Morphology and distribution of nasal telangiectasia in HHT-patients with epistaxis

Recurrent Anterior Epistaxis in Children With Allergic Rhinitis and Non-Allergic Rhinitis: Clinical Features

OBJECTIVE

This study described the endoscopic characteristics of recurrent anterior epistaxis (RAE) with and without allergic rhinitis (AR), and the outcomes of treatment with mupirocin ointment.

MATERIAL AND METHODS

Children with RAE were examined using nasal endoscopy, serum specific immunoglobulin E antibodies, and skin-prick test. The children were divided into AR (RAE with AR) and non-AR (RAE without AR) groups. All children received mupirocin ointment topically twice daily for 4 weeks. Recurrent epistaxis and epistaxis severity scores were compared at 2, 4, and 12 weeks of follow-up.

RESULTS

A total of 326 patients with 432 nostrils with RAE were included; 76.4% of patients had the bad habit of frequent nose-picking or rubbing. Of the 178 nostrils in the AR group, diffuse telangiectasia was found in 89.3%, scattered telangiectasia in 8.4%, and mucosal ulceration in 2.3%. Of the 254 nostrils in the non-AR group, the endoscopic findings of the anterior septum in the bleeding nostrils included mucosal ulceration in 77.6%, scattered telangiectasia in 17.7%, isolated punctate telangiectasias in 3.1%, and diffuse telangiectasia in 1.6%. In addition, the prevalence of mucosal crusts in the non-AR group was significantly higher than in the AR group (76.8% vs 20.8%), whereas the prevalence of severe hypertrophic inferior turbinates or nasal secretion was significantly higher in the AR group. The prevalence of recurrent epistaxis was significantly higher in the AR group than in the non-AR group at 2 (71.3% vs 57.7%), 4 (65.7% vs 37.8%), and 12 (78.1% vs 43.5%) weeks post-treatment.

CONCLUSIONS

AR was common in children with RAE, with prominent diffuse telangiectasia evident by endoscopy in most, while most non-AR RAE children had mucosal ulceration or scattered telangiectasia. Compared with outcomes in non-AR RAE children, the efficacy of mupirocin ointment in the treatment of RAE with AR was not satisfactory.

Hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia inherited as an autosomal dominant trait and caused by loss-of-function pathogenic variants in genes encoding proteins of the BMP signalling pathway. Up to 90% of disease-causal variants are observed in ENG and ACVRL1, with SMAD4 and GDF2 less frequently responsible for HHT. In adults, the most frequent HHT manifestations relate to iron deficiency and anaemia owing to recurrent epistaxis (nosebleeds) or bleeding from gastrointestinal telangiectases. Arteriovenous malformations (AVMs) in the lungs, liver and the central nervous system cause additional major complications and often complex symptoms, primarily due to vascular shunting, which is right-to-left through pulmonary AVMs (causing ischaemic stroke or cerebral abscess) and left-to-right through systemic AVMs (causing high cardiac output). Children usually experience isolated epistaxis; in rare cases, childhood complications occur from large AVMs in the lungs or central nervous system. Management goals encompass control of epistaxis and intestinal bleeding from telangiectases, screening for and treatment of iron deficiency (with or without anaemia) and AVMs, genetic counselling and evaluation of at-risk family members. Novel therapeutics, such as systemic antiangiogenic therapies, are actively being investigated. Although HHT is associated with increased morbidity, the appropriate screening and treatment of visceral AVMs, and the effective management of bleeding and anaemia, improves quality of life and overall survival.

A Microphysiological HHT-on-a-Chip Platform Recapitulates Patient Vascular Lesions

Hereditary Hemorrhagic Telangiectasia (HHT) is a rare congenital disease in which fragile vascular malformations (VM) - including small telangiectasias and large arteriovenous malformations (AVMs) - focally develop in multiple organs. There are few treatment options and no cure for HHT. Most HHT patients are heterozygous for loss-of-function mutations affecting Endoglin (ENG) or Alk1 (ACVRL1); however, why loss of these genes manifests as VMs remains poorly understood. To complement ongoing work in animal models, we have developed a fully human, cell-based microphysiological model based on our Vascularized Micro-organ (VMO) platform (the HHT-VMO) that recapitulates HHT patient VMs. Using inducible ACVRL1 -knockdown, we control timing and extent of endogenous Alk1 expression in primary human endothelial cells (EC). Resulting HHT-VMO VMs develop over several days. Interestingly, in chimera experiments AVM-like lesions can be comprised of both Alk1-intact and Alk1-deficient EC, suggesting possible cell non-autonomous effects. Single cell RNA sequencing data are consistent with microvessel pruning/regression as contributing to AVM formation, while loss of PDGFB implicates mural cell recruitment. Finally, lesion formation is blocked by the VEGFR inhibitor pazopanib, mirroring positive effects of this drug in patients. In summary, we have developed a novel HHT-on-a-chip model that faithfully reproduces HHT patient lesions and that can be used to better understand HHT disease biology and identify potential new HHT drugs.

A Microphysiological HHT-on-a-Chip Platform Recapitulates Patient Vascular Lesions

Hereditary Hemorrhagic Telangiectasia (HHT) is a rare congenital disease in which fragile vascular malformations focally develop in multiple organs. These can be small (telangiectasias) or large (arteriovenous malformations, AVMs) and may rupture leading to frequent, uncontrolled bleeding. There are few treatment options and no cure for HHT. Most HHT patients are heterozygous for loss-of-function mutations for Endoglin (ENG) or Alk1 (ACVRL1), however, why loss of these genes manifests as vascular malformations remains poorly understood. To complement ongoing work in animal models, we have developed a microphysiological system model of HHT. Based on our existing vessel-on-a-chip (VMO) platform, our fully human cell-based HHT-VMO recapitulates HHT patient vascular lesions. Using inducible ACVRL1 (Alk1)-knockdown, we control timing and extent of endogenous Alk1 expression in primary human endothelial cells (EC) in the HHT-VMO. HHT-VMO vascular lesions develop over several days, and are dependent upon timing of Alk1 knockdown. Interestingly, in chimera experiments AVM-like lesions can be comprised of both Alk1-intact and Alk1-deficient EC, suggesting possible cell non-autonomous effects. Single cell RNA sequencing data are consistent with microvessel pruning/regression as contributing to AVM formation, while loss of PDGFB expression implicates mural cell recruitment. Finally, lesion formation is blocked by the VEGFR inhibitor pazopanib, mirroring the positive effects of this drug in patients. In summary, we have developed a novel HHT-on-a-chip model that faithfully reproduces HHT patient lesions and that is sensitive to a treatment effective in patients. The VMO-HHT can be used to better understand HHT disease biology and identify potential new HHT drugs.

Significance

This manuscript describes development of an organ-on-a-chip model of Hereditary Hemorrhagic Telangiectasia (HHT), a rare genetic disease involving development of vascular malformations. Our VMO-HHT model produces vascular malformations similar to those seen in human HHT patients, including small (telangiectasias) and large (arteriovenous malformations) lesions. We show that VMO-HHT lesions are sensitive to a drug, pazopanib, that appears to be effective in HHT human patients. We further use the VMO-HHT platform to demonstrate that there is a critical window during vessel formation in which the HHT gene, Alk1, is required to prevent vascular malformation. Lastly, we show that lesions in the VMO-HHT model are comprised of both Alk1-deficient and Alk1-intact endothelial cells.

Silicone septal splint for recurrent epistaxis in HHT patients: experience of a national referral centre

Objective

To report our experience in the use of silicone septal splint for recurrent severe epistaxis in hereditary haemorrhagic telangiectasia patients (HHT).

Methods

This is a descriptive analysis carried out at the Otorhinolaryngology Department of Fondazione IRCCS Policlinico San Matteo in Pavia, a reference centre for the treatment and diagnosis of HHT. We retrospectively evaluated HHT patients who underwent silicone septal splint positioning after the endoscopic surgical treatment of epistaxis from 2000 to 2022.

Results

Of the 506 patients surgically treated in the period of analysis, 74 patients underwent silicone septal splint positioning and 37 were post-operatively interviewed. With a mean of 2.4 previous surgical treatments and a mean epistaxis severity of 7.38, the majority of patients presented with septal perforation (71.6%). On average, patients maintained the splint in place for 54.5 months, with a good tolerability and a significant reduction in epistaxis severity, need for blood transfusion and improvement of haemoglobin levels.

Conclusions

In HHT patients with recurrent severe epistaxis and with septal perforation, the placement of septal splints offers a useful additional strategy in the management of nosebleeds.

Skin and mucosal telangiectatic lesions in hereditary hemorrhagic telangiectasia patients

BACKGROUND

The diagnostic criteria for hereditary hemorrhagic telangiectasia (HHT) include the presence of telangiectatic lesions in common sites (nose, fingers, oral cavity, and lips). Telangiectatic lesions are described as red spots in the skin, but this description is inadequate. Few studies have investigated the characteristics of telangiectatic lesions in HHT, and we aimed to describe the distribution and morphology of telangiectatic lesions in HHT patients.

METHODS

We reviewed the telangiectatic lesions in 34 adult HHT patients seen at our HHT center. Photo documentation was used to describe the morphology and distribution of the lesions.

RESULTS

The telangiectatic lesions in both HHT1 and HHT2 patients were predominantly round and either flat or slightly elevated. However, elongated flat lesions and larger round, elevated lesions were also observed. Patients with HHT1 had more lesions in the mucosa (tongue and oral cavity) compared with HHT2 patients. There was no difference between HHT1 and HHT2 patients in the total number of lesions in the skin and mucosa.

CONCLUSIONS

The typical round, flat telangiectatic lesion is the most common lesion in HHT, but it is very often accompanied by elevated or elongated lesions. The total number of lesions did not vary between gender, but women had significantly more lesions in the mucosa (p = 0.027). The presentation of telangiectatic lesions may vary a little between HHT1 and HHT2 patients but not in such a way that allows the morphology and location of the lesions to predict the HHT subtype.

TIMolol nasal spray as a treatment for epistaxis in hereditary hemorrhagic telangiectasia (HHT) - study protocol of the prospective, randomized, double-blind, controlled cross-over TIM-HHT trial

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an inherited orphan disease, in which the absence of capillary beds between arterioles and venules lead to arteriovenous shunts. Epistaxis is the core symptom. Several case reports have described the nonselective beta-adrenergic receptor antagonist timolol as a successful treatment method of nosebleeds due in HHT patients.

OBJECTIVE

TIM-HHT is a single-site, prospective, randomized, placebo-controlled, double-blind, cross-over study to investigate whether the efficacy of standard laser treatment of epistaxis in HHT patients can be increased by the additional use of timolol nasal spray (1 mg/d).

METHODS

Twenty patients will be randomly allocated to one of two treatment sequences. Primary outcome is the severity of epistaxis determined by the Epistaxis Severity Score (ESS). Secondary outcomes are subjective satisfaction, quality of life, as well as the hemoglobin, ferritin, and transferrin levels of the participating patients. Safety outcome is assessed by means of pulse, blood pressure, and adverse events.

CONCLUSION

TIM-HHT will evaluate the efficacy and safety of timolol as an additional treatment of epistaxis in HHT patients in a three-month trial period. Benzalkonium chloride is used as a placebo, which has no documented positive effect on the nasal mucosa and hence on epistaxis in HHT patients (in contrast to saline).

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00020994. Registered on 10 March 2020.

Classification of endonasal HHT lesions using digital microscopy

BACKGROUND

Recurrent spontaneous epistaxis is the most common clinical manifestation and the most debilitating symptom in hereditary haemorrhagic telangiectasia (HHT) patients. To this date, there exist only a classification of HHT patients by different genetic mutations. There is no standard classification for the mucocutaneous endonasal manifestations of HHT. The aim of the present study was to document the variety of endonasal HHT lesions using digital microscopy and to propose a clinical classification.

METHODS

We recorded the endonasal HHT lesions of 28 patients using a digital microscope. We reconstructed the 3D images und videos recorded by digital microscope afterwards and classified the endonasal lesions of HHT in two classes: Grade A, presence of only flat telangiectasias in the mucosa level and Grade B, (additional) presence of raised berry or wart-like telangiectasia spots. We investigated also Haemoglobin level by routine laboratory procedures, plasma VEGF level by ELISA, Severity of epistaxis by epistaxis severity score (ESS) and quality of life by a linear visual analogue scale (VAS).

RESULTS

We found a higher quality of life and a lower severity of epistaxis in Grade A patients in comparison to Grade B patients. No difference in plasma VEGF level and in Haemoglobin between Grad A patients and Grade B patients could be detected. Plasma VEGF levels showed no gender specific differences. It could also not be correlated to the extranasal manifestation.

CONCLUSION

The classification for endonasal manifestation of HHT proposed in this study indicates severity of epistaxis und quality of life. Digital microscopy with the ability of 3D reconstruction of images presents a useful tool for such classifications. The classification of endonasal HHT lesions using digital microscopy allows to evaluate the dynamic of HHT lesions in the course of time independent of examiner. This allows also to evaluate the efficacy of the different treatment modalities by dynamic of HHT lesions. Moreover digital microscopy is very beneficial in academic teaching of rare diseases.

Rapid hemostasis: a novel and effective outpatient procedure using microwave ablation to control epistaxis of isolated mucosal bulge lesions

Introduction

Recurrent epistaxis is commonly encountered in the rhinology outpatient clinic. Under endoscopic guidance, both bipolar cautery and monopolar forceps (combined with suction) have been employed to control the bleeding. However, the use of monopolar forceps requires the placement of grounding pads. Most procedures are currently performed in operating rooms.

Objective

We investigated outcomes after the use of Microwave Ablation (MWA) to control epistaxis in adults with isolated mucosal bulge lesions. All procedures were performed with patients under local anesthesia in our outpatient clinic.

Methods

This is a retrospective cohort study. We included 83 adults with epistaxis of isolated mucosal bulge lesions. Microwave ablation was performed in the outpatient clinic to control bleeding, after induction of local anesthesia. The primary outcome was successful hemostasis. The secondary outcomes were the rebleeding rates at weeks 1 and 4 and month 6, and complications (crust or synechiae formation, septal perforation, and/or orbit or brain complications).

Results

All bleeding points were successfully ablated; hemostasis was achieved within 1–2 min. The mean pain score was 1.83 intra-operatively and 0.95 1 h postoperatively. No patient re-bled, and no severe MWA-related complication (septal perforation, synechiae formation, or orbit or brain complication) was recorded to 6 months of follow-up.

Conclusions

Endoscopic microwave ablation with patients under local anesthesia is a novel, safe, effective, rapid, well-tolerated, outpatient treatment for adults with epistaxis of isolated mucosal bulge lesions, especially those for whom general anesthesia might be risky, those with electrical implants, and those exhibiting contraindications for arterial embolization.

A new endoscopic staging system for hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is predominantly characterized by nasal telangiectases that cause severe epistaxis. Recently, the Epistaxis Severity Score (ESS) was developed and validated as a standardized measurement to evaluate epistaxis treatment efficacy. We propose a new endoscopic staging system to characterize nasal findings in HHT patients and correlate this to the ESS.

METHODS

This is a prospective cohort study. A total of 33 individuals with HHT confirmed by Curaçao criteria were recruited and evaluated by a single otolaryngologist between August 2010 and February 2013. Endoscopic parameters including patterns and sites of telangiectases and degree of nasal crusting were used to construct an endoscopy score for each subject. Multiple linear regression models were used to correlate this endoscopy score to the ESS.

RESULTS

A total of 33 subjects completed the study. The mean ± standard deviation (SD) age was 50.3 ± 13.2 years, and 20 (60.6%) were female. In the cohort, mean ± SD ESS was 4.05 ± 2.13 (range, 0.50 to 8.22). Most subjects (53.1%) had more than 4 nasal sites involved and (56.2%) had punctate telangiectases; 30.3% had mild crusting and 21.2% had moderate/severe crusting. These endoscopic findings were weighted by their correlation coefficients against epistaxis severity and normalized to create a new endoscopy score. After adjusting for confounding variables, the HHT Endoscopy Score (HES) was strongly associated with the ESS (r = 0.79, p < 0.001).

CONCLUSION

The HES correlates highly with patient-reported epistaxis severity and may provide a useful outcome measure in future studies.

[Bevacizumab in therapy-refractory epistaxis: case report of low-dose antibody therapy for hereditary hemorrhagic telangiectasia]

We report on the submucosal injection of bevacizumab (Avastin) at a dose of 0.3 to 3.75 mg per side in a patient with hereditary hemorrhagic telangiectasia. Application of such low doses has not been described in the literature yet. Our case report shows the positive effect of low-dose bevacizumab on therapy-refractory epistaxis. No complications were caused by the bevacizumab treatment.

Does Hereditary Hemorrhagic Telangiectasia Affect Olfactory or Gustatory Function?

Background

The olfactory and gustatory functions of hereditary hemorrhagic telangiectasia (HHT) patients have not been documented by validated tests. Disorders of the nasal/oral cavity may interfere with the olfactory and gustatory functions. Fifty-four HHT patients were investigated by smell/taste tests.

Methods

HHT patients provided subjective ratings in areas such as ability to perceive smell/taste. “Sniffin’ Sticks” were used for smell tests, and taste strips were used for taste tests.

Results

HHT patients rated their subjective olfactory and gustatory function on a visual analog scale from 0 (none) to 100 (high) as 65.3 ± 27.7 and 68.1 ± 25.1, respectively. Comparison of smell test results of HHT patients with normative data of sex- and age-matched controls from Hummel et al. revealed that HHT patients had lower threshold values, whereas there was no difference in identification and discrimination values. HHT patients were hyposmic. In the case of taste qualities, all values (sweet, sour, salty, and bitter) in HHT patients were lower than those in normative data of Mueller et al. However, HHT patients were not hypogeusic. The duration of disease, extranasal manifestation, and treatments did not significantly correlate with smell/taste test values.

Conclusion

Compared with healthy people, HHT patients exhibit reduced olfactory and gustatory function; however, HHT patients are hyposmic and not hypogeusic. This chemosensory deficit may highlight an early sign of disease and has no correlation with disease severity. HHT patients should be informed about these potential disease manifestations, thus enabling them to improve their quality of life.

A retrospective analysis of low dose, intranasal injected bevacizumab (Avastin) in hereditary haemorrhagic telangiectasia

The constantly recurring epistaxis means a great reduction of quality of life for patients with hereditary haemorrhagic telangiectasia (HHT). As yet, an ideal treatment has not been found. Vascular endothelial growth factor (VEGF) has been described as a possible new therapy. In particular, the success of submucosal doses <100 mg has not been analysed before. We injected bevacizumab (Avastin) submucosally in addition to Nd:YAG laser therapy. Doses <7.5 mg were used. To investigate the effect of these additional injections in comparison to laser therapy alone, a retrospective analysis was done. For this purpose a standardized patient questionnaire was completed, which included recording the patients' Epistaxis Severity Score (ESS) before and after the antibody treatment. Besides, patient files were analysed to collect objective data like haemoglobin levels and the number of blood transfusions needed. Data for eleven patients could be analysed. A significant improvement in the ESS resulting from additional bevacizumab therapy was observed (p < 0.01). In particular, the frequency of epistaxis (p = 0.011), duration of epistaxis (p < 0.01), severity of epistaxis (p < 0.01) and the need for acute medical treatment (p = 0.014) decreased significantly. The haemoglobin levels increased significantly (p = 0.011) and the number of blood transfusions declined. There were no side effects caused by the antibody treatment. Additional injections of a low dose of bevacizumab seem to be superior to Nd:YAG laser therapy alone. These results justify further studies.

Correlation of severity of epistaxis with nasal telangiectasias in hereditary hemorrhagic telangiectasia (HHT) patients

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disease that leads to multiregional angiodysplasia. The presence of telangiectasias in nasal mucosa leads to recurrent epistaxis that affects up to 96% of patients but with unpredictable severity. Some authors have previously explained that endonasal morphology and distribution of telangiectasias can be variable too. The purpose of this study was to evaluate any possible relationship between the severity of epistaxis and the different morphology and distribution of nasal telangiectasias in HHT patients.

METHODS

A review was performed of nasal endoscopy records of 76 consecutive HHT patients treated for epistaxis between 2003 and 2007 at our institution. An evaluation was performed of severity of epistaxis in the same patient group using a questionnaire and considering frequency, intensity, duration of nosebleeds, and need for blood transfusions. Comparison of data collected on morphology and distribution of nasal telangiectasias with data collected on severity of epistaxis was performed.

RESULTS

Morphology and distribution of nasal telangiectasias showed a statistically significant correlation with frequency and intensity of epistaxis. Presence of telangiectasias endoscopically appearing as large and prominent correlates with higher frequency of epistaxis. An increase in number of nasal subsites involved correlates with higher intensity of nosebleeds.

CONCLUSION

Our data suggest that to reduce frequency and intensity of epistaxis in HHT patients, treatments should be directed also at lesions located in the posterior part of nasal fossae and especially on telangiectasias endoscopically appearing as large and prominent.

[Nasal cavity dermoplasty as a treatment of recurrent bleeding in Rendu-Osler-Weber's disease]

INTRODUCTION

Rendu-Osler-Weber's (ROW) disease is a systemic disorder of blood vessels classified as a capillary malformation. The most common manifestation of hereditary hemorrhagic teleangiectasia is recurrent epistaxis. The diagnosis of ROW disease is made clinically using the Curacao criteria. Management of epistaxis is usually difficult and many types of treatment have been described.

MATERIAL AND METHODS

We report 12 patients, 7 female and 5 male, aged 52 to 78 with ROW disease and recurrent epistaxis with frequency varying from 5 episodes monthly to 3 - 5 episodes daily. In most of them blood transfusion was required. The patients were treated with intranasal dermoplasty described by Saunders. The dermoplasty was performed on the septal, lateral or both walls of the anterior part of the nasal cavities.

RESULTS

In all the patients the graft was taken completely. Two patients had scars and narrowing of nasal valve region. Recurrence and increase in the intensity of nasal bleeding were observed in 3 patients. In the course of further therapy the second partial septal dermoplasty was successfully performed in 2 of them. The second surgery revealed new bleeding teleangiectases beyond of the dermal graft.

CONCLUSION

Nasal cavity dermoplasty remains an effective way of reducing epistaxis and blood transfusion in patients with ROW disease and subjectively improves their quality of life. The surgical treatment can be repeated, if nasal bleeding recur.

Contact endoscopy of the nose in patients with Rendu-Osler-Weber syndrome

OBJECTIVE

Teleangiectases are the source of hemorrhage in many HHT patients. Most frequent site of bleeding is the nose and more than 90% of all individuals with HHT suffer from recurrent epistaxis. Despite all efforts, treatment of epistaxis in HHT continues to be a problem for many otorhinolaryngologists, who can alleviate recurrent nosebleeds by Septodermoplasty or laser therapy, but rarely can stop nasal hemorrhages permanently. Recurrence is almost inevitable, but the mechanisms of recurrence are not fully understood.

METHODS

Prior to routine Nd:YAG laser therapy of nasal telangiectases the nasal mucosa of 17 patients with HHT according to the clinical diagnostic criteria of the HHT Foundation International was examined with a 0 degrees contact rhinoscope in areas with clinically visible telangiectases as well as in clinically normal mucosa. The digitally recorded images were compared to findings of a group of five healthy volunteers and the findings of five patients with polypoid sinusitis.

RESULTS

Visualization of subepithelial vessels was feasible in all individuals of the study group as well as the control groups. Dilated vascular loops and tortuous vessels could be found in the study groups as well as in the control group, but the overall density of telangiectatic vessels was on an average higher in the HHT group. The process of vessel dilatation and tortuous configuration seemed to progress with age.

CONCLUSION

Contact endoscopy allows the investigation of the angioarchitecture of capillaries of the nasal mucosa in vivo. This observation may be of significance for studies of nasal diseases, which are accompanied by epistaxis. With this regard it seems to be of special interest for studies of HHT.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Nasal dermoplasty for Japanese hereditary hemorrhagic telangiectasia

OBJECTIVE

While generally considered an effective treatment for moderate to severe epistaxis in hereditary hemorrhagic telangiectasia (HHT), nasal dermoplasty (ND) has not been well established in Japan. This prompted the present Japanese assessment of clinical efficacy and patient satisfaction following this procedure.

METHODS

Retrospective analysis of clinical records of 15 patients with HHT undergoing ND between August 1991 and May 2004 and survey of these patients as to postsurgical conditions. Main outcome measures were skin graft "take" frequency after surgery (all patients), reported patient satisfaction (eight recent patients), and reported volume and frequency of epistaxis after versus before surgery (eight recent patients).

RESULTS

Graft take rate was 100%. Most patients experienced reduced frequency and volume of bleeding. One patient required an additional operation, total closure of the external nares, 2 years later. Overall patients felt satisfied with ND, experiencing less nasal obstruction than expected.

CONCLUSIONS

ND is effective in Japanese patients with moderate and severe nasal bleeding from HHT, reducing their risk of bleeding.

Manifestations of hereditary hemorrhagic telangiectasia in children and adolescents

The medical literature provides little information on manifestations of hereditary hemorrhagic telangiectasia (HHT) in children. The presented investigation was initiated to analyze early presenting symptoms in HHT, which should help to make the diagnosis at a young age and thus prevent potential complications from occult visceral arteriovenous malformations (AVM), which have commonly been described in HHT. A series of 15 children and adolescents with a suspicious diagnosis of HHT were examined clinically for typical signs and symptoms of the disorder. If the diagnosis of HHT seemed to be likely, recommendations for non-invasive screening procedures were given. Screening was directed at the detection of occult visceral AVMs. Main outcome measures were the definition of principal signs of HHT in children and adolescents. Family history was positive for HHT in 13 persons. The principal sign of recurrent epistaxis was present in 10/15 individuals and the earliest age of onset with regard to epistaxis was 4 years. Cutaneous vascular lesions were present in 5/15 patients. Screening for AVMs was performed in six individuals and revealed vascular lesions of the brain in two patients and vascular lesions of the lung in two patients. Gastrointestinal hemorrhages were present in one infant. Based on these findings, diagnosis of HHT seemed likely in ten individuals and unlikely in five individuals. Signs and symptoms of HHT in children and adolescents may be discrete, but are detectable at an earlier age than previously thought. Clinical examinations in children from HHT families may help identify candidates who will benefit from molecular genetic testing or screening imaging studies.