A case of spontaneous hemorrhage into the maxillary sinus was encountered. The bleeding could be arrested only after diabetes, which was discovered during the course of this hemorrhagic condition, was successfully brought under control.
The patient was a 49-year-old male public service worker who began to have epistaxis on October 6, 1978. The bleeding occurred in a few episodes daily, though readily controllable each time. After receiving examination and treatment at internist's and surgeon's office, he visited the outpatient service of the Department of Otolaryngology, Hamanomachi Hospital to seek help for the disorder.
Rhinologic examination revealed polypoid enlargement of the left middle turbinate at its anterior tip and bleeding from the middle meatus on the same side. Under the diagnosis of hemorrhage from the left maxillary sinus he was hospitalized late in the evening of October 9.
The bleeding being considered idiopathic, steroid therapy was given.
After his hospitalization the bleeding continued to occur in repeated episodes. At around 7:00a.m. on October 12 he suddenly developed a fainting spell with incontinuence and convulsive seizures in an elevator while he was being taken in a wheel chair to the outpatient service to receive treatment for bleeding which occurred 2 hours previously. With treatment he recovered his consciousness in a matter of 5 minutes. His blood pressure was 98-56mmHg at the time of fainting, which was elevated to 110-70mmHg after the treatment.
On that day the patient was found to be positive for urinary glucose and his blood sugar was estimated at 185mg/dl. Subsequent determinations of glucose and insulin in a glucose tolerance test led to a diagnosis of primary chemical diabetes. At that time his red blood cell count was 241×10
4 and hemoglobin content was 6.9g/dl. However, aside from anemia, there was no evidence of hematological disorders.
The steroid therapy was replaced by a dietary regimen, under which the diabetes could successfully be brought under control without resorting to insulin and other remedies for diabetes. Hematopoietics were prescribed for anemia. He was free of epistaxis from October 12 onwards. Plain x-ray and tomography of his skull revealed a diffuse shadow in the left maxillary sinus but with no evidence of bone destruction. On October 19 puncture and lavage of the antrum performed via the middle meatus yielded a plenty of old clotted blood. Roentgenologic study with 20% moljodol instillation by antero-posterior projection failed to disclose any abnormalities in the sinusal mucosa, while lateral projections revealed a slight hypertrophy of the membrane lining the anterior wall of the sinus. Probe antrotomy was considered unnecissary under these circumstances. The polyp at the anterior tip of the middle turbinate was resected. Pathological examination demonstrated it to be of inflammatory origin. Henceforth there has been no recurrence of epistaxis.
Spontaneous intramaxillary hemorrhage is of rare occurrence. In the present case there was an intercurrent diabetes and the bleeding could be stopped only after the diabetes was adequately controlled. This fact suggests that the diabetes might be a significant factor in the causation of the intramaxillary hemorrhage.
Our experience tells that adrenocortical hormones are more effective than any hemostatic agents available to date in the management of spontaneous nasal bleeding. For this reason we used these steroids in the present case. Contrary to our expectations, however, this regimen worsened the diabets and protracted the bleeding. Emphasis must therefore be placed on the importance of monitoring patients for urinary and blood sugar while they are on adrenocortical hormones.
View full abstract