Case Report: Massive epistaxis from juvenile angiofibroma in an adolescent with severe haemophilia A

Jose Florencio F Lapeña,Olivia Agnes D Mejia

doi:10.12688/f1000research.20147.1

Abstract

Epistaxis may be profuse in individuals with normal bleeding parameters, but in an individual with haemophilia, it may be life-threatening. It is even more dangerous when epistaxis is caused by an undetected concomitant juvenile angiofibroma, and only one such case has been reported in the English literature. We report another case, of an 18-year-old Filipino adolescent with severe haemophilia A who was referred for repeated massive epistaxis. The epistaxis had been attributed to his haemophilia and managed with nasal packing, multiple blood transfusions and Factor VIII administration. After two years of unsuccessful management, nasal endoscopy was performed for the first time, revealing an intranasal mass. Imaging showed a right intranasal vascular tumour supplied mainly by the right sphenopalatine artery. He subsequently underwent preoperative embolization and endoscopic excision of the tumour with Factor VIII transfused pre-, intra-, and post-operatively, and recombinant Factor VII added post-operatively. Final histopathology was consistent with juvenile angiofibroma. There has been no nasal obstruction or recurrence of epistaxis seven years since the surgery. Clinicians should be more meticulous in assessing epistaxis in any patient with a bleeding disorder and investigate more subtle symptoms such as nasal obstruction. Verification of the source by direct visualization and ancillary diagnostic techniques (such as imaging) when indicated should be the standard of care for all patients presenting with epistaxis, whether or not a concomitant bleeding disorder exists. A high index of suspicion for juvenile angiofibroma should be maintained in adolescent males with epistaxis and nasal obstruction.

Highlights

Juvenile angiofibroma (JA) is a benign vascular tumour accounting for 0.5% of all head and neck neoplasms1
Contrast-enhanced computed tomography (CT) scans showed a hyperdense right intranasal mass corroborated by preoperative embolization angiography as an intranasal vascular tumour supplied by the right sphenopalatine artery and internal maxillary artery (IMA) (Figure 1A and 1B)
The preliminary diagnosis of JA was confirmed by biopsy at a different medical centre, where massive haemorrhage jeopardized the patient’s life

Summary

Introduction

Juvenile angiofibroma (JA) is a benign vascular tumour accounting for 0.5% of all head and neck neoplasms. Diagnosed with severe haemophilia A at age 16, he initially presented with recurrent right nasal congestion and an episode of predominantly right-sided epistaxis described as sudden and profuse, amounting to 1500 ml At that time, he was admitted to a provincial hospital and received blood and cryoprecipitate transfusions. After two years of such management, nasal endoscopy performed for the first time by a visiting otorhinolaryngologist revealed a right intranasal mass He was referred to our institution and admitted with an impression of JA (Radkowski IA) and severe haemophilia A. Contrast-enhanced computed tomography (CT) scans showed a hyperdense right intranasal mass corroborated by preoperative embolization angiography as an intranasal vascular tumour supplied by the right sphenopalatine artery and internal maxillary artery (IMA) (Figure 1A and 1B).

Discussion

Findings

National ENT Trainee Research Network