Carotid Blow-out syndrome: Challenges in management of epistaxis in a post-surgical intervention and radiated patient

Goh, Siang Poon and Rebecca, Welfred and Salina, Binti Hussain and Tang, Ing Ping (2021) Carotid Blow-out syndrome: Challenges in management of epistaxis in a post-surgical intervention and radiated patient. Medical Journal of Malaysia, 76 (1). p. 72. ISSN 0300-5283

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Abstract

Recurrent epistaxis is a red flag in post-nasal surgery and previously radiated cancer patients. The incidence of carotid blow-out syndrome is seven times higher in previously radiated patients. Today, nasal endoscopy has become an essential tool in our practice. It helps in identifying the source of bleeding and facilitates therapeutic management. On the other hand, radio imaging is highly sensitive and specific to detect vascular lesions. However, they are not perfect. This paper presents a treated sphenoid sinus carcinoma patient with the right internal carotid thrombosis who presented with sentinel epistaxis. Endoscopic nasal examination and radio imaging failed to identify the bleeder and misled to a wrong source of bleeding. The bleeder was finally detected via the examination under anaesthesia (EUA). The carotid blowout occurred intraoperatively. Management of this patient is extra challenging as the blow-out vessel was the only major blood supply to the anterior cerebral circulation. The haemostasis was secured with a muscular patch and a vascular stent inserted. He was free from the neurological deficit. Unfortunately, profuse epistaxis recurred on post-operative day five. Although nasal packing controlled his recurrent epistaxis, he developed anterior circulation infarct later on and succumbed to death. The authors wish to highlight the importance of EUA if radio imaging does not correlate to the clinical findings. Management options for carotid blow-out should tailor to the patients’ medical conditions.

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