Efficacy of Trans-nasal Endoscopic Sphenopalatine Artery Ligation in the Management of Recurrent Posterior Epistaxis

Background: Recurrent posterior epistaxis is a challenging problem for most otolaryngologists. Of the several proposed treatment modalities, endoscopic ligation of SPA (Sphenopalatine artery) provides a simple and effective solution with relatively minor complications. Objectives: Aim of this study was to find out the success rate and complications of endoscopic ligation of SPA in the management of recurrent posterior epistaxis. Materials and Methods: This was an observational study conducted from Jan 2019 to Jan 2021. Total 60 patients were included in this study. Inclusion criteria were - recurrent epistaxis (at least 4 episodes in last 2 months) with bleeding point not seen in anterior rhinoscopy, Failure of previous conservative management with medications and nasal packing, age between 18–60 years of both sexes. All the patients underwent trans-nasal endoscopic Sphenopalatine artery ligation, and patients were followed up for 12 weeks to identify repeated bleeding and to evaluate complications. Results: In this study male to female ratio was 1.5:1. Mean age of study group was 44.66 (±8.62) years. No recurrent bleeding occurred in 51 (85%) and in 9 (15%) nasal bleeding occurred in the 2 months postoperative period. Anesthesia of incisor teeth occurred in 18 patients (30%), 22 patients (37%) complained about increased nasal crusting. Conclusion: Endoscopic ligation of Sphenopalatine artery shows good outcome in prevention of further episodes of epistaxis in most patients. Although some minor complications can occur, these are manageable. KYAMC Journal. 2021;12(3): 133-137

Etiology and treatment modalities in epistaxis

<p><strong>Background:</strong> Epistaxis or 'hemorrhage from the nose' is a frequent presentation in the otorhinolaryngologic emergency and both conservative and surgical modalities have been used in the treatment. The present study was undertaken to estimate the proportion of patients with epistaxis who are effectively managed with conservative modalities.</p><p class="abstract"><strong>Methods:</strong> A total of 60 patients (39 males and 21 females) between 18 and 70 years, with epistaxis were studied in the department of otorhinolaryngology and emergency units of Dr. Somervell Memorial C.S.I Medical College Hospital, Karakonam, Thiruvananthapuram, between November 2018 and April 2020. The data, that is the proportion of patients who are effectively managed with conservative modalities, was entered into Microsoft - Excel sheet and analysis was done using statistical package for social sciences (SPSS) software trial version.</p><p class="abstract"><strong>Results: </strong>Out of 60 cases of epistaxis, 81.67% were effectively controlled by conservative management like general first aid (43.33%), chemical cautery (10%), and nasal packings via anterior (21.67%) and posterior (6.67%).</p><p class="abstract"><strong>Conclusions:</strong> In 81.67% nasal bleeding was effectively controlled by conservative treatment measures and in 18.33% surgical measures were required. </p>

Alar cartilage hematoma of the nose secondary to facial trauma.

<p>A 27 years old male patient victim of road traffic accident presented to emergency department by ambulance team with ankle swelling and decrease range of motion, seen by orthopedic team and admitted as case of right ankle fracture for surgical intervention. Patient then referred to otolaryngology regarding on and off nasal bleeding and right nasal swelling arising from inner surface of right lower lateral cartilage of the nose 6 hour after the facial trauma, we present this case of hematoma of lower lateral cartilage which consider as one of the unique and rare condition following nasal and facial trauma. Early recognition of this condition is important, also differentiation between alar hematoma and septal cartilage hematoma is not easy for non-otolaryngology doctor, so increase awareness of this condition as one of possible sequel of fecal trauma and early referral to otolaryngology services is crucial. We present here a case of right sided alar cartilage hematoma, including the approach, management and follow up of the patient. We recommend early surgical drainage to optimize aesthetic out come after trauma.</p>

Comparison of hemostatic effect and safety between epinephrine and tramazoline during nasotracheal intubation: a double-blind randomized trial

Background Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal mucosa is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI. Methods This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal mucosa was treated using either E or T. The E used in this study was BOSMIN® SOLUTION 0.1% (Daiichi-Sankyo Co., Ltd., Tokyo), and the T used in this study was TRAMAZOLIN Nasal Solution 0.118% AFP, (Alfresa Pharma Corporation, Osaka). E was diluted five times according to the package insert (final concentration of E = 0.02%), and T was used in its original solution. After 2 min, NTI was performed via the right nostril. Primary outcome were the presence of nasal bleeding (if bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding) and the degree of bleeding (classified as none, mild, moderate, or severe). Secondary outcomes were arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors. Results The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T). No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups. Conclusions Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI. Trial registration UMIN-CTR (Registration No. UMIN000037907). Registered (05/09/2019).

​Application of Rhododendron for Human Welfare: A Review

National flower of Nepal and Uttarakhand is Rhododendron arboreum locally called buransh, a small tree with bright red flowers and green leaves. Rhododendron is derived from a Greek word RHODO and DENDRON which means rose-tree is used traditionally as medicine and also as food. Buransh normally grows in Himalayas, at high altitude is being used popularly for its processed juice from flowers as buransh or sharbat and in medicines that has many health benefits. Burans products are also used in decorations, refreshing drinks, firewood and as food colouring agents. Its numerous use also include in treatment of bile’s and liver disorders, nasal bleeding, blood dysentery, stomach ache, asthma, fever, gout, coughs, blurry vision, heart problems and diabetes. This review focuses on the phytochemical and nutrition profile, pharmacological and biological properties of Rhododendron arboreum in sustainable development of rural population with many job opportunities.

Unusual cause of recalcitrant epistaxis

Nosebleeds are among the most familiar presentations to the emergency department as well as otorhinolaryngologic outpatient services. Bleeding from nasal septal branches of the anterior ethmoid artery (AEA) is common and can be effectively controlled endoscopically. However, the bleeding from a pseudoaneurysm involving the nasal septal branches of AEA is extremely rare and can be troublesome to control using endoscopic methods. We report an adult patient presenting with profuse nasal bleeding postroad traffic accident due to the formation of AEA septal branch pseudoaneurysm. The patient required repeated nasal packing, and the diagnosis was revealed using digital subtraction angiography. Since profuse active bleeding precluded endoscopic visualisation, an external approach had to be adopted to ligate the AEA to control the bleeding. We discuss the management options and nuances for this rare cause of the troublesome nasal bleeding.

Nasal Maggot Infection in a Patient With Nasal Non-Hodgkin’s Lymphoma

We describe a case of nasal non-Hodgkin’s lymphoma in a 79-year-old Chinese patient accompany with nasal myiasis. The first 2 biopsies in this case were false negative. Subsequently, nasal maggots developed in this patient. After removing all maggots under nasal endoscopy, the patient continued to have recurrent fever and was transferred to a higher hospital for further treatment, in which he received a third biopsy. Unfortunately, several hours after the biopsy, the patient died for severe nasal bleeding. The final biopsy result indicated the neoplasm of the left nasal cavity was non-Hodgkin’s lymphoma. This case illustrates the importance of repeated biopsies for nasal non-Hodgkin’s lymphoma if necessary. Nasal myiasis is a secondary disease of nasal non-Hodgkin’s lymphoma in this case.

Factor V11 deficiency: A rare cause of nasal bleeding

Factor VII deficiency is a rare inherited disorder. Clinically the patient presents with bleeding tendencies. Diagnosis is made by prolonged prothrombin time, normal activated partial thromboplastin time and low functions factor VII assay or factor VII antigen. Therapy involves factor VII concentrates, recombinant factor VII, fresh frozen plasma and fibrinolytic inhibitors. We present a 6 years old boy with nose bleed for six months of whom prothrombin time was prolonged with functional factor VII assay of less than 1% confirming factor VII deficiency. He was managed with fresh frozen plasma, blood transfusion, tranexamic acid. Factor VII deficiency even though rare should be sought out in children presenting with bleeding. Keywords: Factor VII deficiency; coagulation; hemorrhage.

Epistaxis: a retrospective clinical study

<p class="abstract"><strong>Background:</strong> Epistaxis is one of the common emergencies in otorhinolaryngology. The aims and objectives of present work were to study incidence of epistaxis, etiological factors responsible for epistaxis and management of epistaxis.</p><p class="abstract"><strong>Methods:</strong> A retrospective study (February 2019 to March 2020) of patients admitted in department of otorhinolaryngology with complaint of nasal bleeding was done. The study was conducted on 96 patients for the incidence, age and sex relation, etiological factors, clinical findings and treatment methods for epistaxis.</p><p class="abstract"><strong>Results:</strong> Out of the total 96 cases of epistaxis, 58.3% were males and 41.6% were females. Most of the patients were over 40 years of age. The maximum, 19 (19.79%) were in the age group of 51-60 years and minimum, 2 (2.08%) were in the age group of 90-100 years. In the study of 96 cases, common group in this series was of cardiovascular causes (hypertension, arteriosclerosis, on antiplatelet drugs), 59 cases (61.45%), out of 59 cases, 9 patients were on antiplatelet drugs followed by idiopathic cases 13 (13.54%), trauma 12 (12.5%), 7 cases (7.29%) blood dyscrasias, spur with DNS 3 (3.12%), infection 1 (1.04%), alcoholic liver disease 1 (1.04%). Out of 96 cases, 92 cases (95.8%) responded to nonsurgical methods.</p><p class="abstract"><strong>Conclusions:</strong> Epistaxis can be seen in any age. Hypertension, trauma and coagulopathy were the most common etiological factors. Anterior nasal packing was the most common treatment method applied to these patients.</p>

Natural nasal–esophageal fiberscopy in the COVID-19 pandemic—preventing sneezing without anesthesia: a case report

Background We are laryngologists. We observe natural phonatory and swallowing functions in clinical examinations with a trans-nasal laryngeal fiberscope (TNLF). Before each observation, we use epinephrine to enlarge and smooth the common nasal meatus (bottom of nostril) and then insert a wet swab inside the nose, as in taking a swab culture in the nasopharynx. During the current COVID-19 pandemic situation, this careful technique prevents any complications, including nasal bleeding, painfulness, and induced sneezing. Here, we introduce our routine to observe esophageal movement in swallowing in a natural (sitting) position without anesthesia. Case presentation The case was a 70-year-old female who complained that something was stuck in her esophagus; there was a strange sensation below the larynx and pharynx. After enlarging and smoothing the common nasal meatus, we inserted the TNLF (slim type ⌀2.9 mm fiberscope, VNL8-J10, PENTAX Medical, Tokyo, Japan.) in the normal way. We then observed the phonatory and swallowing movements of the vocal folds. As usual, to not interfere with natural movements, we used no anesthesia. We found no pathological condition in the pyriform sinus. We asked the patient to swallow the fiberscope. During the swallow, we pushed the TNLF and inserted the tip a bit deeper, which made the fiberscope easily enter the esophagus, like in the insertion of a nasogastric tube. We then asked the patient to swallow a sip of water or saliva to clear and enlarge the lumen of the esophagus. This made it possible to observe the esophagus easily without any air supply. With tone enhancement scan, the esophagus was found to be completely normal except for glycogenic acanthosis. Conclusions The advantage of this examination is that it is easily able to perform without anesthesia and with the patient in sitting position. It is quick and minimally invasive, enabling observation the physiologically natural swallowing. It is also possible to observe without anesthesia down to the level of the esophagogastric junction using with a thin type flexible bronchoscope. In the future, gastric fiberscopes might be thinner, even with narrow band imaging (NBI) function. Before that time, physicians should remember to just insert along the bottom of the nose.