Epistaxis is common in the paediatric population and is usually minor and self limiting. This case illustrates an atypical presentation of epistaxis with hypovolaemic shock due to a dissecting false aneurysm of the internal carotid artery caused by an impalement injury to the oropharynx.
- Dissecting aneurysm
- impalement of oropharynx
- internal carotid artery
- nose bleeds
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A mother and her 10 month old baby girl arrived in the paediatric accident and emergency department in the middle of the night with fresh blood soaking their nightclothes and smearing the child’s face, chin, and neck. The mother described two episodes of nose bleeding in the child in the preceding few days, along with constant snuffles. Their general practitioner had prescribed some nose drops to be massaged into the nostrils the day before for the nasal congestion.
The child was found to be in hypovolaemic shock with a capillary refill time of 6 seconds. She was not in respiratory distress and not pyrexial. She responded well to 0.9% normal saline bolus fluid resuscitation (a total of 30 ml/kg), and intravenous antibiotics and ranitidine were commenced. Detailed examination later revealed only minor axillary and inguinal lymphadenopathy. There were no bruises, cutaneous haemangioma, or visceral organomegaly. All other systemic examinations, including a detailed neurological examination were unremarkable.
Her laboratory results were: haemoglobin 6.4 g/dL, white cell count 13.2×109/l, platelets 819×109/l, international normalised ratio 1.0, activated partial thromboplastin time 0.9 seconds, fibrinogen 2.3 g/L. Blood film was normal. Platelet dysfunction and other rare forms of clotting disorder were excluded, and childhood leukaemia was deemed unlikely. Her liver function tests and other biochemistry tests were all normal. An abdominal ultrasound showed no abnormality.
The child was given a blood transfusion. An urgent ear, nose, and throat (ENT) assessment with endoscopy revealed no obvious cause for the recent bleed from the upper airway. The child was discharged 4 days later to continue with oral ranitidine at home. While at home, she was generally irritable, did not feed well, and lost some weight.
A week later, following a further episode of nose bleeding, the child was readmitted and underwent an upper gastrointestinal endoscopy, which showed no upper gastrointestinal abnormality. She started having episodes of stridor and intermittent upper airway obstruction. She then developed apnoea and was transferred to the nearest paediatric intensive care unit.
A repeat ENT assessment subsequently demonstrated a large pulsatile mass in the right parapharyngeal area extending inferiorly to the level of the pharynx, which on computed tomography scanning was found to be a large, blood filled mass extending up to the skull base. A magnetic resonance angiography went on to confirm a large dissecting aneurysm of the right internal carotid artery (ICA) that extended throughout the artery, traversing in close proximity to the nasopharynx. Cranial embolisation of the ICA proximal to the carotid artery aneurysm was successfully performed, after which the patient developed transient right sided Horner’s syndrome.
On closer questioning, the mother recalled an incident prior to the onset of nose bleeds when the child was accidentally hit during play while holding the handle side of a wooden spoon in her mouth, by a force directed along the length of the spoon into the oropharynx. There was no immediate bleeding at that time, although mild nosebleeds were observed when she came down with a cold the following week. Significant bleeding only occurred after the child’s nostrils had been massaged with the prescribed nose drops.
Impalement injuries of the soft palate and oropharynx in children are common. Injury to the ICA may occur after direct trauma to the tonsillar fossa, and may cause immediate disruption to the vessel should there be penetrating trauma, or take the more indolent form of false aneurysms with the risk of dissection should the trauma be blunt. This may occur after a fall with an object in the child’s mouth, the so called "pencil point injury",1 as in our patient’s case.
The structures of the neck are enclosed within a deep and a superficial fascia. The fascial layers can tamponade a bleed from the large vessels but can also lead to compression of the airway through increased pressure within the neck compartments, as exemplified by our patient’s later respiratory compromise.
Neurological sequelae are rare but well documented, and can occur between 3 and 60 hours following injury. They result from the initial thromboembolism following injury to the intima of the carotid artery. Mural thrombus formation, false aneurysm, or dissecting aneurysm with occlusion of the vessel and subsequent propagation of the thrombus can lead to further neurological damage.2,3,4,5,6,7,8,9,10,11,12 A review of 131 cases over a 17 year period concluded that the majority of soft palate and oropharyngeal impalement injuries can be managed on an outpatient basis. Parental counselling and close follow up in clinic are reasonable and safe.13
Fortunately, our patient suffered only a transient neurological deficit in the form of Horner’s syndrome post-embolisation. Thereafter, she had a few further nosebleeds, but only with concurrent upper respiratory tract infections. A recent endoscopic assessment showed no recurrence of her right ICA aneurysm.
This case is interesting as there are no previously described cases of epistaxis with hypovolaemic shock as the initial presentation of a dissecting carotid aneurysm following an impalement injury to the palate. It also highlights the importance of thorough history taking and prompt investigation in atypical presentations of common complaints.
Competing interests: none declared
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