Management of recurrent epistaxis in an anticoagulated patient by temporarily closing the nares with sutures.

Abstract

We describe an unusual case of recurrent, refractory anterior epistaxis in an 86-year-old man with two mechanical heart valves who was on permanent warfarin therapy. His numerous episodes of epistaxis were incited by chronic nose-picking and strong nose-blowing, practices that he continued to engage in despite repeated medical advice to stop. Stopping his anticoagulation therapy was not considered as a management option because of an unacceptably high risk that this would lead to a thromboembolic event. Eventually, we temporarily sutured his nares closed, and his nosebleeds ceased. The suturing was performed in the ward with local anesthesia. This procedure was simple to perform, fairly well tolerated, easily reversible, and highly effective.

Introduction

Epistaxis is one of the most common reasons for emergency admissions to ENT wards. (1) When epistaxis occurs in a patient who has a coagulopathy or who is taking warfarin, it can be difficult to treat; the need to arrest the epistaxis must be balanced against the risk of inciting a thromboembolic event by stopping the warfarin. (2) Prevention of bleeding in such cases can be complicated by repeated nose-picking and strong nose-blowing in defiance of medical advice. In this article, we describe a novel method of preventing nasal trauma and promoting healing in a patient with a long history of recurrent, refractory epistaxis.

Case report

The patient was an 86-year-old man who had been repeatedly presenting to the ENT Department with refractory bilateral anterior epistaxis. He had two mechanical heart valves and was on permanent warfarin therapy, which made both the prevention and treatment of his epistaxis difficult. Prevention was also complicated by the fact that he engaged in chronic nose-picking and strong nose-blowing despite repeated advice to cease.

Previous hospitalizations. During a 4-year period, the patient had been admitted 13 times: twice in 2001, five times in 2003, and six times in 2004. His five most recent admissions had occurred within a period of 3 months.

During each of the patient's admissions, he underwent a general examination, cardiovascular assessment, rigid nasendoscopy, and serology, which included measurements of the complete blood count, urea and electrolyte levels, liver function, and coagulation parameters, including the international normalized ratio (INR). During his series of admissions, his INR ranged from 2.7 to 5.0 (mean: 3.8; target: 3.5 to 4.5) and his hemoglobin level ranged from 8.1 to 12.2 g/dl (mean: 9.89; normal: 13.0 to 18.0). The INR was checked once daily, and the warfarin dose was titrated to achieve the target. During a hematology and cardiology consult, we were advised that stopping the warfarin or even lowering the target INR should not be attempted because doing so would raise the risk of a thromboembolic event to an unacceptably high level.

During most of the previous admissions, treatment involved cauterization and/or nasal packing with a Merocel sponge:

* On four occasions, the patient underwent both cauterization and nasal packing with a Merocel sponge.

* Three times, he was treated with cauterization only.

* On four occasions, he underwent Merocel packing only.

* During one admission, he was packed with bismuth iodoform petrolatum paste after Merocel packing had failed.

* On one occasion (his most recent visit), the epistaxis resolved spontaneously.

In addition, silver nitrate was applied to a bleeding point whenever one was visible. Bedrest was instituted, and the nasal packs were kept in place for 24 to 48 hours. The length of hospital stay ranged from 1 to 15 days (mean: 4.7). The patient responded well to these treatments, and he did not require surgical intervention under general anesthesia at any time.

Current encounter. Although the patient's most recent epistaxis had resolved spontaneously, he agreed to undergo suturing to close the nares as a means of preventing nasal trauma and promoting healing. The procedure was performed in the ward with local anesthesia. A 1-0 Ethilon suture was placed through the nose from one side to the other and back again. A knot was tied and supported by a piece of Silastic to prevent pressure necrosis (figure).

The patient was observed overnight, and he experienced no complication. He was discharged and scheduled for follow-up in 2 weeks. At follow-up, he reported no further nosebleeds, although he did complain of some discomfort. Two weeks later, he was still experiencing discomfort, and the suture was removed. For the next 4 months, he was evaluated monthly in the ENT outpat lent clinic, and he reported no further episodes of epistaxis then or thereafter.

Discussion

For a patient with an artificial heart valve, stopping anticoagulation therapy would increase the risk of a thromboembolic event to approximately 6 to 10% per year? We deemed this risk unacceptably high for our patient, who had recurrent anterior epistaxis. Therefore, for most of his treatment course, we tried routine measures. But eventually, the patient said that the frequency of his bleeds and the subsequent hospital admissions had become unacceptably disruptive, so we performed nasal cavity closure. The closure was intended to prevent further digital trauma, discourage strong nose-blowing, promote the formation of adhesion tissue, and allow the traumatized nasal mucosa to heal.

For several reasons, most patients with chronic nose-bleed would not agree to undergo such a procedure. Outward appearances aside, many patients would fear that they would experience problems with respiration and olfaction. Because adults are facultative nose breathers, respiration would not be a problem, but they would notice a decrease in their sense of smell, and they would experience a feeling of nasal blockage. In our elderly and infirm patient, however, the episodes of epistaxis were intractable, morbid, and potentially life-threatening, and his compliance with simple advice on nasal care was poor. Therefore, we deemed it necessary to proceed with the closure procedure. Fortunately, our patient did not consider the aesthetic result to be an important issue.

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Lund and Howard (4) and Gluckman and Portugal (5) have reported that formal closure of the nasal cavities under general anesthesia for the treatment of refractory epistaxis (modified Young procedure) was successful in patients with hereditary hemorrhagic telangiectasia. However, both sets of authors reported clinical relapse following reopening of the nose. Brooker and Cinnamond described the successful prevention of epistaxis with closure of the nostrils for self-inflicted digital trauma. (6) In our patient, the procedure was simple to perform, fairly well tolerated, easily reversible, and highly effective.

References

(1.) Srinivasan V, Patel H, John DG, Worsley A. Warfarin and epistaxis: Should warfarin always be discontinued? Clin Otolaryngol Allied Sci 1997;22(6):542-4.

(2.) Walshe P, Harkin C, Murphy S, et al. The use of fibrin glue in refractory coagulopathic epistaxis. Clin Otolaryngol Allied Sci 2001;26(4):284-5.

(3.) Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994;89(2):635-41.

(4.) Lund VJ, Howard DJ. Closure of the nasal cavities in the treatment of refractory hereditary haemorrhagic telangiectasia. J Laryngol Otol 1997;111 (1):30-3.

(5.) Gluckman JL, Portugal LG. Modified Young's procedure for refractory epistaxis due to hereditary hemorrhagic telangiectasia. Laryngoscope 1994;104(9):1174-7.

(6.) Brooker DS, Cinnamond MJ. Young's procedure in the treatment of epistaxis. J Laryngol Otol 1991; 105(10):847-8.

Chee-Yean Eng, MBChB, MRCS; Teck-Aun Yew. MBChB; Wai-Siene Ng, MBChB; Amged S. El-Hawrani, FRCS(ORI-HNS)

From the ENT Department, Raigmore Hospital, Inverness, U.K.

Corresponding author: Dr. Chee-Yean Eng, 7 Hallamshire View, Sandygate, Sheffield S10 5ST, UK. Phone: [phone]; fax: [phone]; e-mail: [e-mail]