[Abstract]: Objective To investigate the clinical characteristics and effective treatment methods of elderly patients with persistent rhinorrhea. Methods The clinical data of 240 patients with persistent rhinorrhea admitted to our department from October 2005 to June 2011 were collected, and the clinical characteristics and treatment methods of this group of patients were statistically collated and retrospectively analyzed. Results Most of the elderly patients with persistent rhinorrhea were accompanied by at least one medical disease; the bleeding site was mostly in the nasal septum, then in the order of the nasopharyngeal Wu area and the lower nasal tract; most patients could clarify the bleeding point by meticulous, multi-angle nasal endoscopy; radiofrequency bipolar or single-stage coagulation was used to stop bleeding. Conclusion Comprehensive and meticulous endoscopic examination clarifies the bleeding points in most elderly patients with persistent rhinorrhea; hemostasis with bipolar or single-stage is accurate and less painful, and the treatment of rhinorrhea should be accompanied by good treatment of internal diseases.
Persistent rhinorrhea in the elderly refers to elderly patients who have had, for example, nasal tamponade treatment before this rhinorrhea and then bleed again. As China is rapidly entering an aging society, the incidence of rhinorrhea in the elderly is increasing year by year. These patients suffer from more medical diseases and have high vascular fragility, and because they have been treated for rhinorrhea before, they have many concerns about the treatment of re-bleeding and poor cooperation. Therefore, how to effectively treat rhinorrhea in the elderly and prevent various complications in a timely manner is the most important issue of rhinorrhea in the elderly. The clinical data and treatment methods of 240 cases of persistent rhinorrhea in the elderly admitted to our department from October 2005 to October 2011 were collected and analyzed, and are reported as follows.
1 Data and methods
1.1 Clinical data
1.1.1 Selection and criteria: Elderly patients with rhinorrhea who were older than 60 years old; who had been treated for rhinorrhea in foreign hospitals or in our hospital after hemostasis; except for traumatic rhinorrhea and postoperative rhinorrhea; except for neoplastic rhinorrhea.
1.1.2 Cure criteria
No active bleeding at the primary site within 4 weeks after re-treatment.
1.1.3 General information
Among 240 elderly patients with persistent rhinorrhea, 205 were male and 35 were female, aged from 60 to 82 years old, with a mean age of 68.7 years old; 235 cases were unilateral and 4 cases were bilateral; 168 cases had anterior nostril caulking, 62 cases had simple nasal constriction treatment, and 10 cases had combined anterior and posterior nostril caulking, with bleeding time of 30 minutes to 1 week.
1. 2 Treatment methods
1.2.1 Apparatus
4mm diameter 00 , 300 , 700 and 2mm diameter nasal endoscopes, radiofrequency plasma therapy instrument (single-stage and bipolar), various diameters of suction heads (at least one can be bent), hemostatic lozenges, gelatin sponges, oil gauze strips, expansion sponges, posterior nostril filling plugs and other materials.
1.2.2 Treatment method
Firstly, comfort the patient and let the patient stabilize as much as possible. Remove the nasal stuffing or aspirate the bleeding mass, fully anesthetize and constrict the nasal mucosa on the bleeding side with a cotton pad soaked in a mixture of 0.5% dicaine and epinephrine injection; carefully examine all parts of the nasal cavity with nasal endoscopes at different angles and try to find the bleeding site:
Vascular bleeding in the nasal septum: use bipolar electrocoagulation to stop the bleeding, place the bleeding site between the two levels of bipolar electrocoagulation; at the same time, properly coagulate around the bleeding site to enhance the hemostatic effect, and apply hemostatic materials such as hemostatic lozenges to the wound surface after hemostasis.
Bleeding from mucosal erosion of the nasal septum: hemostasis is stopped by bipolar coagulation with interval coagulation, and hemostatic lozenges such as hemostatic lozenges are applied to the trabecular surface after coagulation and are compressed.
Bleeding at the junction of inferior turbinate and lateral wall of nasal cavity: Apply 700 endoscope, after sufficient contraction and anesthesia, fracture the inferior turbinate medially with stripper to expose the bleeding site, and choose suitable single-stage or bipolar coagulation to stop bleeding. If necessary, hemostatic materials such as hemostatic lozenges were selected to compress on the bleeding site, and then oil gauze strips were filled locally in the inferior nasal tract to stop bleeding.
Bleeding in the Wu area of the nasopharynx: fully anesthetize and contract, bend the suction device appropriately just enough to reach the bleeding site, and use single-stage electrocoagulation to coagulate the bleeding site under direct endoscopic view to stop the bleeding for just enough time.
If the above methods are ineffective, patients with suspected posterior nostril bleeding but cannot find the specific bleeding site are treated with posterior nostril filling, and those who still cannot stop bleeding are treated with angiography to clarify the bleeding site and perform vascular embolization.
1.4 Internal medicine treatment
Elderly patients with rhinorrhea are mostly accompanied by internal diseases, so while stopping the bleeding, we should understand the condition of the patient while stopping the bleeding. The patient should be treated with appropriate anti-infective therapy, suspension of anticoagulant drugs for 1-2 weeks, keeping bowel movements smooth and avoiding straining. After hemostasis, nasal peppermint oil drops were applied to prevent nasal dryness.
2 Results
2.1 Treatment results
Among 240 patients, 230 cases stopped bleeding after one treatment (95.8%), 10 cases bleeding again, 5 cases stopped bleeding after the same treatment again, 4 cases stopped bleeding by posterior nostril caulking, 1 case posterior nostril caulking was ineffective, extra maxillary arteriogram was given and the right maxillary artery was embolized to stop bleeding, no recurrence of nasal bleeding in the above patients within 4 weeks.
2.2 Statistics of concomitant diseases and related problems
Among the 240 elderly patients with persistent rhinorrhea, 205 (85.4%) were suffering from more than one medical disease; among them, 96 (40%) were combined with hypertension, 31 (22.9%) with diabetes, 60 (25%) with coronary atherosclerotic heart disease, 11 (4.6%) with cerebrovascular-related diseases, 185 (77.1%) with deviated nasal septum, and 185 (77.1%) were usually taking anticoagulants (such as aspirin, pansentine, etc.) in 35 cases (14.6%).
2.3 Statistics of bleeding sites, see Table 1
Table 1: Statistics of bleeding sites in 240 cases of elderly patients with persistent rhinorrhea
Bleeding site Number of patient cases (pcs) Percentage
Anterior nasal septum 132 55%
Middle nasal septum 36 15%
Lower nasal septum 24 10%
Posterior nasal septum 19 8%
Nasopharyngeal Woo’s area 12 5%
Posterior end of the inferior nasal tract 10 4.2%
Middle turbinate 5 2%
Other 2 1 %
2.4 Statistics of treatment methods, see Table 2
Table 2 Statistics of treatment methods for 240 patients with persistent rhinorrhea
Method used Number of patient cases Percentage (%)
Radiofrequency bipolar + hemostatic lozenge 216 90%
Single-stage + local filling of nasal cavity 12 5%
Single-stage + hemostatic lozenge 6 2.5%
Posterior nostril tamponade 4 1.7%
Internal maxillary artery embolization 1 0.4%
3 Discussion
Elderly patients with persistent rhinorrhea are often accompanied by medical diseases such as hypertension, diabetes mellitus, heart disease and vascular sclerosis, which are clinically tricky to manage. If simple nasal tamponade is given again, it is difficult for their psychology and body to bear, and it will aggravate the chance of hypertension and other medical diseases ” 2 “. Retreatment requires comprehensive and holistic consideration, finding the bleeding point as much as possible, striving for a successful hemostasis, and refraining from caulking as much as possible. The majority of the nosebleeds in this paper can find the bleeding site, and the main reason for repeated bleeding is that the real bleeding location is not found. In addition, when dealing with nosebleeds again, strive to stop the bleeding at once to prevent its recurrence.
When dealing with nasal bleeding again, the preparation should be very adequate, including anesthetic drugs, blood pressure control, endoscopes of various angles and different diameters, different types of suction heads, hemostatic equipment and materials, etc. It is important to observe carefully under the nasal endoscope, and appropriate amount of epinephrine should be added to the dicaine swabs to make the anesthesia more adequate and the contraction of the nasal mucosa more complete. Find the bleeding site as quickly as possible. In this group of cases, the hidden sites of bleeding were mainly located at the middle and posterior end of the junction between the inferior turbinate and the lateral wall of the nasal cavity, the corresponding septal area of the superior nasal tract, and the anterior parietal wall of the middle nasal tract. When dealing with bleeding points in these areas, it is necessary to do appropriate fracture displacement of the inferior turbinate, middle turbinate, and superior turbinate structures in order to expose the bleeding points as much as possible. It can be said that most of the persistent nasal bleeding can be found, and once the site is identified, proper hemostasis is then performed. It is important to note that RF bipolar should pay attention to the control of energy in the treatment of nasal bleeding, and the energy should not be too large in order to stop the bleeding properly. In this group of cases, there was a patient with nasal septum perforation due to too much energy. After bipolar or unipolar coagulation hemostasis, the trauma surface is attached with hemostatic lozenges, which can strengthen the hemostatic effect on the one hand and protect the trauma surface on the other.
In elderly patients with rhinorrhea, the proportion of hypertension is high, and even in patients with low blood pressure, the blood pressure is also increased due to the stimulation of mental tension and other factors. If the blood pressure increases significantly above 180/100mmHg, intravenous infusion of antihypertensive drugs is needed as soon as possible to lower the blood pressure. Timely psychological support is important to ensure that the patient is treated in a sedated state.
The bleeding has already stopped due to natural vasoconstriction when the patient is seen. If a small local soft tissue elevation is found during the examination, the bleeding point can be clarified by gently touching it with a lance forceps or the head of an aspirator to induce it, and then the bleeding can be stopped according to the above method. For patients with obvious nasal septal deviation, their nasal bleeding is considered to be related to septal deviation, and patients should be advised to undergo elective septal correction treatment. 20 cases in this group were treated with elective septal correction, and no nasal bleeding occurred again after long-term observation.
For patients with unresponsiveness and unconsciousness, hemorrhagic shock should be considered first, and blood volume should be replenished immediately to improve circulation and maintain cardiac function; blood swallowed into the stomach can cause stomach discomfort or even nausea and vomiting, which can affect the treatment process. In the subsequent treatment, appropriate gastrodynamic drugs should be given for symptomatic treatment; since elderly patients with rhinorrhea are in a hypercoagulable state, the application of hemostatic drugs should be cautious.
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