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+A 64 year old female known for HHT is referred to our clinic for recurrent epistaxis for nearly 50 years.
+She has had recurrent symptoms since the age of 16 when her condition was diagnosed.
+All three of her siblings also were diagnosed with HHT and her mother passed away from an intracranial hemorrhage.
+Eight years prior to presentation she had undergone a left-sided septodermoplasty via a lateral rhinotomy approach.
+This operation had significantly reduced the frequency of her symptoms and for several years her epistaxis was under control with the use of low dose thalidomide.
+However, she was referred to our clinic due to increased epistaxis severity and frequency over the prior 12 months necessitating more frequent transfusions.
+At the time of consultation the patient was concerned about daily severe left sided epistaxis despite several months use of topical bevacizumab and oral tranexamic acid.
+She required intravenous iron and blood transfusions every two months.
+Her baseline hemoglobin at the time of our consultation was 75 g/L (normal = 120 – 160 g/L).
+Her HHT epistaxis severity score [17] was severe (normalized score 9.49).
+On examination, she had multiple telangiectasia on her fingers, face, lips and palate.
+Her endoscopic examination revealed bilateral telangiectasia along the nasal septum.
+There was extensive crusting along the entire left nasal cavity with which any manipulation resulted in immediate profuse epistaxis.
+Given the severity of the patient’s epistaxis despite medical therapy, she was offered endoscopic left-sided septodermoplasty.
+The surgical goals were to improve her quality of life by reducing the number and severity of epistaxis episodes while diminishing the need for blood transfusions.
+The patient was content with the treatment plan and agreed to undergo surgical intervention.
+The endoscopic procedure was performed under general anesthesia with endotracheal intubation.
+The nasal cavity was prepared by inserting pledgets soaked in topical adrenaline (1:1000) placed in both nostrils for decongestion.
+Using a zero degree endoscope the residual STSG and mucosa of the left septum was dissected in a supraperichondrial plane that resulted in the expected significant diffuse hemorrhage.
+Immediate hemostasis was attained using a topical gelatin-thrombin matrix, Floseal (FloSeal Hemostatic Matrix; Baxter Healthcare Corporation, Deerfield, IL, USA) (Fig.1).
+The mucosal defect (Fig.2) measured approximately 3 cm in anterior-posterior dimension.
+A 4 x 2 cm split thickness skin graft was harvested from the right thigh, pie-crusted with a 15 blade and then placed endoscopically along the length of the septal defect.
+As seen in Fig.3, the graft was placed with an overlap of the mucosa of the nasal floor and the residual superior septal mucosa.
+Finally, 2 mL of fibrin sealant (TISSEEL fibrin sealant, Baxter Healthcare Corporation, Deerfield, IL, USA) was then applied first to the edges then central portion of the STSG (Fig.4).
+Packing was not used post-operatively and the patient was discharged home on the same day of surgery.
+Clinical follow-up two weeks after surgery (Fig.5) showed that the entire graft had taken and the left-sided epistaxis had dramatically diminished.
+The patient was very content with the results of the procedure.
+At 6 months follow-up, her baseline hemoglobin had improved to 102 g/L and she was requiring transfusions every 4 months with her hematologist’s intent to stop the transfusions if her hemoglobin remained greater than 100 g/L.
+Her epistaxis severity score at 6 month follow up was mild (normalized score 3.05).