26714786 Visualization

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