key: cord-0853237-vukj3d6n
authors: Soloperto, Davide; Dallari, Virginia; Caiazza, Nicole; Marchioni, Daniele
title: Hide and seek epistaxis after COVID-19 infection
date: 2022-01-21
journal: Eur Ann Otorhinolaryngol Head Neck Dis
DOI: 10.1016/j.anorl.2021.12.004
sha: f6adc8a74052ebaf43b664de78ee9e40284840bb
doc_id: 853237
cord_uid: vukj3d6n

nan

This letter describes an anatomical variant of the descending palatine artery (DPA), which has never been described before and may mislead surgeons faced with the surgical hemostasis of an epistaxis.

We hereby present the intriguing case of a 56-year-old man suffering from recurrent left-side epistaxis occurring one week after his hospitalization for COVID-19 pneumonia.

A 56-year-old male patient was admitted to the emergency department with left-side epistaxis. He required nasal packing with Merocel twice, until he was admitted to ENT department due to persistent bleeding and anaemia (Hb 8 g/dl).

The patient's recent medical history included a hospitalization of one week for COVID-19 pneumonia. During his hospital stay, he required oxygen therapy via a low-flow nasal cannula and low-molecular-weight heparin (LMWH), both of which are known to facilitate nosebleeds [1, 2] .

During the first admission to the ENT, the patient was transfused to bring his haemoglobin values back into range. On removal of the nasal tampons, however, he started bleeding again from the left nasal fossa. He therefore underwent the angiographic procedure of embolization of the left internal maxillary artery. After 3 days, the patient was discharged with no evidence of bleeding.

Four days later, the patient was readmitted in ENT department for recurrence of epistaxis from the left nasal fossa. An urgent selective angiographic procedure with carotid study was performed. And the real culprit was finally discovered: an unusual anastomosis between one terminal branch of the right descending palatine artery (DPA) with the sphenopalatine artery of the contralateral side ( Figure 1 ). Therefore, the patient underwent endoscopic cauterization of the terminal branch of the right DPA with complete cessation of bleeding. Then he was discharged and to date, after more than three months, has not presented any epistaxis. The DPA originates from the internal maxillary artery (IMA) in the pterygopalatine fossa and participates in the vascularization of the maxilla, hard and soft palate. Different variation has been described in patient anatomy. In most cases (95%) the short DPA splits into the greater and lesser palatine arteries at the end of the pterygopalatine canal [3] . In the remaining cases, the DPA presents as a single artery or more than two branches [4] . When multiple branches compose the DPA, a branch crosses the lateral wing of the pterygoid process and it consistently displays an anastomosis with the terminal branch of the SPA through the incisive foramen [4] .

In the case described above, one of the terminal branches of DPA, a palatine artery (PA), creates anastomosis also with the terminal branch of posterior septal artery (PSA) of SPA of the contralateral side ( Figure 2) . Thus, the left-side epistaxis is caused by the bleeding of one terminal branch of the right DPA.

The importance of possible anastomoses across the midline must not be overlooked. Indeed, as reported by Mostafa et al. [5] , cross-circulation from the contralateral maxillary artery may cause recurrent bleeding. In their study, there was cross-circulation across nasal supplying branches of the IMA in 19% of cases.

To date, few studies have examined variability in the DPA, and, to our knowledge, this is the first described case of an anastomosis of the DPA that crosses the midline.

To conclude, the moral of the story is: watch out for the nosebleed side, anatomical variations are always ready to confuse us!

The authors declare that they have no competing interest. 

Epistaxis in hospitalized patients with COVID-19

Clinical Recommendations for Epistaxis Management During the COVID-19 Pandemic. Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery

The Clinical Anatomy of the Maxillary Artery in the Pterygopalatine Fossa. American Association of Oral and Maxillofacial Surgeons

Distribution of the maxillary artery in the deep regions of the face and the maxilla: Clinical applications

Arterial Blood Supply of the Nose: An Angiographic Study. ORL; journal for oto-rhino-laryngology and its related specialties