Year : 1972 | Volume
: 20 | Issue : 3 | Page : 136--138
Severe epistaxis after dacryocystorhinostomy
RC Saxena, M Bhatia, VB Pratap
Department of Ophthalmology, King George's Medical College, Lucknow, India
R C Saxena
Department of Ophthalmology, King George«SQ»s Medical College, Lucknow
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Saxena R C, Bhatia M, Pratap V B. Severe epistaxis after dacryocystorhinostomy.Indian J Ophthalmol 1972;20:136-138
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Saxena R C, Bhatia M, Pratap V B. Severe epistaxis after dacryocystorhinostomy. Indian J Ophthalmol [serial online] 1972 [cited 2021 Sep 25 ];20:136-138
Available from: https://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.
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.
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  , 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  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.
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.
|1||Dena, F. P., Society Proceedings, N.Y. Society for Clin. Ophth. (April, 1957). Am. J. Ophth., Vol. 46, 86-87, (1958).|
|2||McPherson, S. D. Jr. DuBose, C. Dacryostorhinostomy Am. J. Ophth. Vol. No. 3, 328-331, (1959).|