrent epistaxis. SYMPTOMS: Nasal bleeding. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: Pediatrics and Neonatology. OBJECTIVE: Congenital defects/diseases. BACKGROUND: Recurrent epistaxis is a common disorder among children and young adults. We report an unusual cause, intranasal supernumerary tooth causing friction with Little's area of the nasal septum. CASE REPORT: A 22-year-old male presented with recurrent, mild, unilateral left-sided epistaxis once to twice per month for 3 years. This usually occurred after minor nasal trauma or rubbing his nose. The patient also suffered from recurrent tonsillitis. There was neither history of blood transfusion or nasal packing, nor a history suggestive of bleeding diathesis. Anterior rhinoscopy revealed ivory white nasal mass antero-inferiorly in the left nasal cavity touching Little's area. There was no bleeding. Nasal endoscopy showed a white cylindrical bony mass 1 cm long arising from the floor of the nose, with no attachment to the nasal septum or the lateral wall of the nose. Examination of the right nasal cavity was unremarkable. CONCLUSIONS: Nasal teeth result from the ectopic eruption of supernumerary teeth and may cause a variety of symptoms including recurrent epistaxis. Their clinical and radiologic presentation is so characteristic that their diagnosis is not difficult. CT scan is helpful in planning management. Early extraction prevents further complications and prevents further attacks of epistaxis.

Endoscopic embolization with onyx prior to resection of JNA: a new approach.

OBJECTIVE: To report a novel pioneering approach of endoscopic embolization (EE) and resection of juvenile nasopharyngeal angiofibroma (JNA) and describe all outcomes and results. METHODS: Four patients presented to the University of Miami with repeated episodes of unilateral epistaxis diagnosed by fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNA's under fluoroscopic and endoscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and post-operative results are reported and compared to published literature. RESULTS: A total of 4 patients (all males), had EE of JNA and subsequent endoscopic resection between September 2008 and January 2009. Average EBL during surgery was 412.5 ml (range 150-800) with an average operating room time of 228 min (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week post-operatively. No other complications were encountered. CONCLUSIONS: This is the first published report of direct endoscopic embolization of JNA with Onyx. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile.

Unusual presentation of 42 foreign bodies in a child's maxilla.

The diagnosis of foreign bodies (such as radiolucent bristles) in the maxillary sinus, particularly in a child, is difficult. We report an unusual case of a 9-year-old boy who presented with 42 bristles in his left maxillary sinus. The presence of these foreign bodies was noted only during operation for removal of nasal polyps. All the foreign bodies were removed at the same operation. The route of entry of the foreign bodies was found to be a rare self-inflicted oroantral fistula in the interdental region of the upper premolar and molar teeth.

A rare unilateral case of ocular mucous membrane pemphigoid.

PURPOSE: Ocular mucous membrane pemphigoid (MMP) is known to be rapidly progressive in younger patients and affects both eyes. We are aware of only one other reported case of unilateral ocular MMP. The case presented in this study is unique in that it demonstrates genuinely unilateral ocular MMP in a younger patient. METHODS: We report a case of a 50-year-old man who presented with a 3-month history of left eye redness, irritation, and mild discharge. He also suffered from mouth ulcers, skin lesions, and recurrent nose bleeds secondary to nasal mucosal lesions. RESULTS: Examination revealed unilateral lid granulomas and cicatricial conjunctivitis in his left eye. There were no abnormal findings in his right eye. Biopsy of the lesions showed nonspecific inflammation with positive immunofluorescence for immunoglobulin G and C3 on epithelial basement membranes of conjunctiva, buccal mucosa, and skin, which were consistent with MMP. He was treated with immunosuppression and had no disease progression at 12-month follow-up. CONCLUSIONS: This represents a rare case of unilateral nonprogressive ocular MMP in a younger patient. Histological analysis and immunofluorescence testing excluded a neoplastic process and confirmed the diagnosis. This case demonstrates that the presentation of unilateral eyelid pyogenic granulomas should include ocular MMP in the differential diagnosis once a neoplastic process has been excluded.