Epistaxis

Clinically, the leading symptom in von Willebrand disease (VWD) is bleeding, chiefly of mucosal type, for example, epistaxis, gingival, or gastrointestinal bleeding, and menorrhagia. In severe forms of VWD with secondary deficiency of factor VIII, spontaneous joint bleeding, resembling that observed in severe haemophilia A, may also be observed. The bleeding patterns of VWD can affect quality of life, and may be life-threatening. The von Willebrand Disease Prophylaxis Network is an international study group formed with the goal of investigating the role of prophylaxis in clinically severe VWD. The objective of the present study is to investigate the response to prophylaxis focusing primarily on epistaxis, joint bleeding, gastrointestinal bleeding, and heavy bleeding associated with menses. Data from 105 subjects, 10 enrolled in a prospective study and 95 in a retrospective study between 2008 and 2013, were available for analysis. The median annualized rate reductions in bleeding wer...

The differentiation of SIDS from accidental or inflicted suffocation may be impossible in some cases. Severe pulmonary intra-alveolar hemorrhage has been suggested as a potential marker for such differentiation. Our aims are to: (1) Compare pulmonary hemorrhage in SIDS and a control group comprised of infants whose deaths were attributed to accidental or inflicted suffocation. (2) Review individual cases with the most severe pulmonary hemorrhage regardless of the cause of death, and (3) Assess the effect of age, bedsharing, cardiopulmonary resuscitation, and postmortem interval, with regard to the severity of pulmonary hemorrhage in SIDS cases. We conducted a retrospective study of all postneonatal cases accessioned by the Office of the Medical Examiner in San Diego County, California who died of SIDS or suffocation between 1999 and 2004. A total of 444 cases of sudden infant death caused by SIDS (405), accidental suffocation (36), and inflicted suffocation (3) from the San Diego SIDS/SUDC Research Project database were compared using a semiquantitative measure of pulmonary intra-alveolar hemorrhage [absent (0) to severe (4)]. Grades 3 or 4 pulmonary hemorrhage occurred in 33% of deaths attributed to suffocation, but in only 11% of the SIDS cases, however, all grades of pulmonary hemorrhage occurred in both groups. Therefore, our results indicate that the severity of pulmonary hemorrhage cannot be used in isolation to determine the cause or manner of sudden infant death. Among SIDS cases, those with a higher pulmonary hemorrhage grade (3 or 4) were more likely to bedshare, and with more than one co-sleeper, than those with a lower pulmonary hemorrhage grade (0 or 1). We conclude that each case must be evaluated on its own merits after thorough review of the medical history, circumstances of death, and postmortem findings.

The purpose of this study is to describe the treatment of epistaxis in hospital emergency departments and to identify the principal risk factors for more severe episodes of bleeding. Prospective cross-sectional epidemiological study This study was carried out in 23 hospital centres in France, most of them teaching hospitals. Every patient presenting non-traumatic epistaxis or else associated with hereditary hemangioma during two consecutive and separate 24-hour periods were included. Fifty patients were included in the study. Nasal bleeding was stopped within 30 minutes for 47 patients. Fourteen patients were hospitalized. The risk factors for severe epistaxis included either copious bleeding or else bleeding for more than 6 hours or patients aged 65 and over. A history of repeated nasal packing and/or taking medication with a known hemorrhagic risk was associated with the amount and duration of bleeding (p < 0.05). Risk factors for severe epistaxis should be identified as to imp...

Epistaxis is a condition mainly self-limiting or easily treated conservatively, although in rare cases it could become life-threatening. We discuss the case of a 73 year comorbid old woman with severe and recurrent epistaxis treated with superselective catheterism and embolization of the internal maxillary artery. The possible underlying causes, including drug related issues, are discussed.

It is known that many physiological variables show a rhythmic variability along a time span, e.g.: day, week, month or year. It is possible that the temporal overlapping of a constellation of factors may act as favouring and/or triggering factors for the onset of several acute diseases. Among these, epistaxis shows a circadian variability too. Such pattern, characterised by a prevalent peak in the morning and a secondary one in the evening, strictly resembles that of arterial blood pressure. The lack of differences between the temporal pattern of hypertensive and normotensive subjects suggests that the physiological pattern of blood pressure, and not strictly a condition of hypertension, may play a favouring role in certain hours of the day, probably together other local factors.

To evaluate outcomes of intractable epistaxis managed with arterial embolisation. Fourteen sequential cases of intractable epistaxis that underwent embolisation in our centre were evaluated retrospectively and interviewed over the phone. All patients had several failed treatment modalities prior to embolisation. Patients' follow up ranged from 1 to 57 months with median of 26 months. All 14 cases underwent a single embolisation procedure with successful arrest of epistaxis. Four cases (29%) developed recurrent epistaxis at a later date. One (7%) required re-embolisation 19 months after his first procedure. One bled 17 days after embolisation, but this settled with hospital admission and Bismuth Iodoform Paraffin Paste packing. The other two developed minor episodes of epistaxis, which did not require hospital admission. Two patients developed local ischaemic complications following arterial embolisation. Of those, one developed necrosis of the left alar skin and cartilage that healed reasonably well after 5 months. The other case developed mucosal necrosis of the right side of the hard palate; this patient was the one who bled 17 days post-embolisation. The palatal necrosis healed in a satisfactory manner without causing any functional impairment of the oral cavity. Embolisation is a successful intervention in management of persistent epistaxis, when other interventions fail. The risks of major complications such as stroke are well known, and discussed with patients prior to the procedure. It is also important to discuss the risks of ischaemic damage to the face and oral cavity. In our experience, these complications have been minor and the benefits still outweigh the complications.

A 59-year-old man presented to the emergency department with lightheadedness. He had started intranasal administration of ophthalmic timolol for the prevention of epistaxis associated with hereditary haemorrhagic telangiectasia approximately 3 weeks earlier with excellent response. His heart rate was about half its normal rate, an ECG revealed sinus bradycardia, and it was determined he had significant cardiac issues in his family history. Essentially all other tests were normal. The discontinuation of the intranasal use of timolol resolved any further episodes of lightheadedness and bradycardia. It was determined through genetic testing that he is an intermediate metaboliser of CYP2D6, the main enzyme contributing to the metabolism of timolol. This explains the development of the bradycardia after intranasal timolol use. The metabolising variants of CYP2D6 need to be considered when prescribing medications metabolised by this enzyme, so possible adverse effects can be avoided.