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ARTICLES
Year : 1972  |  Volume : 20  |  Issue : 3  |  Page : 136-138

Severe epistaxis after dacryocystorhinostomy


Department of Ophthalmology, King George's Medical College, Lucknow, India

Correspondence Address:
R C Saxena
Department of Ophthalmology, King George's Medical College, Lucknow
India
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Source of Support: None, Conflict of Interest: None


PMID: 4668489

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How to cite this article:
Saxena R C, Bhatia M, Pratap V B. Severe epistaxis after dacryocystorhinostomy. Indian J Ophthalmol 1972;20:136-8

How to cite this URL:
Saxena R C, Bhatia M, Pratap V B. Severe epistaxis after dacryocystorhinostomy. Indian J Ophthalmol [serial online] 1972 [cited 2019 Dec 7];20:136-8. Available from: http://www.ijo.in/text.asp?1972/20/3/136/34653

After Dacryocystorhinostomy, mild epistaxis may commonly occur but is limited to the first 24 hours. Severe haemorrhage after 48 hours is un­common.

Recently, we came across a patient in whom severe epistaxis developed 96 hours after operation. Incidently the patient was suffering from syphilis. Hence, we present this case to consi­der if there can be any relationship of such a haemorrhagic complication taking place in patients with syphilis.


  Case Report Top


Patient R. K., aged 18 years, female unmarried, muslim, suffering from epiphora, came to the ophthalmic out­patients of G.M. and Associated Hos­pitals, Lucknow, in April, 1969. She had a small swelling in the lacrimal sac area of her left eye. On pressing, the fluid regurgitated both in conjunc­tival sac and the nostril. She was given 8 sittings of syringing with Crys­talline Penicillin 500,000 and 1/4 cc. (1 mgm.) of Dacadron dissolved in 10 cc of distilied water on alternate days. After a fortnight, the swelling disappeared and she got complete re­lief of her symptoms. In the second week of October, 1969, she developed epiphora again. This was followed by subacute dacryocystitis and abscess formation. This got burst and an ulcer developed in no time. With this, the patient was admitted to the inpatients on 17th October, 1969.

She had suffered from small pox 10 years back. There was no personal or family history of syphilis.

On examination, the patient showed inflammatory swelling with marked induration and a big discharging sinus below the medial palpebral ligament of the left eye. The discharge was thick and copious. E.N.T. check up revealed chronic tonsilitis, and deviat­ed nasal septum. Her gynaecological examination did not reveal any abnor­mality in favour of syphilis. The pa­tient did not show any stigmata of congenital syphilis.

Her total leucocytic count was 8,000/cmm. The differential leuco­cytic count showed polymorphs 63%, lymphocytes 35% and eosinophils 2%. Her E.S.R. was 44 mm. The pus from the wound was positive for pseudomonas pyocyaneous which was sensitive to Chloromycetin and Ery­thromycin. Her W. R. was strongly positive and V. D. R. L. weakly positive.

Besides the local dressings with Eusol pack and Magsulph cream the patient was put on oral Chloromycetin, for 6 days. In addition, she was giv­en a routine course of high (loses of parentral Penicillin, followed by P.A.M. and Bismostab for another 6 weeks to treat her syphilis. Vitamin C and B complex were other adju­vants.

With the above treatment, the ulcer cleared to form a lacrimal fistula.

On 8th December 1969, the patient was operated under general anaesthe­sia for Dacryocystorhinostomy after Dupuy-Dutemps and Bourgeuts tech­nique. Fistula was dissected away from the anterior wall of the sac and the opening in the sac was sealed. A small piece of the posterior wall of the sac was excised and sent for biopsy.

The operation had only moderate amount of bleeding.

During the first 24 hours there was slight epistaxis through the left nostril. First post-operative syringing with 4 % sterile sodium citrate solution was done after 72 hours which showed a freely patent passages. There was no regurgitation through the fistula. After 96 hours the patient started getting severe bout of epistaxis in which she lost nearly 100-125 cc. of blood be­fore it could be stopped.

The attending E.N.T. surgeon found arterial spurting. The bleeding was stopped by anterior nasal packs. In addition the patient was put on coagulants. Her blood was checked for bleeding, coagulation and clot retrac­tion time. It was within normal limits. Her platelet count was also normal. The nasal pack was removed after 72 hours. The stitches were re­moved on the 9th day of operation. No post-operative syringing was done for nearly one month. After this period, syringing with Penicillin lotion (10,000/units/cc.) showed absolute

I patency of the passages and the pa­tient had complete relief of symptoms. The incisional scar, however, was quite thick and prominent.

The biopsy of the posterior wall of the sac showed infiltration of chronic inflammatory cells only.


  Discussion Top


In the experience of the authors, luring the last 6 years this was the first case of Dacryocystorhinostomy in whom epistaxis occured after a period of 48 hours. An example of such severe haemorrhage, which occured in this case after 96 hours, could not be traced in available ophthalmic litera­ture. SAMUEL, MCPHERSON AND Du­BosE [2] , However mentioned a case in whom severe epistaxis due to mechani­cal factors developed on third day of operation.

In the pathogenesis of post-opera­tive epistaxis, DENA [1] has discussed the role of local trauma due to severe blowing of the nose and violent sneez­ing. No such factor was available in the present case.

The haemorrhage on the table was moderate which stopped before the wound was closed. Moreover, the la­boratory tests were not in favour of any bleeding diathesis.

In the mind of the authors, the source of spurting was from one of the branches of the sphenopalatine artery which supplies the mucous membrane covering the conchae, the meatuses and the septum. Syphilis is known to produce periarteritis and endarteritis of small vissels. It is be­lieved that such changes were present in the sphenopalatine artery of this case. Late haemorrhage, however, could be explained in two ways. Either, the patient developed second­ary hemorrhage due to infection or else the blood clot which formed on the leaking blood vessels, got dis­lodged by sodium citrate solution used for syringing. Since, there was no sign of secondary infection, the second cause appears more probable. The continuous spurting could be explained by the poor retraction of the branches of the sphenopalatine artery due to syphilitic 'periarteritis' and endarteritis.

Thus, it is advisable to restrict the use of sodium citrate solution in cases having arterial disease.

In the management, anterior nasal packing given to this patient did not produce any harmful effect on the passages.


  Summary Top


A patient, who developed severe epistaxis, 96 hours after dacryocys­torhinostomy has been described. The role of syphilitic periarteritis and en­darteritis of sphenopalatine artery in pathogenesis of severe epistaxis has been discussed. The value of anterior nasal packing in such cases has been emphasised.

 
  References Top

1.
Dena, F. P., Society Proceedings, N.Y. Society for Clin. Ophth. (April, 1957). Am. J. Ophth., Vol. 46, 86-87, (1958).  Back to cited text no. 1
    
2.
McPherson, S. D. Jr. DuBose, C. Dacryostorhinostomy Am. J. Ophth. Vol. No. 3, 328-331, (1959).  Back to cited text no. 2
    




 

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