A clinical case. Stopping dangerous nosebleeds

 

With arterial nosebleeds (damage to sufficiently large vascular trunks, which are mainly localized in the walls of the deep parts of the nasal cavity), the volume of blood loss increases rapidly, which can be life-threatening. It is extremely rare to stop such bleeding on your own. In such cases, tightly obturating nasal tampons are used, which remain in the nasal cavity for 3 to 7 days. During this time, the patient is under the supervision of a doctor on an outpatient basis.

 

This type of bleeding occurred in a patient who came to our clinic for the first time, and at first the doctors did not understand the causes of it. During the examination, it turned out that the patient suffers from arterial hypertension, which he did not know about. The probable weakness of the vascular wall in combination with a slight increase in blood pressure (up to 150 mmHg) on the background of stress caused bleeding from one of the arteries feeding the brain and nasal cavity. 

 

Anatomically, the mucous membrane of the anterior and posterior nasal sections is fed by branches of the cranial, anterior and posterior latticed and upper labial arteries, which are branches of the internal and external carotid arteries. High blood pressure in these vessels causes extremely intense bleeding and makes it difficult to identify the artery that is the source of epistaxis. 

 

Upon admission to the emergency department, the patient underwent an anterior nasal tamponade in parallel with intravenous massive hemostatic therapy and the administration of drugs to lower blood pressure. Since the anterior tamponade did not stop the bleeding, after a while the on-duty otorhinolaryngologist installed tampons in the posterior nasal cavity. 

 

None of the above treatment methods proved effective, and due to the loss of a large amount of blood, the patient's hemoglobin decreased, weakness and dizziness appeared, so it was decided to conduct urgent surgery to stop the bleeding. At the first stage, it was necessary to find out which of the branches of the carotid artery was bleeding. The anesthesiologists medically lowered the pressure to a level at which the bleeding was stopped. An endoscopic examination of the nasal cavity revealed that the source of the problem is the anterior latticed artery, which passes through the orbit of the eye. When the source of nosebleeds is the latticed arteries (branches of the internal carotid artery), endonasal dissection of the latticed labyrinth on the bleeding side can be performed, however, surgeons Jean-Rene Millier and Romanova Olga Nikolaevna decided to clip the latticed artery through the eye socket above the rupture site. An incision was made between the inner edge of the eye socket and the bridge of the nose. The artery was sealed with two metal staples. The operation lasted about 20 minutes, and the performed manipulations helped to stop the bleeding. In the postoperative period, there was a redistribution of the volume of blood flow through the extensive network of anastomoses of the facial vessels, and the blockage of the anterior latticed artery did not cause negative consequences in the blood supply to the organs. The operation did not affect the appearance and function of the eye. 2 hours after the end of the operation, the patient was fully conscious. He was in the hospital under the supervision of a doctor for another 3 days. The stitches were removed 7 days later. Due to the cosmetic suture applied to the surgical wound, there was practically no trace of the incision on the face. After completing the treatment, the patient was advised to consult a cardiologist in order to prescribe a course of treatment to stabilize blood pressure and avoid recurrence of complex bleeding in the future.