Persistent Epistaxis Research Articles

Surgical management of intractable epistaxis:Endoscopic sphenopalatine artery coagulation

<b>Introduction:</b> Epistaxis is one of the most common challenges for emergency departments. Hypertension is regarded as a risk factor of epistaxis. Anticoagulant therapy in hypertensive patients increases the risk of nosebleed even more. Approximately 10% of patients with epistaxis require hospital admission for this condition, some of which need surgical intervention. Management can be problematic, mainly in case of recurrent posterior epistaxis. Over the past decade, with the widespread popularization of endoscopic sinus surgery and the deeper understanding of local regional anatomy, endoscopic control of the sphenopalatine artery (SPA) has been advocated as an effective alternative for the control of posterior epistaxis.</br></br> <b>Aim:</b> The aim of this article is to familiarize the reader with local anatomy and surgical technique of SPA ligation/coagulation.</br></br> <b>Material and method:</b> The SPA ligation or coagulation is indicated for intractable epistaxis, which is defined as recurrent bleeding despite adequate anterior and posterior nasal packing. The sphenopalatine artery (SPA) is a terminal branch of the internal maxillary artery, which is a branch of the external carotid artery. The SPA supplies the turbinates, the lateral nasal wall and nasal septum. The most important anatomical landmark enabling to identify the artery at its entry to the nasal cavity is crista ethmoidalis, which is typically located above the sphenopalatine foramen. The artery can be localized with or without creating the middle antrostomy. Locating the SPA without opening of the maxillary sinus can be challenging for inexperienced surgeon. The middle-meatal antrostomy prior to SPA ligation reveals more anatomical landmarks. Efficacy of SPA coagulation/ligation ranges between 74 to 100%. Failure to localize all the branches of the SPA is regarded as the most common reason for re-bleeding. Complications of the procedure are rare, mild and transient.</br></br> <b>Conclusion:</b> Endoscopic sphenopalatine artery coagulation or ligation is a safe and effective technique for controlling persistent posterior epistaxis. Understanding the anatomic relationships is important in performing this procedure. It has become established standard treatment for intractable epistaxis.

361: PROFOUND EPISTAXIS IN CYTOKINE RELEASE SYNDROME FOLLOWING CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY

Introduction: Chimeric antigen receptor T-cells (CAR-T) represent a promising immunotherapeutic approach in the treatment of refractory malignancies, but carry the risk of unique inflammatory toxicities including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). In moderate to severe cases, these toxicities necessitate intensive care unit (ICU) admission for aggressive support and management. Description: A 63-year-old male with a history of pulmonary embolism, prostate cancer with resection and relapsed/refractory IgG-κ multiple myeloma (diagnosed 4 years earlier and status-post multiple chemotherapy regimens) was admitted for conditioning chemotherapy and CAR-T cell infusion. 1 day post-infusion on the ward, he developed CRS and ICANS, with fever and altered mental status, for which he received tocilizumab, dexamethasone, and anakinra, in addition to empiric antibiotics. He progressed with worsening hypotension and encephalopathy and was admitted to the ICU and required vasopressors, pulse-dose steroids, and siltuximab. A nasal swab was performed to rule out COVID-19, following which he developed persistent epistaxis, requiring packing and, after aspiration of blood, intubation for airway protection. Laboratory data showed anemia and thrombocytopenia, prolonged PT and aPTT, low fibrinogen, and elevated levels of ferritin of 44,124 mg/mL, D-Dimer of 1.35 µg/mL, interleukin-6 of 8,595 pg/mL, interleukin-10 of 1,042 pg/mL, tumor necrosis factor-α of 103 pg/mL, and interferon-γ above 244 pg/mL. The patient received numerous red cell and platelet transfusions, aminocaproic acid, cryoprecipitate, and additional packing and thrombin application by ENT before his epistaxis was controlled. Ultimately, he was weaned from vasopressors, extubated after two weeks and transferred out of the ICU, discharged to rehabilitation, and later home. Discussion: Severe CRS can be associated with hemophagocytic lymphohistiocytosis and disseminated intravascular coagulation (DIC), which can lead to life-threatening bleeding as demonstrated in our patient. Effective and timely treatment of bleeding associated with DIC and severe CRS can be life-saving. It behooves the intensivist to recognize the toxicities of CAR-T as therapeutic applications broaden in the coming years.

Cases from a Community Hospital… JCHIMP Series #1: 55-Year-Old Male with Acute PE Who Developed Persistent Epistaxis.

This is the first in a new series of case reports that will present real scenarios from our community hospital. The cases are chosen to highlight clinical dilemmas and offer review and perspective on what is currently known about the topic.We present the case of a 55-year-old Caucasian male who presented to the emergency department of our community hospital for worsening dyspnea. Evaluation in the Emergency department revealed a diagnosis of extensive pulmonary emboli in the pulmonary vasculature. The patient was admitted to the ICU. A clinical decision was made to initiate treatment with low-dose tissue plasminogen activator (tpa) followed by intravenous heparin infusion. Several hours later the patient developed significant epistaxis. A decision was made to stop the heparin infusion. Later that day, the patient had abrupt clinical deterioration with subsequent cardiac arrest and did not recover. We discuss the classification and treatment of acute pulmonary embolism, the management of epistaxis in an anticoagulated patient, and the clinical conundrum of balancing active bleeding in patient requiring anticoagulation.

Hereditary Haemorrhagic Telangiectasia of Nasal Mucosa- A Case Report

Hereditary Haemorrhagic Telangiectasia (HHT) is also known as Osler-Weber-Rendu syndrome is a development disorder of blood vessels. It is characterised by multiple telangiectases and Arteriovenous Malformations (AVMS) that cause direct connections between arteries and veins bypassing intermediate capillaries. The most prominent sites for telangiectasia are the lips, tongue, face, mucosa of the nose, oral cavity, and gastrointestinal tract. Telangiectases can rupture and bleed easily due to their thin walls, narrow tortuous courses, and proximity to the skin's surface or a mucous membrane. Depending on the organ affected, these symptoms include repeated persistent epistaxis, skin lesions, haemoptysis, gastrointestinal haemorrhage, and stroke. Complications of HHT include bleeding, anaemia, followed by stroke, pulmonary AVM, Transient Ischaemic Attack (TIA), hypovolemic shock due to severe intractable bleed, eventually leading to high output failure. Present case is of a 45-year-old female who presented with complaints of recurrent epistaxis. Diagnostic nasal endoscopy showed multiple telengiectasic spots which were cauterised with trichloroacetic acid. However recurrent episodes of bleed were encountered.

Geriatric epistaxis: Management of epistaxis in the geriatric patient group

OBJECTIVE: In this study, given the recent increases in the geriatric population and the consequent impacts on healthcare services, we examined the characteristics of geriatric patients admitted to the emergency department due to epistaxis. METHODS: This retrospective study included 55 patients (33 males, 22 females; mean age: 72±6.8 years; range, 65 to 93 years) with epistaxis admitted to the Cukurova University Emergency Medicine Department and University of Health Sciences Adana City Training and Research Hospital Otolaryngology Emergency Polyclinic between 01.05.2019-01.04.2020. The patients were divided into two groups according to age: Group 1 consisted of patients aged 65 to 75 years; Group 2 consisted of patients over 75. Postoperative bleeding and trauma history were excluded in all patients in the study. RESULTS: There were no significant differences between the two groups regarding the rate of hospital discharge (p=1.00). Patients with posterior hemorrhage and posterior nasal tampons required significantly more hospitalizations (p<0.001). CONCLUSION: The presence of comorbidities and drug use may cause persistent and recurrent epistaxis. It is necessary for physicians to be more cautious about the use of off-label antiaggregants and anticoagulants.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial

Epistaxis is a common emergency department (ED) presentation and, if simple first aid measures fail, can lead to a need for anterior nasal packing. Tranexamic acid is an agent that contributes to blood clot stability. The aim of this study is to investigate the effectiveness of topical intranasal tranexamic acid in adult patients presenting to the ED with persistent epistaxis, and whether it reduces the need for anterior nasal packing. From May 5, 2017, to March 31, 2019, a double-blind, placebo-controlled, multicenter, 1:1, randomized controlled trial was conducted across 26 EDs in the United Kingdom. Participants with spontaneous epistaxis, persisting after simple first aid and the application of a topical vasoconstrictor, were randomly allocated to receive topical tranexamic acid or placebo. The primary outcome was the need for anterior nasal packing of any kind during the index ED attendance. Secondary outcome measures included hospital admission, need for blood transfusion, recurrent epistaxis, and any thrombotic events requiring any hospital reattendance within 1 week. The study sample consisted of 496 participants with spontaneous epistaxis, persisting after simple first aid and application of a topical vasoconstrictor. In total, 211 participants (42.5%) received anterior nasal packing during the index ED attendance, including 111 of 254 (43.7%) in the tranexamic acid group versus 100 of 242 (41.3%) in the placebo group. The difference was not statistically significant (odds ratio 1.107; 95% confidence interval 0.769 to 1.594; P=.59). Furthermore, there were no statistically significant differences between tranexamic acid and placebo for any of the secondary outcome measures. In patients presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures, topical tranexamic acid applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing.

Epistaxis caused by nasal septum angioleiomyoma

BACKGROUND: Angioleiomyoma is an uncommon, benign tumour originating from vascular smooth muscle. Occurrence in the nasal cavity, especially the nasal septum, is rare with only 16 cases of nasal septal angioleiomyoma reported thus far. We present a new case of nasal septal angioleiomyoma. CASE PRESENTATION: 52-year-old female presented with a three-week history of persistent epistaxis and nasal obstruction. Physical examination revealed a right sided nasal mass originating from the septum. The tumour was endoscopically excised and sent for pathological evaluation which revealed the diagnosis of angioleiomyoma. The patient was followed for six months postoperati- vely and showed no evidence of lesion recurrence. CONCLUSIONS: Because nasal cavity angioleiomyoma recurrence has been reported due to incomplete tumour resection, wide marginal excision is necessary for successful treatment. There have been no cases of malignant transformation of nasal angiolei- omyomas; however, malignant transformation at other sites has been reported. For these reasons, it is important to adequately biopsy and remove angioleiomyoma lesions.

O02 Persistent non-fulminant COVID-19 infection in a GPA patient on rituximab

Case report - IntroductionBased on initial clinical data, it was suggested that patients with vasculitis who were immunosuppressed, would have a more severe COVID-19 infection. Here we present a case of a young 26-year old lady with granulomatosis with polyangiitis (GPA) on rituximab who developed COVID-19 infection while on active GPA treatment. Her COVID-19 infection confirmed on PCR serology, has been protracted but non-fulminant. She did not require mechanical respiratory support. At the same time her GPA remained active and worsened requiring further immunosuppression after she developed mild pulmonary haemorrhage. She is currently still receiving vasculitis treatment.Case report - Case descriptionA 26-year-old lady with a background history of obstructive sleep apnoea and fibromyalgia was diagnosed with ENT-limited GPA in 2017. She was initially treated with azathioprine then methotrexate, and later switched to Rituximab in 2018 after she developed organ-threatening manifestations with bilateral hearing loss. She was stable on periodic infusions of rituximab at 6 to 9-monthly intervals and did not develop other organ-threatening features.She had been given one dose of rituximab for a flare of her GPA. In between rituximab doses, she was admitted with acute COVID-19 infection with related pneumonia and treated with antibiotics, fluids, and oxygen. Shortly after discharge, she was readmitted with worsening symptoms of non-resolving COVID-19 pneumonia which was evident on chest x-ray and levofloxacin treatment was initiated. Her condition improved and she was discharged. No mechanical respiratory support was required. She had her 2nd dose of rituximab after it had been delayed by about 2 weeks. She had been afebrile after the acute COVID-19 infection and her persistent positive results were explained as related viral shedding over a period of 8 weeks.One week later, she represented to hospital with fever, cough and shortness of breath, and her blood results showed a remarkable rise in inflammatory markers, including a CRP of 242. She was treated for non-resolving COVID-19 pneumonitis with worsening chest x-ray features. After hospital discharge, her GPA continued to flare with persistent epistaxis with nasal crusting. She also had worsening inflammatory arthritis with purpuric rash on her legs. An ENT review confirmed nasal septum perforation, but no renal involvement was found. Additional cyclophosphamide was commenced via the day-case unit. Her SARS-CoV-2 serology was negative prior to commencing cyclophosphamide. She is now SARS-CoV-2 positive after two doses of cyclophosphamide, but she is afebrile and stable.Case report – DiscussionCOVID-19 infection carries a high mortality rate in patients with multiple co-morbidities, but recent literature suggests that patients on immunosuppressants may not actually have fulminant COVID-19 disease. This case illustrates the challenges of treating active vasculitis in the context of ongoing COVID-19 infection. Her vasculitis remained active requiring escalation of immunosuppression with caution, while she was concomitantly fighting SARS-CoV-2 and superadded bacterial infection. A similar case has been published by Guilpain et al of a 52-year-old woman with PR3-ANCA vasculitis on maintenance therapy with rituximab and low-dose prednisone who developed COVID-19 infection. They reported milder evolution of COVID-19 infection in comparison with previous reports.It is now well known that some disease-modifying anti-rheumatic drugs (DMARDs) such as tocilizumab, hydroxychloroquine and tofacitinib could suppress the cytokine profile seen in severe COVID-19 infection. In addition, several case reports have even reported possible protective effect of immunosuppressants against severe complications of COVID-19 in patients with rheumatological and non-rheumatological conditions. Another complexity in this case was monitoring the disease progression, since both COVID-19 and GPA can have similar findings on chest CT scan of ground glass opacity. In order to better understand the role of immunosuppressants in rheumatological patients with COVID-19 infection, more data is required, currently European League Against Rheumatism (EULAR) is collecting data to monitor and report outcomes of COVID-19 in adult and paediatric population, this will provide invaluable insight for Rheumatologists. Case report - Key learning points This case poses a challenge for Rheumatologists in managing a patient with active vasculitis and concomitant COVID-19 infection due to limited data available literature. It has also stressed the importance of working in a multidisciplinary team when managing such complex patients. Importance of continuous surveillance of patients receiving immunosuppressive therapy is advised due to possible increased risk to SARS-CoV-2.

TRIGEMINAL-CARDIAC REFLEX: A COMMON BUT UNRECOGNIZED PRESENTATION AMONG PATIENTS WITH EPISTAXIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Trigeminal-cardiac reflex (TCR), is a neurocardiogenic reflex which can produce sudden onset hemodynamic instability. We describe a case of TCR which was observed in a patient presenting with recurrent epistaxis. CASE PRESENTATION: A 71-year-old gentleman with a past medical history of hypertension and metastatic prostate cancer was admitted to the hospital with a chief complaint of persistent epistaxis. As conventional epistaxis management was unsuccessful, he underwent right-sided sphenoidal artery embolization followed by Foley catheter balloon packing. That night, he abruptly developed hemodynamic instability with a drop in his BP from 150/98 to 83/50mmHg, together with a rapid reduction in his HR by 25%. The patient was afebrile, awake, alert, and following commands. He was immediately started on empiric antibiotic therapy and received gentle fluid boluses. Workup for sepsis and cardiopulmonary etiologies of the hemodynamic changes, including complete blood count, comprehensive metabolic panel, blood cultures, chest imaging, and electrocardiogram, were obtained and were negative. His vitals rapidly returned to the baseline with conservative measures. However, within the next hour, the patient was noted to have another transient episode of a sudden drop in BP and HR. The septic and cardiopulmonary workup remained negative. On further chart review, the patient had reported pulling on the Foley packing due to irritation prior to the onset of the episodes. Therefore, the TCR reflex, induced when the patient applied traction on the Foley catheter, was the likely cause of these transient episodes of hemodynamic instability. The nasal packing was not immediately removed due to the high risk of rebleed. Continuous hemodynamic monitoring was maintained while the patient was advised to avoid manipulation of the packing. Once he became stable, the packing was removed, following which the episodes never recurred. DISCUSSION: Epistaxis is one of the most common causes of ER visits in the United States. TCR is defined as an acute reduction in heart rate and mean arterial blood pressure by more than 20% compared to the baseline and is usually triggered with manipulation near the trigeminal nerve endings [1]. In the case of our patient, there was a definite temporal relationship between the episodes of hemodynamic instability and the traction applied on nasal packing, which likely stimulated the nerve and activated TCR [2]. CONCLUSIONS: Although the clinical course of most epistaxis cases is benign, under-diagnosis of this unique brain stem reflex has resulted in severe consequences including patient death [2]. Therefore, trigeminal-cardiac reflex should be included as one of the differentials of acute hemodynamic instability in patients with nasal packing. Reference #1: Schaller BJ, Filis A, Buchfelder M. Trigemino-cardiac reflex in humans initiated by peripheral stimulation during neurosurgical skull-base operations. Its first description. Acta Neurochir (Wien). 2008;150(7):715-718. doi:10.1007/s00701-008-1602-1 Reference #2: Awasthi D, Roy TM, Byrd RP Jr. Epistaxis and Death by the Trigeminocardiac Reflex: A Cautionary Report. Fed Pract. 2015;32(6):45-49. DISCLOSURES: No relevant relationships by Suganya Chandramohan, source=Web Response No relevant relationships by Graciela Rojas, source=Web Response No relevant relationships by Joseph Sebastian, source=Web Response No relevant relationships by Josee Smith, source=Web Response

Relapse of Plasmablastic Lymphoma With Cutaneous Involvement in an Immunocompetent Male.

Plasmablastic lymphoma (PBL) is a rare type of non-Hodgkin lymphoma frequently found in the context of immunosuppression and infection with human immunodeficiency virus (HIV) and/or Epstein-Barr virus (EBV). A 33-year-old immunocompetent male presented with recurrent episodes of epistaxis and a growing intranasal mass. Excisional biopsy of the mass revealed an immunohistochemical profile diagnostic of PBL. Upon completion of chemoradiation, he underwent a transnasal endoscopic mucosal flap tissue rearrangement to restore patency for both functional and surveillance purposes. There was no endoscopic evidence of residual or recurrent disease. However, 8 months later, he was found to have a relapse involving the skin. The nasal cavity is one of the most common sites affected by PBL. Involvement of the nasal cavity may present with symptoms of persistent epistaxis accompanied by an enlarging mass. A plasmablastic immunophenotype in combination with HIV or EBV positivity can aid diagnosis.

Safety of Intranasal Steroids: an Updated Perspective.

Intranasal corticosteroid sprays have been available as over-the-counter (OTC) medications since 2013. As such, clinicians need to be up-to-date with the risks and the safety of INS, as patients may have concerns and detailed questions. The following is a review of the recent medical literature regarding the safety profile, adverse reactions, and special populations using INS. The latest research on intranasal steroid sprays (INS) continue to confirm that INS rarely have significant local side effects, such as severe and persistent epistaxis. Recent studies looking at systemic side effects such as hypothalamic pituitary axis suppression, growth effects, and ocular effects do not indicate any new concerns nor have found significant differences from the past literature. The use of combination INS and topical antihistamine medications did not reveal any new safety issues. Use of INS with topical decongestants found some limited effects of tachyphylaxis and rebound congestion. Studies continue to support the use of newer INS for children and continued monitoring of growth in this population. The HIV population should avoid use of INS with the prescription of ritonavir, given demonstration of adrenal suppression. This updated perspective has found that newer generation INS should be used at the lowest effective dose for the selected population, that clinicians can inform patients using the OTC INS preparations that there are very few safety concerns, and that regular follow-up visits can provide further reassurance with physical examinations and address patient's questions. Future research regarding the safety of INS should study newer preparations when developed and if used in combination with other topical agents.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience.

Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15years in a single academic center. A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL). The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients. This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

Day-Case Admission for External Dacryocystorhinostomy in Preschool Children.

Epistaxis during or after dacryocystorhinostomy may present a risk of circulatory compromise, particularly in young children. In view of this concern, we reviewed the outcome and complications of external dacryocystorhinostomy in preschool children, aged less than 4½ years. Retrospective noncomparative series. A case-note review for a series of preschool children undergoing external dacryocystorhinostomy as a day-case admission at Moorfields Eye Hospital between 1992 and 2018; all surgery was consultant-led. Details were taken of the type of surgery, any intraoperative or postoperative complications (surgical or anesthetic), any unplanned admissions after surgery, and the functional outcome. To assess the veracity of the medical records, the parents for a sample of 67 children were contacted to check whether there had been any unrecorded events or concerns. Anesthetic or surgical complications, unplanned admissions, and postoperative events. One-hundred and eighty-seven children (117 boys; 63%) underwent 228 external dacryocystorhinostomies during 201 admissions, the average admission age being 36.8 months (median, 37.5; range, 5.5-53.5 months). Forty-one children (20%) underwent bilateral dacryocystorhinostomy: the 27 having simultaneous bilateral surgery dacryocystorhinostomy were operated at a mean age of 38.2 months (median, 37.5; range, 15.5-53.5 months), this being significantly different from the average age at first operation in 14 children undergoing sequential admission for bilateral dacryocystorhinostomy (mean, 24.9 months; median, 27.0; range, 5.5-42.5) (p = 0.0023). No adverse anesthetic events were recorded, 2 children (2 dacryocystorhinostomies) required temporary nasal packing at the end of surgery for epistaxis, and one further child was admitted for overnight observation because of persistent mild epistaxis after bilateral dacryocystorhinostomy. Three children (3 dacryocystorhinostomies) had a mild, self-limiting secondary epistaxis, and there were no unplanned emergency admissions. The telephone survey did not reveal any disparity in the medical records. With experienced surgeons and anesthetists in a suitable specialist hospital, external dacryocystorhinostomy in preschool children would appear to be a safe and effective procedure, with few and minor complications. Although facilities for overnight observation should be available, the surgery can typically be planned as a day-case admission, and simultaneous bilateral surgery is also possible in this age-group.

Novel use of tranexamic acid to reduce the need for Nasal Packing in Epistaxis (NoPac) randomised controlled trial: research protocol

IntroductionPatients presenting to emergency departments (EDs) with epistaxis uncontrolled by subsequent simple first aid measures or application of topical vasoconstrictors will typically undergo anterior nasal packing. Packing is effective, but...

Endoscopic Transsphenoidal Salvage Surgery for Symptomatic Residual Cystic Craniopharyngioma after Radiotherapy.

Objectives Ideal treatment of craniopharyngiomas is still controversial. Radiotherapy (RT) is considered effective for recurrences or after subtotal tumor removal (STR). About 40 to 50% of patients may experience tumor cyst expansion soon after RT; in these cases, the role of salvage surgery is debated. Design Operative video. Setting Tertiary care center. Participants An 11-year-old boy diagnosed with persistent craniopharyngioma. In 2015, the patient underwent right frontotemporal craniotomy for STR at another center, complicated by panhypopituitarism. Two years later, fractionated 54-Gy RT was performed on growing residual tumor. After 3 months, he was admitted to our hospital due to persistent malaise, vomiting, pulsating headache, and epistaxis. Ophthalmologic evaluation evidenced left homonymous hemianopsia. Results A contrast-enhanced magnetic resonance imaging (MRI) showed a 27-mm cystic component enlarging from the cranial end of the persistent craniopharyngioma lesion, extending into the third ventricle. Biventricular hydrocephalus and brain midline shift to the right were present. Compared with the early post-RT MRI, the cystic component of the tumor demonstrated growth. The patient underwent external ventricular drainage placement for emergent treatment of hydrocephalus and endoscopic transsphenoidal surgery. After cystic content drainage, the lesion was completely removed with its capsule. A “gasket seal” technique was performed for skull base reconstruction, with autologous fascia lata, septal bone, and mucoperiosteum from inferior turbinate. Histologic examination confirmed the craniopharyngioma diagnosis. Postoperative MRI showed resolution of the hydrocephalus and complete tumor removal. Conclusion Although shrinkage of cystic components of craniopharyngioma residuals may occur within 5 to 6 months after RT, salvage surgery is indicated in symptomatic patients. The link to the video can be found at https://youtu.be/4x6Qe76bf60 .

Current Approaches to Epistaxis Treatment in Primary and Secondary Care.

The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment. This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience. There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk. The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.

Management of Persistent Epistaxis Using Floseal Hemostatic Matrix vs. traditional nasal packing: a prospective randomized control trial

BackgroundEpistaxis is the most common emergent consultation to otolaryngology-head & neck surgery (OHNS) and with 60% of the population having experienced an episode and 1.6 in 10,000 requiring hospitalization in their lifetime. In preliminary studies Floseal® (Baxter, USA) Hemostatic Matrix has shown efficacy in up to 80% of persistent anterior epistaxis. We sought to evaluate the clinical efficacy and cost-effectiveness of Floseal® (Baxter, USA) compared to traditional nasal packing for persistent epistaxis.MethodsA prospective, randomized controlled trial was conducted on all adult patients consulted to the OHNS service at the tertiary referral centers of the University of Alberta Hospital and Royal Alexandra Hospital for persistent epistaxis. Patients were randomized to the Floseal® (Baxter, USA) or traditional packing study arms. Our main clinical outcome measures were: 1) Hemostasis directly following treatment and at 48 h post-treatment, and 2) self-reported patient comfort at 48 h post-treatment. Further, trial data was used for a formal cost-effectiveness analysis to determine incremental cost-effectiveness ratio (ICER). Univariate sensitivity analysis and uncertainty analysis were performed.ResultsThere were no significant differences between groups for initial hemostasis (76.9% vs. 84.6%, p = 1.000) or, hemostasis at 48 h (76.9% vs. 69.2%, p = 1.000), requirement for admission (15.4% vs. 46.1%, p = 0.2016) or 30-day re-presentation rates (15.4% vs. 46.1%, p = 0.2016). Floseal® (Baxter, USA) was superior for decreased pain during placement (2.42 vs. 7.77, p = 0.0022), treatment (0.50 vs. 4.46, p = 0.0007) and removal (0 vs. 3.85, p = 0.0021). Floseal® (Baxter, USA) provides an average $1567.61 per patient savings from the single-payer system point of view and has an ICER of - $11,891 per re-bleed prevented (95% CI: -$37,658 to +$473). Uncertainty analysis shows that Floseal® has >90% chance of not only being cost-effective, but the dominant (preferred) treatment.ConclusionsFloseal® (Baxter, USA) was demonstrated to be an effective, comfortable and cost-effective alternative treatment of persistent epistaxis when compared to traditional packing methods for patients referred to OHNS with a normal coagulation profile.Trial registrationTrial registration number: NCT02488135. Date registered: June 26, 2015.

Alveolar-type rhabdomyosarcoma of nasal cavity and paranasal sinus in adult with pulmonary metastasis: A case report

Alveolar-type rhabdomyosarcoma of head and neck region in adult is extremely rare. We report a case of a 33-year-old lady who presented with persistent right unilateral nasal obstruction and epistaxis for one months’ duration. Examination showed a fleshy, irregular-surfaced mass occupying the whole right nasal cavity and histopathological examination revealed alveolar-type rhabdomyosarcoma. Metastatic work-up showed pulmonary metastasis. After 3months following completion of four cycles of chemotherapy, a repeated scan showed significant shrinkage of the tumor.

Lidocaine Toxicity During Attempted Epistaxis Cautery

BackgroundEpistaxis is a common problem that occurs in up to 60% of the general population, and is a common emergency department (ED) complaint. The use of lidocaine for analgesia is common when cauterization is required for bleeds that are refractory to manual compression. Although the use of lidocaine is generally thought of as a benign intervention, it is not completely without risk. Case ReportWe present the case of a 19-year-old man who presented to the ED with persistent anterior epistaxis. He developed severe lidocaine toxicity resulting from topical anesthesia applied prior to intranasal cautery for the epistaxis. This toxicity, which manifested as seizures, bradycardia, hypotension, nausea, and emesis, was rapidly recognized and appropriately treated, with a good clinical outcome for the patient. Why Should an Emergency Physician Be Aware of This?We present this case to increase awareness among emergency physicians of the potential complications of the intranasal use of topical lidocaine, something that is generally considered a benign intervention. We also discuss the pathophysiology and management of lidocaine toxicity.

Takotsubo cardiomyopathy associated with the administration of intranasal phenylephrine/lignocaine for epistaxis

1as a reversible form of left ventricular dysfunction, followed up by a case series in five patients. Although previously considered rare, over the past two decades there has been a marked rise in the number of publications relating to TTC, with the current estimation being that the condition accounts for over 1% of all cases of acute coronary syndrome presentations. The condition is defined by transient, reversible left ventricular systolic dysfunction with no macrovascular coronary artery disease, as confirmed by coronary angiography. Epidemiologically, postmenopausal women seem to be at highest risk, however the condition has been seen in multiple different patient populations. Although classically described in the setting of acute emotional or physical stress and associated with catecholamine overstimulation, exogenous administration of sympathomimetic agents has been reported to cause stress induced left ventricular dysfunction, particularly when administered intravenously. A 67 year old lady with a background of hypertension, Raynaud’s phenomenon and gastroparesis requiring PEJ (percutaneous endoscopic jejunostomy) feeding, presented with persistent recurrent epistaxis to the emergency department on a Friday evening. She had previously had episodes of nitrate responsive angina over the past decade, and previous coronary angiography in 2008 had demonstrated no significant lesions, with a diagnosis of presumptive microvascular disease noted in the history. She also had a history of ventricular tachycardia, for which she had been treated with flecainide, with a structurally normal heart on previous echocardiography, and no other significant cardiovascular risk factors.