A New Device for Managing Refractory Epistaxis in ICU Patients with COVID-19

Epistaxis is a common and a well-known symptom. Nasal packing is an effective treatment in most cases [1]. The COVID-19 disease treatment includes conventional or high flow nasal oxygen therapy and systemic anticoagulation [2]. Patients in intensive care unit may require therapeutic anticoagulation for venous thromboembolism, hyperinflammatory status, extracorporeal membrane oxygenation (ECMO) and multiple other pathologies. The use of therapeutic anticoagulation increases risk of nose bleeding, and its management may be challenging. CAVI-T (Figures 1 & 2) is a new asymmetrical low-pressure balloon that have shown promising results to control epistaxis in emergency. We report herein the management of severe epistaxis in two COVID-19 patients admitted to ICU for severe respiratory failure.

Nasopharyngeal Coil Dislocation of an Embolized Internal Carotid Artery Pseudoaneurysm

Objective. Severe epistaxis caused by ruptured intracranial pseudoaneurysms can be effectively treated by coil embolization. This is generally an efficient and safe procedure and provides sufficient protection recurrent epistaxis. However, complications such as aneurysm rupture, arterial dissection, bleeding, and emboli can occur. A dislocation of a nasopharyngeal coil is an extremely rare event. Patient. We present a case of a 61-year-old patient with a recurrent undifferentiated nasopharyngeal carcinoma (NPC) treated with severe epistaxis. Initially, epistaxis was successfully controlled by a nasal packing. Recurrent bleeding despite packing required a neuroradiological intervention. An intracranially ruptured pseudoaneurysm was detected by magnetic resonance imaging (MRI) and computed tomography (CT), originating from the internal carotid artery at the junction of the petrous part to the cavernous part. Coiling and endovascular plug embolization was performed for the treatment of aneurysm. Ten months later, the patient removed a foreign body out of his left nose. It was dislocated coil material due to radionecrosis. MRI confirmed sufficient embolization of the internal carotid artery. Conclusions. This case report highlights the possibility of a nasopharyngeal coil dislocation of an embolized internal carotid artery aneurysm emerging as a nasal foreign body.

Unexpected acute pulmonary embolism in an old COVID-19 patient with warfarin overdose: a case report

Background Severe acute respiratory syndrome coronavirus 2 disease is strongly associated with a high incidence of thrombotic events. Anticoagulation could be a cornerstone in successfully managing severe forms of coronavirus disease 2019 (COVID-19). However, optimal anticoagulant dosing in elderly patients is challenging because of high risk of both thrombosis and bleeding. Case summary We present here the case of an 89-year-old patient receiving warfarin for atrial fibrillation and valvular heart disease, admitted to the intensive care unit for respiratory failure due to COVID-19. The patient presented with a severe epistaxis associated with warfarin overdose [international normalized ratio (INR) > 10]. After a successful initial reversal using vitamin K per os, INR values greatly fluctuated up to 10, requiring repeated administrations of vitamin K. Despite starting low-molecular-weight heparin therapy at therapeutic dose as soon as INR value was below 2.0, the patient further developed an acute bilateral and proximal pulmonary embolism concomitantly with a sharp D-dimer increase. The combination of azithromycin intake, a known inhibitor of CYP2C9, with the presence of CYP2C9*2 and −1639G>A VKORC1, two variants associated with warfarin hypersensitivity, have likely contributed to explain the warfarin overdose and the difficulty to reverse warfarin effect in this patient. Discussion This case report illustrates the complexity of COVID-19 pathophysiology and its management for physicians, especially in patients receiving vitamin K antagonists (VKAs). Infection, concurrent medication use, and pharmacogenetic factors involved in VKA metabolism and pharmacodynamics may lead to a loss of control of anticoagulation. Pulmonary embolism should still be considered in COVID-19 patients even with effective or overdosed anticoagulant therapy.

Analysis of risk factors in patients admitted with epistaxis

<p class="abstract"><strong>Background:</strong> Epistaxis can be classified into anterior and posterior epistaxis. All bleeding occurs as a result of disruption of the intact nasal mucosa, whether due to trauma, inflammation, or neoplasm. Management depends on the severity of the bleeding and its underlying cause.</p><p class="abstract"><strong>Methods:</strong> This study was done in department of otorhinolaryngology in a tertiary care centre from September 2018 to December 2020. A total of 143 patients were studies. All patients admitted in our department as a case of epistaxis were analysed for the risk factors present in them which could be the cause of epistaxis.</p><p class="abstract"><strong>Results:</strong> In our study it was seen the risk factor involved in majority of patients was hypertension (70%), followed closely by diabetis mellitis and deranged coagulogram (65%). Chronic kidney disease was an associated risk factor in 64% of patients. All these factors cause microangiopathies which in turn lead to bleeding.</p><p class="abstract"><strong>Conclusions:</strong> The current study can be taken as indirect evidence that while raised blood pressure is seen in patients with severe epistaxis but in general the diseases associated with microangiopathies.</p>

Intraoperative variations of the sphenopalatine artery between epistaxis and non-epistaxis cases: a comparative endoscopic analysis

Background Severe epistaxis is one of the most common emergencies in rhinology practices. The commonly used endoscopic cauterization of the sphenopalatine artery (SPA), alone or with the anterior ethmoidal artery (AEA), has a high success rate for controlling severe epistaxis. The current study was conducted to evaluate the endoscopic intra-operative variations of SPA between epistaxis and non-epistaxis cases. Forty consecutive patients who underwent exploration of SPA were included in the study. They were distributed into two groups depending upon the indication of SPA exploration; the epistaxis group (group A, n=25 patients, n=26 sides) and the non-epistaxis group (group B, n=15 patients, n=25 sides). Criteria of the main SPA in the two groups were compared regarding four parameters; arterial diameter, arterial adherence to the mucosa of the lower part of the basal lamella, sphenopalatine nerve bundle, and crista ethmoidalis erosion. Results A significant difference was found regarding the diameter of SPA between the two groups; a mean diameter of 4.2±0.64 mm was compared to 3.2±0.35 mm for group A and B, respectively (p=0.043). Moreover, a highly significant tendency was observed regarding the arterial adherence to the mucosa of the lower part of the basal lamella and sphenopalatine nerve bundle in the epistaxis group; (p≤0.01). Conclusion These data clearly signify the importance of intraoperative identification of SPA criteria during surgical management of severe epistaxis. These criteria may help in altering the surgical decision between solely SPA and concomitant SPA/AEA cauterization.

Outcome of treatment for severe epistaxis: nasal packing and endoscopic sphenopalatine artery ligation

Background: Severe epistaxis is a frequent emergency condition encountered by otolaryngologists and is often treated with nasal packing. In the event of failure surgical treatment is considered. We aimed to evaluate the efficacy of Nasal Packing (NP) and Endoscopic Sphenopalatine Artery Ligation (ESPAL) as treatment of severe epistaxis in terms of failures and recurrences including risk factors. Methodology: Retrospective descriptive study of patients with epistaxis treated with NP, admitted to an ENT department from 2011-2017. If initial treatment with NP failed, patients were considered for ESPAL. Results: An analysis of 511 patients was performed. All patients were treated with NP at the time of admission, and 14% of pa- tients were treated with ESPAL due to failure of NP. The majority of patients was only admitted once. Twelve percent were readmit- ted within 30 days, 7% were readmitted >30 days later. Treatment failure after ESPAL was 7.9%. No significant difference in the risk of readmission was found between patients treated with NP alone and patients treated with ESPAL. Conclusion: The majority of epistaxis patients were effectively treated with NP alone. We found good effect of ESPAL although no significant differences in risk of readmission NP vs. ESPAL were identified.