Management of severe epistaxis after Young's procedure: a case report

Abstract

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder affecting multiple organ systems, with epistaxis being the most common manifestation. Multiple procedures have been used for the management of epistaxis in the setting of HHT, including closure of the anterior nares via a Young's procedure. While this procedure results in loss of smell and permanent nasal obstruction, proponents note significant improvement in patient symptomatology. Case report. A 70-year-old female with a history of HHT presented to an outside hospital with bleeding into the nasopharynx 2 months after undergoing a modified Young's procedure at an unaffiliated institution. She was transfused with 2 units of packed red blood cells (PRBCs) and transferred to our facility. Due to persistent epistaxis and need for airway protection, the patient was intubated and her throat was packed. She also developed aspiration pneumonia and hypotensive shock requiring vasopressors. Twenty-four hours following bilateral internal maxillary and sphenopalatine artery embolization, she developed significant epistaxis requiring reversal of the Young's procedure on the left and placement of an anterior-posterior pack at the bedside. Upon packing removal several days later in the operating room, she was noted to have significant bleeding that necessitated reversal of the Young's procedure on the right side to obtain adequate exposure and hemostasis. We report a case of significant, life-threatening epistaxis following a modified Young's procedure that requiring multiple transfusions, bilateral embolization, and ultimately reversal of the Young's procedure for control of epistaxis. Although recognized as a potential complication, to our knowledge this is the first report in the English literature of such a case.