İnternal carotid artery (ICA) aneurysms are rare but they can cause high morbidity and mortality. Although these aneurysms are usually asymptomatic, they can reach huge sizes and compress the surrounding neurovascular structures. Patients typically present with neurologic symptoms due to cranial nerve compression. If they rupture, they can lead to massive epistaxis and autorage. In physical examination, pulsatile mass in the middle ear or nasal cavity can be seen. If there is a clinical suspicion of an ICA aneurysms, diagnostic radiological imaging should be performed before the surgical procedure or biopsy. Cerebral digital subtraction angiography (DSA) should be performed for definitive diagnosis. After diagnosis, appropriate endovascular or open intervention should be performed. In this case report, we present a 48-year-old female patient with severe epistaxis complaint due to an ICA aneurysm. This report aims to present this case and review the current literature.

Trastuzumab emtansine (T-DM1) is a targeted therapy combining trastuzumab and emtansine for human epidermal growth factor receptor 2(HER2)-positive breast cancer, with common side effects including fatigue, nausea, pain, headache, low platelet count, and elevated liver enzymes. Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant vascular dysplasia characterized by vascular malformations and telangiectasias in various organs. We present a case of a female patient with advanced breast cancer who developed HHT-like symptoms while on T-DM1 treatment. A 59-year-old woman treated with radiotherapy and T-DM1 every 21 days developed recurring nosebleeds and mucocutaneous and liver telangiectasias indistinguishable from HHT three months after receiving the first dose of T-DM1. Other organ vascular malformations were ruled out through screening protocols. The patient had no previous HHT symptoms or family history. Nasal care measures like lubrication and antifibrinolytics (tranexamic acid) were provided. In addition, propranolol was also prescribed due to its antiangiogenic and antitumoral properties, leading to significantly decreased epistaxis and telangiectasias. Microtubule disruptions caused by T-DM1, along with other angiogenic mechanisms may contribute to the development of telangiectasias resembling HHT. The use of propranolol, an initial approach for HHT, proved to be effective in this case. It is crucial for oncologists and HHT specialists to be aware of this rare adverse event associated with T-DM1 and to implement appropriate management strategies.

Selective serotonin reuptake inhibitors are associated with an increased risk of bleeding, most commonly intracranial and gastric bleeding, especially in conjunction with anticoagulant use. Although uncommon, escitalopram is associated with epistaxis in a dose-dependent manner. Dosage reduction may be sufficient in management.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive syndrome of excessive immune activation. It usually occurs in children, mainly during the first year of life. Primary hemophagocytic lymphohistiocytosis is more common and usually occurs in immunocompromised patients. Secondary hemophagocytic lymphohistiocytosis, on the other hand, is less common, especially in immunocompetent patients. Here, we intend to present a case of a 55-year-old male patient who had no known immune deficiency, presented with epistaxis, and was found to have Epstein-Barr virus (EBV)-induced hemophagocytic lymphohistiocytosis.

BACKGROUND: Immunoglobulin G4-related disease is marked by extensive inflammation and fibrosis of an unknown autoimmune component, with an overall incidence ranging from 0.78 to 1.39 per 105 person-years. Sinonasal immunoglobulin G4-related disease is atypical and exceedingly uncommon in the existing literature, frequently manifesting clinically as chronic rhinosinusitis, epistaxis, and facial pain.
METHODS: This report describes a 25-year-old Iraqi female who has been suffering from symptoms of chronic rhinosinusitis for 8 years. Despite undergoing several surgeries, there has been no improvement in her symptoms. A tissue biopsy that revealed dense lymphoplasmocytosis with noticeable plasma cell infiltration, storiform fibrosis, and obliterative angitis, along with positive immunohistochemical staining for Immunoglobulin G4 plasma cells, finally confirmed the diagnosis of sinonasal immunoglobulin G4-related disease. The patient responded well to oral prednisolone and methotrexate treatments.
CONCLUSIONS: The main objective of the current report is to raise awareness among physicians about the significance of promptly identifying and diagnosing this rarity, thus preventing the adverse consequences linked to delayed diagnosis and treatment initiation.

Retiform hemangioendothelioma (RH) is a rare intermediate (locally aggressive) vascular tumor that mostly affects the dermis of the trunk and limbs, but has never been reported in the inferior turbinate. A 10-year-old Chinese boy presented with recurrent epistaxis in his left nasal cavity and anemia for more than 2 years. Radiographic and electronic video laryngoscopic images showed an expansile mass in the left inferior turbinate. Endoscopic surgery and electrocautery were performed to resect the tumor beyond the macroscopic border. Histopathologically, the tissues were infiltrated by hyperplastic blood vessels arranged in a retiform pattern, and endothelial cells proliferate significantly in some areas. Immunohistochemistry showed a positive result for CD31, CD34, Fli-1, and ERG. No epistaxis, tumor recurrence, or metastasis was found on reexamination over 18 months after surgery.

Osler-Weber-Rendu syndrome or Hereditary Haemorrhagic Telangiectasia (HHT) is a rare condition, with very few reported cases, especially in Pakistan. As healthcare workers, we encounter multiple cases of recurrent epistaxis in the emergency as well as outpatient departments. However, patients are usually treated symptomatically without a thorough workup. HHT should be considered among the differentials for recurrent epistaxis, as a clinical diagnosis can be made with detailed family history and physical examination. Here is the case of a 58-year-old male who presented to the Gastroenterology OPD, Combined Military Hospital, Lahore, in November 2021, with complaints of generalised weakness and blood in stools. He had a history of recurrent epistaxis and telangiectasias, and further inquiry revealed a strong family history of similar symptoms. He was diagnosed as a case of Osler-Weber- Rendu Syndrome. Informed consent was taken from the patient prior to the writing of the manuscript.

Post-traumatic pseudoaneurysms of the internal carotid are a rare but potentially fatal cause of epistaxis; they are associated with fractures of the base of the skull with involvement of the carotid canal. Endovascular management is the preferred therapeutic strategy, with optimal long-term results and low complication rates. Complications may include thromboembolic events, infarction of perforating arteries, and rupture of the pseudoaneurysm. We present a case of a 28-year-old male with a post-traumatic pseudoaneurysm of the internal carotid who was managed with endovascular therapy. A late complication was the extrusion of the embolization material into the nasal cavity and nasopharynx, which was safely and effectively treated through endovascular and endoscopic approaches.

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Lobular capillary hemangioma is a benign lesion commonly affecting the head and neck region. However, in children, it is commonly seen in the buccal mucosa, gingiva, and the tongue, but its presence in the nasal cavity is less frequent. The most common symptoms of nasal hemangiomas are epistaxis and nasal obstruction. However, we present a case of a thirteen-year-old male having intranasal lobular capillary hemangioma with a 2-day history of left-sided epistaxis. The diagnosis is confirmed by histological examination, and the treatment is done by endonasal endoscopic excision of the hemangioma with cauterization of the feeding vessel has performed to remove the lesion completely. Moreover, the diagnosis of lobular capillary hemangioma must always be kept in mind when discussing the differential diagnosis of a bleeding mass within the nasal cavity, even though it is a rare condition and surgical excision is still the preferred first-line treatment.