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Arifov Sayfitdin Saidazimovich, Tashkent institute of advanced doctors Umarov Ravshan Ziyaiddinovich, Tashkent institute of advanced doctors Khushbakov Abdumumin Chorievich, Tashkent institute of advanced doctors Yunusova Gulnoza Yarkinovna, Tashkent institute of advanced doctors E-mail: bonusha-uz@list.ru
CASE OF BLEEDING FROM THE INTERNAL CAROTID ARTERY WITH A LETHAL OUTCOME
Abstract: The aim of this research was to present a clinical case of profuse nasal bleeding associated with a complication of invasive fungal sinusitis, leading to arrosive bleeding from the internal carotid artery. The study showed that the observation confirms once again the need to provide close attention and conduct an in-depth examination in the first episode of nasal bleeding, especially when it is not revealed its source and the presence of destruction of the bony walls of the nasal cavity and paranasal sinuses to consider as a potential potential cause of profuse bleeding.
Keywords: nasal bleeding, internal carotid artery, fungal sinusitis, nasal cavity and paranasal sinuses.
Nasal bleeding (NB) ranks first in frequency among vative treatment in the clinic in the community. After treat-
spontaneous bleeding and is one of the most common indications for emergency hospitalization (up to 20.5% of all urgent conditions) [1]. Bleeding of this localization is controlled with difficulty and in 7-10% of observations lead to fatal outcomes. The causes of NB are not always obvious. As a rule, these bleedings are single, but in 4% of cases they are persistent and recurrent, representing a real threat to the life of the patient [2]. This group includes profuse bleeding from the internal carotid artery (ICA) [3-6]. Bleeding from the ICA is rarely observed. Special difficulties are caused by the diagnosis of rare diseases and pathological conditions for which nosebleeds are uncharacteristic [7].
We present a clinical case of profuse nasal bleeding associated with a complication of invasive fungal sinusitis, leading to arrosive bleeding from the internal carotid artery.
Patient N. K., born in 1986, resident of Takhtakupyr district ofthe Republic of Karakalpakstan, arrived at 15:30 hours on 7 July 2016 as a matter of urgency in the ENT department of the first clinical hospital in Tashkent.
Complaints on admission to pain in the left half of the face, left orbit, headache, difficulty in nasal breathing on the left and the presence of purulent discharge with an unpleasant smell on the same side, reduced left vision, swelling of the eyelids and protrusion of the left orbit, severe weakness.
From the anamnesis, it was found out that 5 months ago, with complaints of nasal congestion on the left, difficulty in breathing and the presence of purulent discharge from this side, the discharge towards the nasopharynx received conser-
ment, some clinical improvement was noted. In June, congestion and difficulty breathing from the left half of the nose, as well as discharge into the nasopharynx, increased. The patient began to notice the discharge of purulent discharge with an unpleasant odor on this side. For several days in the clinic at the place of residence was conducted conservative therapy, but due to the lack of effect from the activities, as well as due to the appearance of edema of the eyelids, exophthalmos on the left, the patient was sent for in-depth examination and treatment in Tashkent.
According to the patient's brother in history in May 2016, acute renal failure occurred as a complication of the nephrotic form of chronic diffuse glomerulonephritis, which previously had no manifest clinical manifestations. In this regard, started conservative therapy, and held 5 sessions of hemodialysis. After the end of the hemodialysis sessions as prescribed by the doctor, the patient received systemic glucocorticoid therapy with prednisone for one month, and subsequently arbitrarily sharply reduced the recommended dose and mode of prednisolone. At the time of treatment, medical documents, specifying the above pathology are not presented.
It was also found that 29 June 2016 and 3 July 2016, nose bleeds from the left half of the nose were noted with an approximate volume of 200-250 ml, which were stopped by anterior tamponade of the nose and hemostatic therapy.
Within 9 days prior to hospitalization in the ENT department of the first clinical hospital in Tashkent, a survey was conducted in various clinics, including a MSCT of paranasal
Section 2. Medical science
sinuses, a histological examination of biopsy material taken from the nasal cavity.
Conclusion MSCT of the nose and paranasal sinuses of 30 June 2016 - complete homogeneous darkening of all the paranasal sinuses with a density of35-80 HU. In the main sinus on the left against the background of homogeneous darkening, the presence of single dense small foci with a density of 95-130 HU is determined. Marked bone destruction in the lateral wall of the main sinus on the left.
The conclusion of the oncologist from 06 July 2016: Thrombosis of the cavernous sinus. Syndrome of the upper eye gap. Based on clinical, radiological, morphological studies, a tumor of the nose and paranasal sinuses is excluded.
The conclusion of the ophthalmologist: exophthal-mos. Subperiosteal abscess of the orbit. Defeat n.abducens, n.oculomotorius.
Objective status at the time of going to the clinic: the general state of moderate severity, conscious, sluggish, the skin and visible mucous membranes are pale. Blood pressure is 90/60 mm Hg. Pulse 89 beats per minute, weak filling. There is an exophthalmos on the left with the displacement of the eyeball to the outside, ptosis of the upper eyelid, chemosis, injection of the conjunctival vessels, restriction of the mobility of the eyeball to the left outwards.
Anterior rhinoscopy: on the left, the mucous membrane of the nasal cavity is hyperemic, the lower and middle nasal conchae are swollen, are reduced after anemization; Signs of nasal bleeding are not available. Other ENT organs without pathology.
The patient was hospitalized as a matter of urgency in the ENT department. It was decided to conduct surgery on the same day in an urgent manner after further examination and preparation of the patient.
In 16:10 of 07 July 2016, that is, in the process of preoperative preparation (in the 40th minute of being in the ward), a spontaneous massive bleeding from the left half of the nose appeared in the patient's ward bed. Developed acute hem-orrhagic shock. The doctors on duty attempted to impose a rear tampon. In parallel, appropriate resuscitation measures were performed in the ward - a closed heart massage, artificial mouth-to-mouth breathing. In spite of the measures taken, in 16:15 the resuscitating physician who arrived at the department stated biological death.
Final diagnosis:
Primary: Exacerbation of chronic purulent pansinusta. Complications: Subperiosteal abscess of the orbit. Defeat n.abducens, n.oculomotorius. Profuse arrosive nasal bleeding due to the destruction of the lateral wall of the left main sinus. Acute hemorrhagic shock IV degree. Aspiration syndrome. Acute post-hemorrhagic anemia severe.
Companion: Chronic diffuse glomerulonephritis. Ne-phrotic form.
Conclusion morphological studies: In the lumen of the main sinus on the left and posterior cells of the ethmoid bone on the same side, isolated dull, dense consistency, gray-brown pieces (formations) ranging in size from 0.4 cm to 4 cm with a rough surface, thick purulent discharge were found. In the lumen of all other paranasal sinuses there is a thick purulent discharge. The mucous membrane of the paranasal sinuses is thickened due to their hyperplasia.
Histological examination of the mucous membrane of the main sinus of the posterior group of ethmoid cells revealed areas with polypoid growths and signs of chronic inflammation, extensive areas of necrotic masses, including mycotic druses from interwoven mycelium strains, invading into the deep layers of the mucous membrane and underlying tissues, lesion of the vascular walls with pronounced tissue necrosis.
The pathoanatomical diagnosis of 07 July 2016:
Primary: Chronic suppurative hyperplastic sphenoiditis, frontal sinusitis, ethmoiditis, antritis on both sides. Subperi-osteal abscess of the orbit.
Complications: Exophthalmos. Partial destruction of the side wall of the left main sinus and the Turkish saddle. Arro-sive bleeding from the internal carotid artery. Destruction of the left cavernous sinus. Post-hemorrhagic anemia. Purulent fusion of the pituitary gland.
Companion: Chronic glomerulonephritis. Pyelonephritis.
The results of cultural mycological research revealed mold fungi of the genus Aspergillus flavus.
Thus, on the basis of an assessment of the clinical course of the disease, the results of instrumental and histological studies, the patient had an acute (fulminant) form of invasive fungal sinusitis. This is consistent with the data of literary sources [8].
This observation once again confirms the invasive course of fungal lesions of paranasal sinuses with the destruction of their bone walls. The peculiarity of this observation is that the relatively massive lateral bony wall of the main sinus was subjected to destruction, which created the conditions for unimpeded arrosion of the internal carotid artery wall. In the literature available to us, we did not find a description with a similar mechanism for the development of bleeding from the internal carotid artery.
Our observation confirms once again:
- the need to provide close attention and conduct an in-depth examination in the first episode of nasal bleeding, especially when it is not revealed its source;
- the presence of destruction of the bony walls of the nasal cavity and paranasal sinuses to consider as a potential potential cause of profuse bleeding.
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