Strategy of the diagnosis and treatment for epistaxis and guideline for clinical application of MasterPillar / 临床耳鼻咽喉头颈外科杂志

Epistaxis is a common otorhinolaryngological emergency with complex etiological factors and varied clinical manifestations. The key to epistaxis treatment is accurate diagnosis and adequate hemostasis. Electrocoagulation is a reliable, safe and effective treatment for epistaxis. However, there are still several deficiencies in application of the commonly used electrocoagulation surgical products. This paper introduces a new type of radiofrequency head incorporating the dynamic circulatory functions of drip, irrigation, hemostasis and aspiration. We aim to achieve noninvasive, effective and accurate hemostasis in the treatment of epistaxis or nasal sinus surgery.

Connotation of distal bleeding based on modern pathophysiological mechanism and application of Huangtu Decoction for acute coronary syndrome complicated with acute upper gastrointestinal hemorrhage in critical care medicine / 中国中药杂志

Huangtu Decoction, first recorded in Essentials from the Golden Cabinet(Jin Kui Yao Lue) from ZHANG Zhong-jing in Han dynasty, is used to treat distal bleeding. It is mainly treated for the syndrome of failing to control blood with spleen-yang deficiency. The connotation of distal bleeding is more extensive, including not only upper gastrointestinal bleeding in the traditional sense such as peptic ulcer bleeding, gastrointestinal tumors, gastric mucosal lesions, vascular dysplasia, esophagogastric variceal bleeding, and pancreatic and biliary tract injury, but also other anorectal diseases such as part colon and rectal cancer swelling or polyps, hemorrhoids, and anal fissure and other parts of bleeding such as epistaxis, thrombocytopenia, functional uterine bleeding, threatened abortion, and unexplained hematuria. Distal bleeding also involves syndromes of failing to keep part deficient and cold fluids in interior, such as nocturia, enuresis, clear nose, sweating, cold tears, and leucorrhea, and excessive gastrointestinal bleeding caused by anti-plate and anticoagulant drugs, unexplained positive in the fecal occult blood test, and other modern clinical new problems. The indications of Huangtu Decoction include not only lower blood, defecation before blood, distant blood, hematemesis, epistaxis, and other diseases in traditional Chinese medicine, but also three types of clinical manifestations including bleeding, deficiency syndrome, and stagnant heat syndrome. In the clinic, Huangtu Decoction can be used to treat acute upper gastrointestinal bleeding, acute coronary syndrome complicated with acute upper gastrointestinal bleeding, bleeding events caused by excessive antiplatelet and anticoagulant drugs, unexplained positive in the fecal occult blood test, gastrointestinal tumor with bleeding, thrombocytopenia, and other acute and critical diseases. The dosage of Cooking Stove Earthkey, Rehmanniae Radix, and Asini Corii Colla in Huangtu Decoction is the key to hemostasis.

Sarcoma de Ewing extraesquelético en cavidad nasal y senos paranasales, reporte de caso / Extra-skeletal Ewing sarcoma in the nasal cavity and paranasal sinus, case report

El sarcoma de ewing es un tumor maligno de rápido crecimiento, con prevalencia de 1-5 casos por cada 1.000.000 habitantes, su forma extraesquelética en la cavidad sinonasal o senos paranasales es inusual. Objetivo: describir la localización atípica de esta neoplasia y la importancia de lograr un diagnóstico oportuno. Paciente femenina, con una masa en la cavidad nasal derecha de dos meses de evolución, cefalea y epistaxis. Con asimetría en región orbitaria derecha y deformidad del tabique nasal, senos paranasales con sintomas de obstrucción. La tomografía reveló una masa que invade senos paranasales. La biopsia mostró un sarcoma de Ewing. Se confirmó con CD99. La paciente recibió quimioterapia y plan de resección quirúrgica, pero falleció. El diagnóstico y tratamiento oportuno del sarcoma de ewing en cavidad sinonasal debe apoyarse con examenes tomográficos, histopatológicos, inmunohistoquímicos y de ser posible citogenéticos para llegar al diagnóstico definitivo en etapas tempranas del tumor

Ewing's sarcoma is a rapidly growing malignant tumor, with a prevalence of 1-5 cases per 1,000,000 inhabitants, its extraskeletal shape in the sinonasal cavity or paranasal sinuses is unusual. Objective: to describe the atypical location of this neoplasm and the importance of achieving a timely diagnosis. Female patient, with a mass in the right nasal cavity of two months of evolution, headache and epistaxis. With asymmetry in the right orbital region and deformity of the nasal septum, paranasal sinuses with symptoms of obstruction. Tomography revealed a mass that invades the paranasal sinuses. The biopsy showed Ewing's sarcoma. It was confirmed with CD99. The patient received chemotherapy and a surgical resection plan, however she died. The timely diagnosis and treatment of Ewing's sarcoma in the sinonasal cavity should not be based solely on clinical evaluation, it requires a tomographic, histopathological, immunohistochemical and, if possible, cytogenetic examination to reach a definitive diagnosis in the early stages of the tumor.

Recurrent epistaxis with coagulation disorders in a boy aged 2 years / 中国当代儿科杂志

A boy, aged 2 years and 5 months, had recurrent epistaxis, and the coagulation function examination showed that activated partial thromboplastin time (APTT) was significantly prolonged. Further laboratory examinations showed that the prolonged APTT was not immediately corrected in the APTT correction test, with positive lupus anticoagulant and low prothrombin activity. The boy was diagnosed with hypoprothrombinemia-lupus anticoagulant syndrome. The condition was improved after treatment with glucocorticoid, immunoglobulin, and vitamin K1. The boy has been followed up for 6 months, and no epistaxis was observed. Prothrombin activity returned to normal, and lupus anticoagulant remained positive. This is a relatively rare disease, and for patients with bleeding symptoms and coagulation disorders, it is recommended to perform the tests such as APTT correction test, lupus anticoagulant testing, and coagulation factor dilution test, which can improve the detection rate of this disease, so as to achieve early diagnosis, provide rational treatment in the early stage, and improve the prognosis.

Effet de la prémédication par des corticoïdes systémiques sur la chirurgie endonasale de la polypose naso-sinusienne / Effect of premedication with systemic corticosteroids on endonasal surgery for naso-sinus polyposis

Déterminer si une cure préopératoire de corticoïdes systémiques réduirait le saignement au cours de la chirurgie endonasale de la polypose naso-sinusienne (PNS) et améliorerait la visualisation du champ opératoire. Méthodes: Étude prospective randomisée incluant des adultes (>18 ans) atteints de PNS primitive résistante au traitement médical et qui vont bénéficier d'une chirurgie endoscopique endonasale. Ces patients sont randomisés en deux groupes: un groupe préparé par des comprimés de prednisolone 20mg, à la posologie de 0.5mg/Kg/j pendant 7 jours avant la chirurgie et un groupe non préparé. Les critères d'évaluation sont: la perte sanguine avec la comparaison des hémoglobines (Hb) pré et postopératoires, le temps opératoire et la visibilité du champ opératoire évaluée par le chirurgien selon le score de Boezaart. Résultats: Nous avons inclus 32 patients. Dix-sept patients dans le groupe non préparé et 15 patients dans le groupe préparé. Les deux groupes étaient comparables sur le plan épidémiologique, clinique et paraclinique (p>0,05). La perte sanguine moyenne était plus importante dans le groupe non préparé (700±487 ml versus 500±480 ml) mais sans différence significative (p=0,38). La différence était statistiquement non significative (p=0,24) entre les 2 groupes pour l'Hb postopératoire et pour la différence d'Hb préopératoire - Hb post opératoire. Le temps opératoire était plus court dans le groupe préparé (80±24 min versus 90±64 min) sans différence statistiquement significative (p=0,11). Le score de Boezaart était comparable (médiane=3) (p=0,29). Conclusion: Cet essai clinique n'a pas démontré que l'administration d'une cure préopératoire de corticothérapie orale peut réduire considérablement la perte de sang au cours de la chirurgie de la PNS et améliorer la visualisation du champ opératoire

Effet de la prémédication par des corticoïdes systémiques sur la chirurgie endonasale de la polypose naso-sinusienne / Effect of premedication with systemic corticosteroids on endonasal surgery for naso-sinus polyposis

Déterminer si une cure préopératoire de corticoïdes systémiques réduirait le saignement au cours de la chirurgie endonasale de la polypose naso-sinusienne (PNS) et améliorerait la visualisation du champ opératoire. Méthodes: Étude prospective randomisée incluant des adultes (>18 ans) atteints de PNS primitive résistante au traitement médical et qui vont bénéficier d'une chirurgie endoscopique endonasale. Ces patients sont randomisés en deux groupes: un groupe préparé par des comprimés de prednisolone 20mg, à la posologie de 0.5mg/Kg/j pendant 7 jours avant la chirurgie et un groupe non préparé. Les critères d'évaluation sont: la perte sanguine avec la comparaison des hémoglobines (Hb) pré et postopératoires, le temps opératoire et la visibilité du champ opératoire évaluée par le chirurgien selon le score de Boezaart. Résultats: Nous avons inclus 32 patients. Dix-sept patients dans le groupe non préparé et 15 patients dans le groupe préparé. Les deux groupes étaient comparables sur le plan épidémiologique, clinique et paraclinique (p>0,05). La perte sanguine moyenne était plus importante dans le groupe non préparé (700±487 ml versus 500±480 ml) mais sans différence significative (p=0,38). La différence était statistiquement non significative (p=0,24) entre les 2 groupes pour l'Hb postopératoire et pour la différence d'Hb préopératoire - Hb post opératoire. Le temps opératoire était plus court dans le groupe préparé (80±24 min versus 90±64 min) sans différence statistiquement significative (p=0,11). Le score de Boezaart était comparable (médiane=3) (p=0,29). Conclusion: Cet essai clinique n'a pas démontré que l'administration d'une cure préopératoire de corticothérapie orale peut réduire considérablement la perte de sang au cours de la chirurgie de la PNS et améliorer la visualisation du champ opératoire.

Epistaxis: aspectos nuevos a considerar / Epistaxis: new aspects to consider

La epistaxis es una de las urgencias otorrinolaringológicas más frecuentes, y se estima que un 6% requerirá algún tipo de intervención. Según la localización del sitio de sangrado puede clasificarse en anterior, posterior o superior. A lo largo de la historia su manejo ha seguido ciertos ejes que se mantienen vigentes, como son la compresión nasal, posicionamiento de la cabeza, taponamiento nasal, entre otros. Tras la implementación de la evaluación endoscópica sistemática del sitio de sangrado, estudios han descrito un nuevo punto de sangrado denominado S-point, que debiese ser especialmente considerado en epistaxis severa. Además, durante los últimos años la evidencia ha revelado ciertos aspectos especiales y relevantes en torno a la evaluación y/o manejo de pacientes con epistaxis y condiciones asociadas, como el uso de terapia antitrombótica, telangiectasia hemorrágica hereditaria o con hipertensión arterial. El objetivo de esta revisión es resumir aspectos novedosos en la evaluación, estudio y manejo de la epistaxis, donde se incluirán el uso de ácido tranexámico y de nuevos dispositivos intranasales.

Epistaxis is one of the most frequent otorhinolaryngological emergencies, and it is estimated that 6% require some type of intervention. Depending on the location of the bleeding site, it may be classified as anterior, posterior or superior. Throughout history, its treatment has remained the same, including nasal compression, head positioning, nasal packing, among others. After the implementation of the systematic endoscopic assessment of the bleeding site, studies have described a new point of bleeding called S-point, which should be especially considered in severe epistaxis. In addition, during the last years the evidence has revealed certain special and relevant aspects regarding the evaluation and/or management of patients with epistaxis and associated conditions, such as the use of antithrombotic therapy, hereditary hemorrhagic telangiectasia or arterial hypertension. The objective of this review is to summarize novel aspects in the evaluation, study and management of epistaxis, which include the use of tranexamic acid and new intranasal devices.

Cauterización transoral de la arteria maxilar interna en la fosa infratemporal: informe de un caso / Transoral cauterization of the internal maxillary artery in the infratemporal fossa: case report

Se describe el caso clínico de una paciente de 84 años que tuvo epistaxis recidivante por padecer enfermedad de Rendu-Osler-Weber. Tuvo antecedentes de diversos tratamientos quirúrgicos que incluyeron el cierre de la fosa nasal izquierda (operación de Young). Por la persistencia de epistaxis izquierda se indicó una angiografía y embolización. Esta última no se hizo porque se diagnosticaron anastomosis entre el sistema carotídeo externo y el interno. Se realizó un abordaje intraoral paramaxilar asistido con endoscopios para cauterizar la arteria maxilar interna en la fosa infratemporal y un abordaje externo para cauterizar la arteria etmoidal anterior solucionando la epistaxis. (AU)

The clinical case of an 84-year-old patient who had recurrent epistaxis due to Rendu-Osler- Weber disease is described. She had a history of various surgical treatments including closure of the left nostril (Young's operation).Due to the persistence of left epistaxis, angiography and embolization were indicated. The latter was not done because anastomosis between the external and internal carotid system was diagnosed. An intraoral paramaxillary approach assisted with endoscopes was performed to cauterize the internal maxillary artery in the infratemporal fossa and an external approach to cauterize the anterior ethmoidal artery solving the epistaxis. (AU)

Prevalence and characteristics of S-point bleeding compared to non S-point bleeding in severe epistaxis / Prevalência e características do sangramento no S-point em comparação com outros pontos sangramento na epistaxe grave

Abstract Introduction Stamm's S-point is gaining importance as a bleeding focus in severe epistaxis. However, prevalence and features of S-point bleeding compared to non S-point bleeding have not been studied. Objective To investigate the characteristics of patients with S-point bleeding among those with severe epistaxis and to compare the factors involved in the treatment of epistaxis. Methods We retrospectively analyzed medical records of 268 patients admitted to the otorhinolaryngology department of Konkuk University Hospital and Chung-Ang University Hospital with epistaxis of which the bleeding focus clarified. Patients with anterior nasal bleeding (n = 129) were excluded. The study was conducted at the department of otorhinolaryngology from January 2008 to August 2019. Collected data included patients' demographic information, bleeding focus, body mass index underlying medical and sinonasal diseases, laboratory test results (initial hemoglobin, platelet count, and triglyceride level), use of anticoagulants, direction of epistaxis, initial and final treatments, and need for blood transfusion. Results The prevalence of S-point bleeding was 28.8% of non-anterior bleeding cases. Mean body mass index score was lower in the S-point group (23.41 ± 3.71) compared to the non S-point group (24.93 ± 3.97) (p = 0.039). Underweight patients tended to show a greater incidence of S-point bleeding (15.0%) than non S-point bleeding (2.0%) (p = 0.010). Incidence of anemia was higher in the S-point group (67.5%) than in the non S-point group (36.4%). Anemia (Odds ratio [OR]: 3.635; 95% confidence interval [CI]: 1.669-7.914, p = 0.001) and underweight (body mass index < 18.5, OR: 8.559, CI: 1.648-44.445, p = 0.011) were significantly associated with S-point bleeding. Conclusion Prevalence of S-point bleeding was significant, underlining the importance of examining the S-point in patients with severe epistaxis. Patients with S-point bleeding had lower body mass index scores and a higher incidence of anemia than those with non S-point bleeding.

Resumo Introdução O S-point de Stamm tem ganhado importância como foco de sangramento na epistaxe grave. Entretanto, a prevalência e as características do sangramento no S-point em comparação com o sangramento em outros locais ainda não foram estudadas. Objetivo Investigar as características dos pacientes com epistaxe grave com sangramento no S-point e comparar os fatores envolvidos no tratamento da epistaxe. Método Analisamos retrospectivamente os prontuários médicos de 268 pacientes internados no Departamento de Otorrinolaringologia do Konkuk University Hospital e do Chung-Ang University Hospital com epistaxe cujo foco hemorrágico foi esclarecido. Pacientes com sangramento anterior (n = 129) foram excluídos. O estudo foi feito no Departamento de Otorrinolaringologia de janeiro de 2008 a agosto de 2019. Os dados coletados incluíram informações demográficas dos pacientes, foco hemorrágico, índice de massa corporal doenças médicas e nasosinusais subjacentes, resultados de exames laboratoriais (hemoglobina, contagem de plaquetas e nível de triglicerídeos iniciais), uso de anticoagulantes, direção da epistaxe, tratamentos iniciais e finais e necessidade de transfusão de sangue. Resultados A prevalência de sangramento no S-point foi de 28,8% dos casos de sangramento não anterior. O índice de massa corpórea médio foi menor no grupo com sangramento no S-point (23,41 ± 3,71) em comparação com o grupo não S-point (24,93 ± 3,97) (p = 0,039). Pacientes com baixo peso tenderam a apresentar maior incidência de sangramento no S-point (15,0%) do que sangramento em ponto não S (2,0%) (p = 0,010). A incidência de anemia foi maior no grupo com sangramento no S-point (67,5%) do que no grupo não S-point (36,4%). A anemia (odds ratio [OR]: 3,635; intervalo de confiança de 95% [IC95%]: 1,669-7,914, p = 0,001) e o baixo peso (IMC < 18,5, OR: 8,559, IC95%: 1,648-44,445, p = 0,011) foram significantemente associados com sangramento no S-point. Conclusão A prevalência de sangramento no S-point foi significativa, enfatizou a importância de examinar o S-point em pacientes com epistaxe grave. Pacientes com sangramento no S-point apresentaram escores mais baixos no índice de massa corpórea e maior incidência de anemia do que aqueles com sangramento em locais que não o S-point.

Rapid hemostasis: a novel and effective outpatient procedure using microwave ablation to control epistaxis of isolated mucosal bulge lesions / Hemostasia rápida: um procedimento ambulatorial novo e eficaz utilizando ablação por micro-ondas para controlar a epistaxe de lesões isoladas protuberantes da mucosa

Abstract Introduction Recurrent epistaxis is commonly encountered in the rhinology outpatient clinic. Under endoscopic guidance, both bipolar cautery and monopolar forceps (combined with suction) have been employed to control the bleeding. However, the use of monopolar forceps requires the placement of grounding pads. Most procedures are currently performed in operating rooms. Objective We investigated outcomes after the use of Microwave Ablation (MWA) to control epistaxis in adults with isolated mucosal bulge lesions. All procedures were performed with patients under local anesthesia in our outpatient clinic. Methods This is a retrospective cohort study. We included 83 adults with epistaxis of isolated mucosal bulge lesions. Microwave ablation was performed in the outpatient clinic to control bleeding, after induction of local anesthesia. The primary outcome was successful hemostasis. The secondary outcomes were the rebleeding rates at weeks 1 and 4 and month 6, and complications (crust or synechiae formation, septal perforation, and/or orbit or brain complications). Results All bleeding points were successfully ablated; hemostasis was achieved within 1-2 min. The mean pain score was 1.83 intra-operatively and 0.95 1 h postoperatively. No patient re-bled, and no severe MWA-related complication (septal perforation, synechiae formation, or orbit or brain complication) was recorded to 6 months of follow-up. Conclusions Endoscopic microwave ablation with patients under local anesthesia is a novel, safe, effective, rapid, well-tolerated, outpatient treatment for adults with epistaxis of isolated mucosal bulge lesions, especially those for whom general anesthesia might be risky, those with electrical implants, and those exhibiting contraindications for arterial embolization.

Resumo Introdução Epistaxe recorrente é comumente encontrada no ambulatório de rinologia. Sob orientação endoscópica, foram empregados tanto o cautério bipolar quanto a pinça monopolar (combinados à sucção) para controlar a condição. No entanto, o uso de pinças monopolares requer a colocação de placas de aterramento. Atualmente, a maioria dos procedimentos é feita em salas de cirurgia. Objetivo Investigamos os resultados após o uso da ablação por micro-ondas (MWA, do inglês Microwave Ablation) no controle da epistaxe em adultos com lesões isoladas protuberantes da mucosa. Todos os procedimentos foram feitos em nosso ambulatório com os pacientes sob anestesia local. Métodos Estudo de coorte retrospectivo. Foram incluídos 83 adultos com epistaxe de lesões isoladas protuberantes da mucosa. A ablação por micro-ondas foi feita no ambulatório para controlar o sangramento, após a administração de anestesia local. O desfecho primário foi uma hemostasia bem-sucedida. Os desfechos secundários foram as taxas de ressangramento, nas semanas 1 e 4 e no mês 6, e complicações (formação de crostas ou sinéquias, perfuração septal e/ou complicações orbitais ou cerebrais). Resultados Todos os pontos de sangramento foram contidos com sucesso; a hemostasia foi alcançada em 1-2 minutos. O escore médio de dor foi de 1,83 no intraoperatório e de 0,95 1 h no pós-operatório. Nenhum paciente apresentou ressangramento e nenhuma complicação grave relacionada à MWA (perfuração septal, formação de sinéquias ou complicações orbitais ou cerebrais) foi registrada em 6 meses de seguimento. Conclusões A ablação endoscópica por micro-ondas com pacientes sob anestesia local é um tratamento ambulatorial novo, seguro, eficaz, rápido e bem tolerado para adultos com epistaxe de lesões isoladas protuberantes da mucosa, especialmente aqueles para os quais a anestesia geral pode ser arriscada, indivíduos com implantes elétricos e aqueles com contraindicações para embolização arterial.

Comparação de métodos de tratamento tópico utilizados na epistaxe anterior recorrente: ensaio clínico randomizado / Comparison of topical treatment methods used in recurrent anterior epistaxis: a randomized clinical trial

Resumo Introdução: A epistaxe recorrente é uma doença comumente vista por especialistas em otorrinolaringologia, médicos de emergência e pediatras. O fato de que muitas modalidades de tratamento estejam sendo pesquisadas e nenhum método único de tratamento seja universalmente aceito apoiam ainda mais essa informação. Objetivo: Comparar a eficácia clínica do uso de pomada antisséptica tópica, pomada descongestionante tópica e tratamentos de cauterização química, que são frequentemente usados em epistaxe anterior recorrente, tanto isoladamente como em combinação. Método: Entre agosto de 2017 e fevereiro de 2018, 137 pacientes diagnosticados com epistaxe anterior recorrente foram divididos aleatoriamente em 5 grupos. O grupo I foi tratado com pomada antisséptica tópica, o grupo II com pomada descongestionante tópica, o grupo III foi submetido a cauterização química, o grupo IV foi tratado com pomada antisséptica tópica + cauterização química e o grupo V com pomada descongestionante tópica + tratamento de cauterização química. Todos os pacientes foram contatados por telefone 2 semanas e um mês após o tratamento e perguntados sobre a presença (falha) ou ausência (sucesso) de pelo menos um episódio de epistaxe. Pacientes com comorbidades foram excluídos. O sucesso do tratamento foi analisado estatisticamente. Resultados: Não houve diferença significante (p > 0,05) entre os grupos em relação à taxa de sucesso no 15° dia após o tratamento. Os grupos IV e V tiveram maiores taxas de sucesso no 30° dia após o tratamento em comparação com os grupo I e II (p < 0,05). No grupo III, o sucesso do tratamento no 30° dia não foi diferente dos outros 4 grupos (p > 0,05). Conclusão: Embora o número de pacientes que melhoraram com a cauterização química (grupo III) tenha sido maior em nosso estudo, nenhuma diferença significante foi observada nas modalidades de tratamento único (grupos I - III) no 14° dia e no 30° dia após o tratamento. Embora não tenha sido observada diferença estatisticamente significante entre os tratamentos combinados (grupos IV - V) e os tratamentos simples (grupos I - III) na 2ª semana após o tratamento, os tratamentos combinados foram significantemente mais eficazes no 1° mês.

Encefalopatia reversível induzida por contraste após embolização com espiras por epistaxe / Reversible contrast-induced encephalopathy after coil embolization of epistaxis

RESUMO Uma mulher com 37 anos de idade, gestante de 35 semanas, foi admitida em um hospital local em razão de epistaxe grave, que resultou em choque e em necessidade de realização de cesárea emergencial. Após falha do tamponamento para controlar a hemorragia, decidiu-se por tratamento angiográfico. Após o procedimento, ela foi admitida à unidade de terapia intensiva neurocrítica, encontrando-se confusa e agitada, com necessidade de sedação e intubação orotraqueal. Na unidade de terapia intensiva, as investigações incluíram exames de ressonância magnética, punção lombar com painel viral, eletroencefalograma, testes para autoimunidade e avaliações hidroeletrolítica e metabólica. O exame de ressonância magnética mostrou área puntiforme restrita na corona radiata esquerda nas sequências de imagens pesadas em difusão, além de leve edema cortical posterior (sem restrição à difusão), e o eletroencefalograma mostrou atividade lenta difusa moderada, atividade frontoparietal lenta e escassos componentes paroxísticos associados no hemisfério esquerdo. Outros exames não mostraram alterações relevantes. Por causa da relação temporal e da história clínica, assim como imagens de ressonância magnética, formulou-se o diagnóstico de encefalopatia induzida por contraste. A sedação foi retirada após 2 dias na unidade de terapia intensiva, e a paciente foi extubada, verificando-se completa recuperação neurológica dentro das 24 horas seguintes.

ABSTRACT A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

Consenso de epistaxis en pediatría: causas, clínica y tratamiento / Consensus on pediatrics epistaxis: Causes, clinic and treatment

Se define la epistaxis como el sangrado proveniente del vestíbulo, la cavidad nasal o la nasofaringe. Representa el 3 % de las consultas de guardia. El 30 % de los niños menores de 5 años presentan, al menos, un episodio de epistaxis. La edad media de presentación es entre los 7,5 y los 8,5 años. Predomina en el sexo masculino (el 56-67 %). La rinorrea es el síntoma más frecuentemente asociado (el 46 %). El origen puede ser anterior o posterior, y las anteriores son las más frecuentes. Es necesario un enfoque integral para determinar la etiología (primaria o secundaria). Los principales objetivos del tratamiento son el control de la hemorragia, de la causa subyacente y la prevención de la recurrencia.La mayoría de las hemorragias son autolimitadas; sin embargo, el taponamiento nasal y la cauterización son requeridos ante casos recurrentes o graves. Cuando estas técnicas fracasan, puede utilizarse un manejo endoscópico, angiografía-embolización y ligadura quirúrgica abierta

Epistaxis is defined as bleeding from the vestibule, nasal cavity or nasopharynx. It represents 3 % of Emergency Room consultations. Thirty per cent of children under 5 years of age have an episode of epistaxis. The average age of presentation is between 7.5 and 8.5 years. It predominates in males (56-67 %). Nasal obstruction (nasal discharge) is the most associated symptom (46 %). The origin can be anterior or posterior, with the previous ones being the most frequent. An integral approach is necessary to determine the etiology (primary or secondary). The main purposes of the treatment are bleeding control and the underlying cause and the prevention of recurrence. Most hemorrhages are self-limiting; however, nasal tamponade and cauterization are required in cases of recurrence and/or severity. When these techniques fail, endoscopic management, angiography-embolization, and open surgical ligation may be used.

Effects of bevacizumab on familial epistaxis caused by hereditary hemorrhagic telangiectasia / 中华耳鼻咽喉头颈外科杂志

Objective: To observe the clinical effects of bevacizumab in the treatment of familial epistaxis caused by hereditary hemorrhagic telangiectasia (HHT). Methods: The data of 27 patients with familial epistaxis caused by HHT who were treated with bevacizumab intravenously from Beijing Anzhen Hospital, the First Clinical Center of Chinese People's Liberation Army General Hospital and Binzhou Central Hospital between December 2016 and December 2019 were retrospectively analyzed. There were 14 males and 13 females, aged (55.3±11.2) years. The dose of bevacizumab was calculated according to the body weight of 5 mg/kg. The curative effect was observed one month after the first treatment. Visual analogue scale (VAS) was used to compare patients' self-scores of systemic symptoms before and after treatment. Epistaxis severity score (ESS) was used to compare and analyze the six problems (including the frequency, duration, intensity, treatment demand, anemia and blood transfusion) of the patients before and after treatment. The changes of hemoglobin levels before and after treatment were compared. SPSS 20.0 statistical software was used to process the data. Results: Among the 27 patients at one month after the first bevacizumab treatment, 22 cases reported that the severity of epistaxis was improved significantly, and 5 cases reported that the treatment effect was not significant. The effective rate was 81.5% (22/27). The significant effect in 22 patients lasted for 5-24 months, with a median duration of 11.23 months. The VAS score of systemic symptoms decreased significantly compared with that before treatment (2.41±2.55 vs 8.19±1.47, t=9.708, P<0.01). The scores of six aspects and standardized scores of ESS were significantly decreased after treatment (epistaxis frequency: 1.78±1.22 vs 3.44±0.80, t=6.814, P<0.01; epistaxis duration: 0.85±0.91 vs 3.00±0.73, t=8.845, P<0.01; epistaxis intensity: 0.19±0.40 vs 1.00±0.00, t=10.696, P<0.01; treatment demand: 0.22 ± 0.42 vs 1.00±0.00, t=9.539, P<0.01; anemia: 0.41±0.50 vs 0.89±0.32, t=4.914, P<0.01; blood transfusion: 0.11±0.32 vs 0.41±0.50, t=3.309, P<0.01; ESS standardized score: 2.50±2.45 vs 7.60±1.30, t=9.344, P<0.01). The hemoglobin level after treatment was significantly higher than that before treatment ((105.48±24.31) g/L vs (73.07±23.71) g/L, t=6.864, P<0.01). Among the 27 patients, there were 8 cases of HHT1 (ENG gene) and 19 cases of HHT2 (ACVRL1 gene). The improvement duration of epistaxis in group HHT1 and group HHT2 was (4.76±5.12) months and (7.60±10.84) months, respectively, which was in group HHT2 longer than that of group HHT1, but there was no significant difference between the two groups (P>0.05). There was no significant difference in ESS scores between the two groups before and after treatment (P>0.05). Two female patients had amenorrhea after the first medication. All patients had no other adverse reactions and complications. Conclusion: Intravenous bevacizumab is significantly effective and safe in the treatment of familial epistaxis caused by HHT.

Epistaxis: the cause found beyond the nose

Renal cell carcinoma (RCC) is a malignant disease that is often diagnosed at a metastatic stage. The head and neck represent up to 3% of the metastatic RCC, and the paranasal sinus area is one of the least involved sites. Here, we introduce the case of a 74-year-old female patient who presented with a history of traumatic nasal bleed. A cranial computed tomography scan and magnetic resonance imaging showed a fronto-ethmoidal mass with pachymeningeal involvement. A nasal biopsy from the paranasal sinuses was taken. On histopathological examination, metastatic clear cell carcinoma was the main hypothesis, which later was confirmed to be RCC on immunohistochemistry. On further radiological examination, an exophytic mass was depicted in the kidney's upper and middle pole. The patient had no renal complaints and was asymptomatic. Fronto-ethmoidal sinus is a rare site for metastatic RCC, especially in cases where the patient is asymptomatic. Early detection by keeping RCC metastasis as the differential diagnosis in such cases can lead to early treatment and improve the overall survival of the patient.

Effects of oral isotretinoin therapy on the nasal cavities / Efeitos nasais da terapia com isotretinoína oral

Abstract Introduction Isotretinoin (13 cis-retinoic acid) is the most effective treatment for acne vulgaris and is the only treatment option that can provide either remission or a permanent cure. Objective The aim of this study was to use both subjective and objective methods to assess the nasal complaints of patients with severe acne who received oral isotretinoin therapy. Methods Fifty-four subjects were enrolled in the study. All the subjects were assessed with subjective (NOSE and VAS questionnaires) and objective (rhinomanometry and saccharine) tests to determine the severity of their nasal complaints. Results The mean severity scores (min: 0; max: 100) for nasal dryness/crusting and epistaxis were 0.47 ± 1.48 (0-5); 0.35 ± 1.30 (0-5) at admission, 3.57 ± 4.45 (0-10); 2.26 ± 4.71 (0-20) at the first month, and 4.28 ± 6 (0-20); 2.26 ± 4.71 (0-20) at the third month of the treatment respectively. Total nasal resistance of 0.195 ± 0.079 (0.12-0.56) Pa/cm3/s at admission, 0.21 ± 0.084 (0.12-0.54) Pa/cm3/s at the first month, and 0.216 ± 0.081 (0.14-0.54) Pa/cm3/s at the third month. Conclusion Oral isotretinoin therapy can cause the complaint of nasal obstruction. In addition, nasal complaints, such as dryness/crusting and epistaxis, significantly increase in patients during the therapy schedule.

Resumo Introdução A isotretinoína (ácido-13 cis-retinóico) é o tratamento por via oral mais eficaz para acne vulgar e é a única opção de tratamento que pode produzir remissão ou cura permanente. Objetivo Usar métodos subjetivos e objetivos para avaliar as queixas nasais de pacientes com acne grave que receberam terapia com isotretinoína oral. Método Foram incluídos no estudo 54 indivíduos. Todos os indivíduos foram avaliados por meio de testes subjetivos (questionários NOSE e escala EVA) e objetivos (rinomanometria e teste de sacarina) para determinar a gravidade de suas queixas nasais. Resultados Os escores médios de gravidade (min: 0; max: 100) para ressecamento/crostas e epistaxe nasal foram de 0,47 ± 1,48 (0-5); 0,35 ± 1,30 (0-5) no início, 3,57 ± 4,45 (0-10); 2,26 ± 4,71 (0-20) no primeiro mês e 4,28 ± 6 (0-20); 2,26 ± 4,71 (0-20) no terceiro mês do tratamento, respectivamente. A resistência nasal total foi de 0,195 ± 0,079 (0,12 a 0,56) Pa/cm3/s no início, 0,21 ± 0,084 (0,12 a 0,54) Pa/cm3/s no primeiro mês e 0,216 ± 0,081 (0,14 a 0,54) Pa/cm3/s no terceiro mês. Conclusão A terapia com isotretinoína por via oral pode resultar em queixa de obstrução nasal. Além disso, queixas nasais, tais como ressecamento/formação de crostas e epistaxe, aumentam significativamente nos pacientes durante o esquema terapêutico.

Does topical application of tranexamic acid reduce intraoperative bleeding in sinus surgery during general anesthesia? / A aplicação tópica de ácido tranexâmico reduz o sangramento intraoperatório em cirurgia sinusal durante anestesia geral?

Abstract Introduction Tranexamic acid is a hemostatic agent, which inhibits fibrin degradation, which may be beneficial in controlling bleeding during surgery. Objectives The purpose of this study was to provide a meta-analysis and review of the effects of tranexamic acid on hemorrhage and surgical fields and side effects on patients during endoscopic sinus surgery. Methods Two authors independently searched six databases (Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane library) from the start of article collection until July 2018. Postoperative complications such as intraoperative bleeding, operative time, hypotension, nausea, vomiting, and coagulation profile were included in the analysis of tranexamic acid (Treatment Group) and placebo (Control Group) during the operation. Results The amount of blood loss during surgery was statistically lower in the treatment group compared to the placebo group, and the surgical field quality was statistically higher in the treatment group than in the placebo group. On the other hand, there was no significant difference in operation time, hemodynamics, or coagulation profile between groups. In addition, tranexamic acid had no significant effect on vomiting and thrombosis compared to the Control Group. Conclusion This meta-analysis has shown that topical administration of tranexamic acid can reduce the amount of bleeding during surgery and improve the overall quality of the surgery. Hemodynamic instability during surgery, vomiting after surgery, or abnormal clotting profile were not reported. Additional studies are needed to confirm the results of this study because there are fewer studies.

Resumo Introdução O ácido tranexâmico é um agente hemostático, que inibe a degradação da fibrina e pode ser benéfico no controle do sangramento durante a cirurgia. Objetivos Fazer uma metanálise e revisão dos efeitos do ácido tranexâmico na hemorragia e nos campos cirúrgicos e efeitos colaterais em pacientes durante a cirurgia endoscópica do seio nasal. Método Dois autores realizaram independentemente uma busca em seis bancos de dados (Medline, Scopus, Embase, Web of Science, Google Scholar e Cochrane) desde o início da coleta de artigos até julho de 2018. Complicações pós-operatórias como sangramento intraoperatório, tempo operatório, hipotensão, náusea, vômitos e perfil de coagulação foram incluídos na análise do ácido tranexâmico (grupo de tratamento) e placebo (grupo controle) durante a cirurgia. Resultados A quantidade de perda de sangue durante a cirurgia foi estatisticamente menor no grupo de tratamento comparado com o grupo placebo e a qualidade do campo cirúrgico foi estatisticamente maior no grupo de tratamento do que no grupo placebo. Por outro lado, não houve diferença significante no tempo cirúrgico, hemodinâmica ou perfil de coagulação entre os grupos. Além disso, o ácido tranexâmico não teve efeito significante na ocorrência de vômitos e trombose em comparação ao grupo controle. Conclusão Esta metanálise mostrou que a administração tópica de ácido tranexâmico pode reduzir a quantidade de sangramento durante a cirurgia e melhorar a qualidade geral dela. Instabilidade hemodinâmica durante a cirurgia, vômitos após a cirurgia ou perfil de coagulação anormal não foram relatados. Estudos adicionais são necessários para confirmar os resultados desta pesquisa, porque há poucos estudos na literatura.

Síndrome de Osler-Weber-Rendu: presentación de un caso clínico y revisión de la literatura / Osler-Weber-Rendu syndrome: a case report and literature review

El síndrome de Osler-Weber-Rendu, también conocido como telangiectasia hemorrágica hereditaria, es una enfermedad de herencia autosómica dominante de baja prevalencia, que se caracteriza por unas paredes delgadas de los vasos sanguíneos que conducen a malformaciones arteriovenosas, principalmente en cerebro, pulmón e hígado, pero que pueden potencialmente afectar cualquier otro órgano. La principal manifestación clínica son las epistaxis recurrentes; sin embargo, también pueden aparecer otras manifestaciones como hemoptisis o sangrado gastrointestinal, y telangiectasias mucocutáneas, entre otras. Su expresión clínica varía de un paciente a otro y el diagnóstico usualmente se basa en los criterios de Curazao. Se describe el caso de una paciente con historia de 12 años de epistaxis recurrente, a quien se le diagnosticó síndrome de Osler-Weber-Rendu hace dos años. Fue referida al servicio de Hepatología por presentar compromiso hepático, además de malformaciones arteriovenosas cerebrales y pulmonares. El manejo óptimo de la telangiectasia hemorrágica en esta paciente por parte de los diferentes especialistas, apoyado en los estudios de imagenología, ha permitido que la paciente tenga una buena calidad de vida hasta el momento. Se presenta el caso de esta paciente de 46 años y se realiza una revisión corta de la literatura.

Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia, is an autosomal dominant low-prevalence disease, characterized by thin blood vessel walls, leading to arteriovenous malformations, mainly in the brain, lung and liver, but can potentially affect any other organ. The main clinical manifestation is recurrent epistaxis; however, other manifestations may also appear, such as hemoptysis or gastrointestinal bleeding, and mucocutaneous telangiectasias, among others. Its clinical expression varies from patient to patient and the diagnosis is usually based on Curacao criteria. We present the case of a patient with a 12-year history of recurrent epistaxis, who was diagnosed with Osler-Weber-Rendu syndrome two years ago. She was referred to the Hepatology service due to liver findings, in addition to brain and pulmonary arteriovenous malformations. The optimal management of hemorrhagic telangiectasia in this patient by the different specialists, supported by imaging studies, has allowed the patient to have a good quality of life. The case of this 46-year-old patient is presented, and a brief literature review is also provided.