Beware of epistaxis: fatal pseudoaneurysm rupture 30 years after treatment of acromegaly.

We present a fatal complication of treatment in a patient with early-onset acromegaly, treated with two transsphenoidal operations, radiotherapy, radiosurgery and pegvisomant. He was diagnosed in his 30s, and controlled from his 40s, with stable residual tumour within the left cavernous sinus. In his 60s, 30 years after surgery/radiotherapy and 14 years after radiosurgery, he developed recurrent episodes of mild epistaxis. A week later, he presented at his local hospital's emergency department with severe epistaxis and altered consciousness. He was diagnosed with a ruptured internal carotid artery (ICA) pseudoaneurysm, but unfortunately died before treatment could be attempted.ICA pseudoaneurysms are rare complications of surgery or radiotherapy and can present with several years of delay, often with epistaxis. This case highlights the importance of life-long monitoring in patients with previous pituitary interventions and early recognition of epistaxis as a herald sign of a potentially catastrophic event, thus leading to timely treatment.

Case report of recurrent epistaxis caused by a live leech in the nasal cavity.

RATIONALE: Epistaxis is one of the common emergencies in otolaryngology. There are many causes of epistaxis, but reports of epistaxis due to nasal foreign bodies like leeches are rare. PATIENT CONCERNS: A 55-year-old male presented with "repeated epistaxis for over 20 days." Nasal endoscopy revealed a live leech in the olfactory area of the left nostril. DIAGNOSES: The patient was diagnosed with epistaxis caused by a live leech in the nasal cavity. INTERVENTIONS: Under nasal endoscopy, the leech was grasped with a vascular clamp and removed from the nasal cavity. The leech measured 8 cm in length. Hemostasis was achieved using a gelatin sponge at the wound site, and the nasal cavity was packed with Vaseline gauze. OUTCOMES: The live leech was removed via nasal endoscopy. Two days later, the Vaseline gauze packing was removed, and the patient experienced no further nasal bleeding. CONCLUSION: Live leeches in the nasal cavity can cause epistaxis. Nasal endoscopic removal of the live leech is an effective treatment. LESSON: There are many causes of epistaxis, which are nonspecific and prone to missed or incorrect diagnosis. In patients with a history of fieldwork or direct contact with leeches who present with recurrent nasal bleeding, the possibility of epistaxis caused by a live leech should be considered, and timely and effective treatment should be provided.

Managing recurrent nosebleeds in children: a retrospective review of 718 children attending a nurse-led epistaxis clinic.

OBJECTIVE: This review assessed the effectiveness of the nurse-led children's epistaxis clinic in streamlining patient care and avoiding unnecessary general anaesthesia. METHODS: A retrospective case note review was conducted of children attending the nurse-led epistaxis clinic between 2019 and 2021. RESULTS: A total of 718 children were seen over three years. Twelve (1.7 per cent) had a known coagulopathy. Of the children, 590 (82 per cent) had visible vessels and 29 (4 per cent) had mucosal crusting. Silver nitrate cautery was attempted under topical anaesthesia in 481 children, with 463 (96 per cent) successful cauterisations. Fifteen (3 per cent) were cauterised under general anaesthesia. Of the children, 706 (99 per cent) were prescribed nasal antiseptic preparations; this was the sole treatment for 58 (8 per cent). Blood investigations were requested for eight children (1 per cent) and haematology referral for three (0.4 per cent). CONCLUSION: This is the largest published series of children's nosebleeds. Given the short-lived benefit from cautery, it is suggested that general anaesthesia should not be offered routinely. However, improved haematology referral criteria are required to increase underlying diagnosis.

Comparing recurrence between cautery techniques in pediatric epistaxis.

OBJECTIVE: To compare the risk of recurrent epistaxis between children treated with silver nitrate (SN) in the office or electrocautery (EC) in the operating room (OR). METHODS: Patients aged 2-18 diagnosed with epistaxis (ICD R04.0) in 2018 and treated with SN or EC were retrospectively reviewed. Epistaxis laterality, history of nasal trauma, and personal or family history of a bleeding disorder were recorded. Patients with prior cautery or epistaxis secondary to a procedure were excluded. Recurrence was defined as initial encounter after cautery with documented epistaxis. Patients were followed up into 2022 to track onset of recurrence. Time to recurrence between SN and EC was compared with hazard curves with predictors for recurrence analyzed via Cox's proportional hazard regression. RESULTS: Among 291 patients cauterized for epistaxis, 62 % (n = 181) received SN compared to 38 % (n = 110) who underwent EC. There was significantly higher risk of recurrence when treated with SN compared to EC (Hazard ratio 2.45, 95 % CI: 1.57-3.82, P < 0.0001). Median time to recurrence was not statistically different between techniques (6.39 months (SN) (IQR: 2.33, 14.82) vs. 4.11 months (EC) (IQR: 1.18, 20.86), P = 0.4154). Complication rates were low for both groups (1.16 % (SN) vs. 0 % (EC), P > 0.05). CONCLUSION: Among patients with epistaxis, risk of recurrence is significantly higher in those cauterized with SN compared to EC. Time to recurrence is not significantly different between cautery techniques.

Environmental impact on pediatric epistaxis and the utility of diagnostic studies: A single-institutional review.

OBJECTIVES: Pediatric epistaxis is a multifactorial disease entity. The objective of this study is to determine the socioeconomic and air-quality contributions to pediatric epistaxis. The study also evaluates the utility of diagnostic lab work as a predictor of bleeding rates and need for operative intervention. METHODS: A case series of pediatric patients treated in an outpatient Otolaryngology clinic at a tertiary care children's hospital in 2021 for epistaxis was performed. Patients with nasal bone trauma (n = 8), consult while inpatient (n = 7), and those with nasal masses (n = 2) were excluded; 181 patients met inclusion criteria. Demographic, clinical, socioeconomic, and air quality (tropospheric ozone, particulate matter) data were recorded. Associations with persistent bleeding and operative interventions were evaluated using logistic regression, Wilcoxon rank-sum, and Spearman rank correlation. RESULTS: Of the 181 patients, 75 (41.4%) were female. Forty-six of 181 (25.4%) had associated allergic symptoms. Twenty-six patients had allergy testing; 14/26 (53.8%) of these had positive results. Re-bleeding was more common in those with allergic symptoms (OR: 2.42, 95% CI: 1.22-4.78, p = 0.01). Patients with re-bleeding lived in counties with more days with ozone over the US standard (median 5 days, range 0-32 days) compared with those with no re-bleeding (median 3 days, range 0-32 days, p = 0.007). There was also an association between the number of visits for re-bleed and percent below poverty level (ρ = 0.259, p = 0.03) as well as the number of days with particulate matter levels over the US standard (ρ = 0.343, p = 0.01). Coagulopathy was present in 9/54 (16.7%) patients, with the majority being Von Willebrand disease (5/54, 9.3%). Easy bruising was not significantly associated with positive lab results. CONCLUSIONS: Environmental pollution, living in a zip code with more residents below the poverty level, and allergic rhinitis were positively associated with recurrent epistaxis. Understanding the geographic background of presenting patients may help direct workup and treatment options.

[Epidemiology and modern methods of treatment of non-traumatic nosebleeds]. / Epidemiologiya i sovremennye metody lecheniya netravmaticheskikh nosovykh krovotechenii.

Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies. OBJECTIVE: To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds. MATERIAL AND METHODS: The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds. RESULTS: The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%. CONCLUSION: The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.

Case 314: Cerebral Proliferative Angiopathy.

HISTORY: An 18-year-old man presented to the neurosurgery outpatient department with recurrent episodes of epistaxis for the past 8 years and altered behavior for the past month. Epistaxis was scanty in amount, intermittent, spontaneous, and not associated with any trauma or nasal obstruction or breathing difficulties. Bleeding used to stop spontaneously after some time. There was no history of associated headache, seizures, vomiting, fever, or loss of consciousness. On physical examination, the patient was afebrile, with normal vital signs and normal Glasgow Coma Scale score (15 of 15) at the time of presentation. Multiple dilated engorged veins were visible on the forehead; however, there was no evidence of abnormal skin pigmentation. Neurologic examination yielded findings that were within normal limits. Laboratory examinations revealed a hemoglobin level of 11 g/dL (normal range, 13.2-16.6 g/dL), with the rest of the parameters within normal limits. This patient underwent unenhanced CT of the brain and paranasal sinuses followed by contrast-enhanced MRI of the brain for further evaluation.

'Juvenile' nasal angiofibroma presenting in adulthood.

Juvenile nasopharyngeal angiofibromas (JNAs) are rare hyper vascular, benign tumours typically demonstrating a locally aggressive growth pattern. The cardinal presenting symptoms are unilateral nasal obstruction and recurrent, spontaneous epistaxis. Cases outside the adolescent male population are exceedingly rare and present a diagnostic challenge. We present the case of a man in his 30s referred to our tertiary skull base centre, presenting with left nasal obstruction. Examination showed left nasopharyngeal fullness without a discrete mass. Cross-sectional imaging detailed a 2.5×2.1×1.3 cm mass localised to his left sphenoid sinus with bony erosion. Due to the suspicion of malignancy, multidisciplinary consensus was to perform a diagnostic excisional biopsy and this revealed a JNA. He remains clinically well and asymptomatic following surgery. This case highlights the potential for subtle symptomatology in the presentation of these tumours and the challenge in diagnosing a JNA outside the adolescent male population.

Frequency of epistaxis and telangiectasia in patients with hereditary hemorrhagic telangiectasia (HHT) in comparison with the general population: Curaçao diagnostic criteria revisited.

PURPOSE: The Curaçao criteria are well-established diagnostic criteria for hereditary hemorrhagic telangiectasia (HHT), but they lack details regarding a predictive presentation of epistaxis and telangiectasias. This study collects and compares data in HHT and population cohorts to inform the application of these criteria. METHODS: In-person interviews regarding epistaxis and targeted examination for telangiectases in a general population cohort (n = 204) and an HHT cohort (n = 432) were conducted. RESULTS: Frequency of epistaxis, rather than intensity or duration, was the best discriminator of HHT. A cutoff of ≥4 nosebleeds per year alone yielded a diagnostic sensitivity of 97%, and specificity of 84%. The mean number of telangiectases at the sites investigated was 0.4 in the general population cohort and 26.5 in the HHT cohort. The most distinctive sites for telangiectases in HHT were lips and palmar fingers, whereas telangiectases of the face and dorsum of the hand were comparable in both cohorts. CONCLUSION: We propose that the Curaçao criteria be modified to include the following cutoffs: (1) epistaxis frequency of ≥4 nosebleeds per year and (2) telangiectasia count of at least 2 in characteristic locations (palmar aspect of fingers, lips, and oral cavity), and that cutaneous telangiectases at other sites not be considered relevant for diagnostic purposes.

Impact of SARS-CoV-2 infection in patients with hereditary hemorrhagic telangiectasia: epidemiological and clinical data from the comprehensive Italian retrospective multicenter study.

Rare Disease patients manifested high concern regarding the possible increased risk of severe outcomes and worsening of disease-specific clinical manifestation due to the impact of COVID-19. Our aim was to assess the prevalence, outcomes, and impact of COVID-19 in patients with a rare disease such as Hereditary Hemorrhagic Telangiectasia (HHT) in Italian population. A nationwide, multicentric, cross-sectional observational study was conducted on patients with HHT from five Italian HHT centers by online survey. The association between COVID-19-related signs and symptoms and nosebleeds worsening, the impact of personal protective equipment on nosebleeds pattern, and the relationship between the presence of visceral AVMs and severe outcomes were analyzed. Out of 605 total survey responses and eligible for analysis, 107 cases of COVID-19 were reported. A mild-course COVID-19 disease, not requiring hospitalization, was observed in 90.7% of patients, while the remaining eight cases needed hospitalization, two of them requiring intensive-care access. No fatal outcome was recorded and 79.3% of patients reported a complete recovery. No difference in infection risk and outcome between HHT patients and general population was evidenced. No significative interference of COVID-19 on HHT-related bleeding was found. The majority of patients received COVID-19 vaccination, with relevant impact on symptoms and need for hospitalization in case of infection. COVID-19 in HHT patients had an infection profile similar to the general population. COVID-19 course and outcome were independent from any specific HHT-related clinical features. Moreover, COVID-19 and anti-SARS-CoV-2 measures did not seem to affect significantly HHT-related bleeding profile.

Providing Evidence for Dogma: Risk of Epistaxis After COVID-19 Nasal-Screening Swab.

OBJECTIVE: There is anecdotal evidence SARS-CoV-2 (COVID) RT-PCR screening nasal swabs confer an elevated epistaxis risk. We aimed to assess the association between epistaxis and exposure to a COVID nasal swab. STUDY DESIGN: A matched pairs design was used. SETTING: The study was performed in a single, integrated health care system. METHODS: All patients who received a single COVID nasal swab at our institution between April 2020 and March 2021 were included. McNemar's test was used to compare rates of epistaxis between the 7 days following the index COVID swab (hazard period), and the 7 days preceding the index COVID swab (control period). Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis. RESULTS: A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis during the hazard period (95% confidence interval [1.73, 2.12]). Older age, Asian/Pacific Islander (PI) (compared to white), male sex, hypertension, prior facial trauma, and warfarin or direct-acting oral anticoagulant use were also associated with significantly increased odds of epistaxis (p ≦ 0.01). CONCLUSION: COVID nasal swabs are associated with increased odds of epistaxis. Physicians should counsel patients, particularly those at the highest risk, including a history of prior facial trauma, anticoagulants/antiplatelets, or hypertension.

Non-Small Cell Lung Cancer Presenting as Anterior Nasal Mass and Epistaxis.

Lung malignancy presentation with an uncommon metastatic site is a diagnostic challenge and often associated with poor prognosis. Nasal cavity is a rare metastatic site for any type of lung cancer. We report an unusual case of poorly differentiated adenosquamous carcinoma of the lung with widespread metastasis presenting as a right vestibular nasal mass with epistaxis. A 76-year-old male patient with chronic obstructive pulmonary disease and 80 pack-year smoking history presented with spontaneous epistaxis. He reported a new rapidly growing right-sided nasal vestibular mass first noticed 2 weeks prior. Physical examination showed fleshy mass with crusting in right nasal vestibule along with a left nasal domus mass. Imaging revealed an ovoid mass in the right anterior nostril and a large mass in the right upper lobe of the lung (RULL) along with thoracic vertebral sclerotic metastasis and large left frontal lobe hemorrhagic lesion with severe vasogenic edema. Positron emission tomography scan showed large right upper lobe mass and suspected to be the primary malignancy along with widespread metastasis. Biopsy of the nasal lesion revealed poorly differentiated non-small cell carcinoma with squamous and glandular features. The diagnosis of very poorly differentiated adenosquamous carcinoma of the lung with widespread metastasis was made. In conclusion, unusual metastatic sites with unknown primary lesions require a thorough diagnostic workup involving biopsy and extensive imaging. Lung cancer with unusual metastatic sites is inherently aggressive and associated with poor prognosis. Multidisciplinary treatment modalities should be employed keeping in view the functional status and comorbidities of the patient.

Case 314.

HISTORY: An 18-year-old man presented to the neurosurgery outpatient department with recurrent episodes of epistaxis for the past 8 years and altered behavior for the past month. Epistaxis was scanty in amount, intermittent, spontaneous, and not associated with any trauma or nasal obstruction or breathing difficulties. Bleeding used to stop spontaneously after some time. There was no history of associated headache, seizures, vomiting, fever, or loss of consciousness. On physical examination, the patient was afebrile, with normal vital signs and normal Glasgow Coma Scale score (15 of 15) at the time of presentation. Multiple dilated engorged veins were visible on the forehead; however, there was no evidence of abnormal skin pigmentation. Neurologic examination yielded findings that were within normal limits. Laboratory examinations revealed a hemoglobin level of 11 g/dL (normal range, 13.2-16.6 g/dL), with the rest of the parameters within normal limits. This patient underwent unenhanced CT of the brain and paranasal sinuses followed by contrast-enhanced MRI of the brain for further evaluation (Figs 1-3).

Nasal leeches and epistaxis: A case series.

Nasal hirudiniasis is uncommon in humans, where a leech invades through the nostrils, adhering to the nasal cavity mucosa. It is rare in urban areas, noted in endemic rural areas, but scarcely documented and, with urbanisation and ecological imbalance has become rarer still. It presents with recurrent epistaxis due to hirudin released by the leech while other symptoms are infinitesimal owing to an analgesic enzyme secreted. A thorough history-taking and examination is of utmost importance as respiratory complications may arise if the leech invades the airways. We present a case series of five patients, within a period of three years.

Differential disease diagnoses of epistaxis based on dynamic uncertain causality graph.

PURPOSE: Epistaxis is a common symptom and can be caused by various diseases, including nasal diseases, systemic diseases, etc. Many misdiagnosis and missed diagnosis of epistaxis are caused by lack of clinical knowledge and experience, especially some interns and the clinicans in primary hospitals. To help inexperienced clinicans improve their diagnostic accuracies of epistaxis, a computer-aided diagnostic system based on Dynamic Uncertain Causality Graph (DUCG) was designed in this study. METHODS: We build a visual epistaxis knowledge base based on medical experts' knowledge and experience. The knowledge base intuitively expresses the causal relationship among diseases, risk factors, symptoms, signs, laboratory checks, and image examinations. The DUCG inference algorithm well addresses the patients' clinical information with the knowledge base to deduce the currently suspected diseases and calculate the probability of each suspected disease. RESULT: The model can differentially diagnose 24 diseases with epistaxis as the chief complaint. A third-party verification was performed, and the total diagnostic precision was 97.81%. In addition, the DUCG-based diagnostic model was applied in Jiaozhou city and Zhongxian county, China, covering hundreds of primary hospitals and clinics. So far, the clinicians using the model have all agreed with the diagnostic results. The 432 real-world application cases show that this model is good for the differential diagnoses of epistaxis. CONCLUSION: The results show that the DUCG-based epistaxis diagnosis model has high diagnostic accuracy. It can assist primary clinicians in completing the differential diagnosis of epistaxis and can be accepted by clinicians.

Not Your Typical Nosebleed: A Case Report and Personal Account of a Patient With Osler-Weber-Rendu Syndrome.

Introduction Osler-Weber-Rendu syndrome, or hereditary hemorrhagic telangiectasia, is a rare genetic disease that causes recurrent epistaxis and anemia. Numerous bleeding vascular malformations can be found throughout the body. Case presentation A 75-year-old woman presented to her hematologist with recurrent epistaxis, iron deficiency anemia, menorrhagia, and hypothyroidism. Her mother had similar nosebleeds, and physical examination revealed small vascular malformations on the conjunctiva, oropharynx, tongue, lip, and palate. Heavy epistaxis occurred several times per week. Multiple nasal and gastrointestinal endoscopic procedures were performed. She received over 100 iron infusions and multiple blood transfusions. Overall treatment involved integrated care with multiple medical specialties. Conclusion Hereditary hemorrhagic telangiectasia and other complex diseases are best treated with a multidisciplinary approach within an integrated health care setting.

[Recurrent epistaxis associated with Randu-Osler disease, requiring ligation of the external carotid arteries on both sides]. / Retsidiviruyushchee nosovoe krovotechenie na fone bolezni Randyu­Oslera, vyzvavshee neobkhodimost' perevyazki naruzhnykh sonnykh arterii s obeikh storon.

A rare clinical case of recurrent nosebleeds associated with Randu-Osler disease, in which drug, hemostatic, transfusion therapy and combined nasal tamponade were ineffective, required ligation of the external carotid arteries on both sides, is presented.

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.