An Unusual Source of Massive Hemoptysis

Abstract

INTRODUCTION: Massive hemoptysis is an uncommon, but life threatening event. Its differential is broad, however rapid identification and control of the source can be life saving. CASE PRESENTATION: A 61 year-old man with a history of bipolar disorder, alcoholism, vascular disease (peripheral vascular bypass, abdominal aortic aneurism and diffuse carotid atherosclerosis) and hypertension, was admitted to the intensive care unit with a sub-arachnoid hemorrhage. A tracheostomy was performed on day 7, due to inability to liberate him from mechanical ventilation. On day 22 he began expectorating massive amounts of blood, spraying it across the room through his tracheostomy tube. Estimated blood loss was 1 liter, with a drop in hemoglobin 12.4 mg/dL to 8.4 mg/dL. A chest x-ray, performed during the initial resuscitation, was unremarkable. Emergent flexible bronchoscopy failed to identify a source. However the anterior wall of the trachea was not adequately visualized, as the tracheostomy tube was resting against it. Due to fear of erosion of the tube into the innominate artery, surgical exploration of his neck was performed. Again, no source of bleeding was found. Computed topographic angiography revealed the culprit vessel to be the ethmoid branch of the ophthalmic artery. Due to the acute angle of its origin, the artery could not be embolized. He was taken to the operating room, where the vessel was successfully cauterized. No further bleeding was observed. DISCUSSION: Management of massive hemoptysis involves a stepwise approach to identifying the source, concurrent with resuscitation. Even when no obvious source can be found, various clues may guide further investigations. In this case, blood pooling in the posterior pharynx led to evaluation of the circulation of the upper airway. CONCLUSIONS: The anterior circulation of the naso-pharynx is a well-known source of bleeding, usually minimal. Large volume bleeding in the upper airway is typically from the posterior nasal circulation. This is the first report of massive hemoptysis from anterior nasal circulation. When confronted with a patient presenting with massive hemoptysis, we suggest the anterior circulation be considered in the differential.