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Bloody Tears from Epistaxis Through the Nasolacrimal Duct
BLOODY T E A R S FROM E P I S T A X I S T H R O U G H T H E NASOLACRIMAL DUCT RICHARD G. BANTA, B.A.,
AND JOSEPH L.
SELTZER,
M.D.
Lexington, Kentucky
The rare clinical phenomenon of bloody tears has been attributed to a variety of causes. Heyrowski, 1 Dejean,2 and Satanowsky3 reported bloody tears associated with the menstrual cycle and menopause, the socalled "vicarious menses." Siggers4 reported blood-stained tears secondary to conjunctival hemorrhages occurring with Henoch-Schoenlein purpura. Pubic crab lice infestation of the eyelid has been implicated as a cause of bloody tears by Belau and Rucker.5 Reports by Galvez Montes and Casado Corzo6 and Dimitry7 describe bloody tears in association with angiomata of the lacrimal sac. Hemorrhagic lacrimation has also followed electric shock, as described by Delord and associates,8 and has occurred in conjunction with con genital heart disease, as reported by Angelone.9 Tears of blood have been observed by Picard 10 and by Bolottes and FribourgBlanc11 following head trauma, and with posttraumatic epilepsy, by Scott.12 The phenome non was seen in association with dacryoadenitis by Jiricka13 during the mecholyl test, and by several others14"19 without proven etiology. We recently treated a patient with epi staxis secondary to vascular hypertension. Her management was complicated by retro grade nasolacrimal duct bleeding following the insertion of anterior and posterior nasal packs. This hemorrhagic epiphora is appar ently a rare complication of epistaxis ; this is the first such case that we have seen at this institution and there are only previous re ports (by Abel20 and Jongkees 21 ) describing this phenomenon with epistaxis. Konikow,22 From the Department of Surgery, Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky. Reprint requests to Richard G. Banta, Box 93, University of Kentucky College of Medicine, Lex ington, Kentucky 40506.
Messner,23 and Schenk24 describe the entity following nasal tamponade. CASE REPORT
A 49-year-old black woman was seen at the Uni versity Hospital with posterior epistaxis of 18 hours' duration. She had no history of eye, ear, nose, throat, or cardiovascular disease, but did have a family history of hypertension. On physical exam ination, her blood pressure was 250/140 mm Hg. and she was spitting about 5 ml of clots and bright red blood every 15 minutes. No blood was seen in the ex ternal nares, and anterior rhinoscopy did not reveal the site of hemorrhage. Blood and clots were present in the oropharynx, but the patient was too agitated to permit indirect nasopharyngoscopy. At this time the conjunctival sacs were clear and the patient was without epiphora bilaterally. Two No. 14 Foley catheters were inserted into the nasopharynx, and the balloons of these were each distended with 3.5 ml of sterile water. At this time the blood and clots were being delivered from the right external nare and the pharynx became clear. After anterior pack ing with gauze strips inpregnated with petroleum jelly, all external nasal bleeding from the right nos tril stopped. The left side was not packed anteriorly and the left posterior pack was left in place and secured to the right posterior pack at the external nares to preclude posterior displacement. At this time, we first noted that the patient had a red epi phora on the right. Upon closer observation it was obvious that blood was being expressed from both the superior and inferior puncta at a slow but steady rate. We decided not to apply topical heparin because we felt that punctal bleeding was too brisk to permit an effective concentration of the drug to reach the lacrimal sac. Instead, we decided to ob serve the patient for the onset of dacryocystitis or unremitting epiphora secondary to obstruction. Her blood pressure was reduced and controlled with hydralazine HC1. Her punctal bleeding and epiphora ceased about 18 hours later and her anterior and posterior packs were removed 36 hours after inser tion. She has been followed for eight months and has had no recurrence of epiphora and no signs or symptoms of dacryocytitis. SUMMARY
A 49-year-old black woman developed ret rograde nasolacrimal duct bleeding in the course of epistaxis secondary to vascular hy pertension. Control of the blood pressure and packing of the nose led to cessation of
m
VOL. 75, NO. 4
BLOODY TEARS
727
11. Bolotte and Fribourg-Blanc : Bloody tears the bleeding at approximately 18 hours with caused by neurovégétative disequilibrium after head out recurrence. Bloody tears have been de trauma. Arch. Opht. 48:697, 1931. scribed in conjunction with a large variety of 12. Scott, Z. R. : Sanguineous lacrimation. Report of a case. Am. J. Dis. Child. 33:907, 1927. abnormalities. REFERENCES 1. Heyrowsky, K.: Vicarious hemorrhage of conjunctiva and bloody tears. Wein. Klin. Wschr. 59:702, 1947. 2. Dejean, C. : Bloody tears ceasing with the first menstruation. Arch. Sod. Sei. Med. Biol. Montpel lier 15 :468, 1934. 3. Satanowsky, P.: Bloody tears due to conjunctival hemorrhage during monopause. Rev. Assoc. Med. Argentina 47:3429,1930. 4. Siggers, D. C. : Blood-stained tears. Brit. Med. J. 4:177, 1970. 5. Belau, P. G., and Rucker, C. W.: Bloody tears : Report of case. Proc. Mayo Clin. 36:234, 1961. 6. Galvez Montes, J., and Casado Corzo, J. P. : Angioma of lacrimal sac ; study apropos of case of tears of blood. Arch. Soc. Oftal. Hispano-Am. 13: 174, 1953. 7. Dimitry, T. J. : Bloody tears : Bilateral capil lary hemangiomas. J.A.M.A. 110:643, 1938. 8. Delord, R., Cazaban, R., and Cadilhac, J. : Unilateral functional amaurosis following lighten ing stroke with excretion of bloody tears ; case with recovery. Bull. Soc. Opht. Franc. 708, 1952. 9. Angelone, L. : Bloody tears and Roger's blue disease. Ann. Othal. Clin. Ocul. 75 :287, 1949. 10. Picard, J. : Bloody tears at onset of posttraumatic epileptic attack. Ann. Med. Psychol. 95 : 824, 1937.
13. Jiricka, Z. : Presence of blood in tears during the mecholyl test. Med. Pharm. Exp. (Basel) 12: 65, 1965. 14. Pur, S.: Bloody tears. Cesk. Oftal. 20:379, 1964. 15. Meyer, F. W., and Kluth, C. : Lacrimation of blood and its causes. Klin. Mbl. Augenheilk. 121 : 719, 1952. 16. Vila Ortiz, J. M., and Imbern, S.: Badly named bloody tears : Two cases. Arch. Oftal. Bue nos Aires 12:711, 1937. 17. Greig, D. M. : Recurrent bleeding from the eyes. Edinburgh Med. J. 39:628, 1932. 18. Manes, A. J.: Bloody tears: Three cases. Diag. Med. 3:679, 1931. 19. Gabrielides, A. : Tears of blood. Ann. Ocul. 160:705, 1923. 20. Abel, S. : Haemorrhage from the lacrimal punctum. Brit. J. Ophth. 34:754, 1950. 21. Jongkees, L. B. W. : Bleeding from lacrimal duct during nasal hemorrhage. Nederl. T. Geneesk. 85:2695, 1941. 22. Konikow, M. J. : A case of bloody tears. Bos ton Med. Surg. J. 175 :607, 1916. 23. Messner, F. : Profuse bloody tears associated with nasal tamponade for epistaxis. Wien Klin. Wschr. 59:469, 1947. 24. Schenk, G. : Bloody tears from bleeding through the nasolacrimal duct. Klin. Mbl. Augen heilk. 41:481,1903.
AND JOSEPH L.
SELTZER,
M.D.
Lexington, Kentucky
The rare clinical phenomenon of bloody tears has been attributed to a variety of causes. Heyrowski, 1 Dejean,2 and Satanowsky3 reported bloody tears associated with the menstrual cycle and menopause, the socalled "vicarious menses." Siggers4 reported blood-stained tears secondary to conjunctival hemorrhages occurring with Henoch-Schoenlein purpura. Pubic crab lice infestation of the eyelid has been implicated as a cause of bloody tears by Belau and Rucker.5 Reports by Galvez Montes and Casado Corzo6 and Dimitry7 describe bloody tears in association with angiomata of the lacrimal sac. Hemorrhagic lacrimation has also followed electric shock, as described by Delord and associates,8 and has occurred in conjunction with con genital heart disease, as reported by Angelone.9 Tears of blood have been observed by Picard 10 and by Bolottes and FribourgBlanc11 following head trauma, and with posttraumatic epilepsy, by Scott.12 The phenome non was seen in association with dacryoadenitis by Jiricka13 during the mecholyl test, and by several others14"19 without proven etiology. We recently treated a patient with epi staxis secondary to vascular hypertension. Her management was complicated by retro grade nasolacrimal duct bleeding following the insertion of anterior and posterior nasal packs. This hemorrhagic epiphora is appar ently a rare complication of epistaxis ; this is the first such case that we have seen at this institution and there are only previous re ports (by Abel20 and Jongkees 21 ) describing this phenomenon with epistaxis. Konikow,22 From the Department of Surgery, Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky. Reprint requests to Richard G. Banta, Box 93, University of Kentucky College of Medicine, Lex ington, Kentucky 40506.
Messner,23 and Schenk24 describe the entity following nasal tamponade. CASE REPORT
A 49-year-old black woman was seen at the Uni versity Hospital with posterior epistaxis of 18 hours' duration. She had no history of eye, ear, nose, throat, or cardiovascular disease, but did have a family history of hypertension. On physical exam ination, her blood pressure was 250/140 mm Hg. and she was spitting about 5 ml of clots and bright red blood every 15 minutes. No blood was seen in the ex ternal nares, and anterior rhinoscopy did not reveal the site of hemorrhage. Blood and clots were present in the oropharynx, but the patient was too agitated to permit indirect nasopharyngoscopy. At this time the conjunctival sacs were clear and the patient was without epiphora bilaterally. Two No. 14 Foley catheters were inserted into the nasopharynx, and the balloons of these were each distended with 3.5 ml of sterile water. At this time the blood and clots were being delivered from the right external nare and the pharynx became clear. After anterior pack ing with gauze strips inpregnated with petroleum jelly, all external nasal bleeding from the right nos tril stopped. The left side was not packed anteriorly and the left posterior pack was left in place and secured to the right posterior pack at the external nares to preclude posterior displacement. At this time, we first noted that the patient had a red epi phora on the right. Upon closer observation it was obvious that blood was being expressed from both the superior and inferior puncta at a slow but steady rate. We decided not to apply topical heparin because we felt that punctal bleeding was too brisk to permit an effective concentration of the drug to reach the lacrimal sac. Instead, we decided to ob serve the patient for the onset of dacryocystitis or unremitting epiphora secondary to obstruction. Her blood pressure was reduced and controlled with hydralazine HC1. Her punctal bleeding and epiphora ceased about 18 hours later and her anterior and posterior packs were removed 36 hours after inser tion. She has been followed for eight months and has had no recurrence of epiphora and no signs or symptoms of dacryocytitis. SUMMARY
A 49-year-old black woman developed ret rograde nasolacrimal duct bleeding in the course of epistaxis secondary to vascular hy pertension. Control of the blood pressure and packing of the nose led to cessation of
m
VOL. 75, NO. 4
BLOODY TEARS
727
11. Bolotte and Fribourg-Blanc : Bloody tears the bleeding at approximately 18 hours with caused by neurovégétative disequilibrium after head out recurrence. Bloody tears have been de trauma. Arch. Opht. 48:697, 1931. scribed in conjunction with a large variety of 12. Scott, Z. R. : Sanguineous lacrimation. Report of a case. Am. J. Dis. Child. 33:907, 1927. abnormalities. REFERENCES 1. Heyrowsky, K.: Vicarious hemorrhage of conjunctiva and bloody tears. Wein. Klin. Wschr. 59:702, 1947. 2. Dejean, C. : Bloody tears ceasing with the first menstruation. Arch. Sod. Sei. Med. Biol. Montpel lier 15 :468, 1934. 3. Satanowsky, P.: Bloody tears due to conjunctival hemorrhage during monopause. Rev. Assoc. Med. Argentina 47:3429,1930. 4. Siggers, D. C. : Blood-stained tears. Brit. Med. J. 4:177, 1970. 5. Belau, P. G., and Rucker, C. W.: Bloody tears : Report of case. Proc. Mayo Clin. 36:234, 1961. 6. Galvez Montes, J., and Casado Corzo, J. P. : Angioma of lacrimal sac ; study apropos of case of tears of blood. Arch. Soc. Oftal. Hispano-Am. 13: 174, 1953. 7. Dimitry, T. J. : Bloody tears : Bilateral capil lary hemangiomas. J.A.M.A. 110:643, 1938. 8. Delord, R., Cazaban, R., and Cadilhac, J. : Unilateral functional amaurosis following lighten ing stroke with excretion of bloody tears ; case with recovery. Bull. Soc. Opht. Franc. 708, 1952. 9. Angelone, L. : Bloody tears and Roger's blue disease. Ann. Othal. Clin. Ocul. 75 :287, 1949. 10. Picard, J. : Bloody tears at onset of posttraumatic epileptic attack. Ann. Med. Psychol. 95 : 824, 1937.
13. Jiricka, Z. : Presence of blood in tears during the mecholyl test. Med. Pharm. Exp. (Basel) 12: 65, 1965. 14. Pur, S.: Bloody tears. Cesk. Oftal. 20:379, 1964. 15. Meyer, F. W., and Kluth, C. : Lacrimation of blood and its causes. Klin. Mbl. Augenheilk. 121 : 719, 1952. 16. Vila Ortiz, J. M., and Imbern, S.: Badly named bloody tears : Two cases. Arch. Oftal. Bue nos Aires 12:711, 1937. 17. Greig, D. M. : Recurrent bleeding from the eyes. Edinburgh Med. J. 39:628, 1932. 18. Manes, A. J.: Bloody tears: Three cases. Diag. Med. 3:679, 1931. 19. Gabrielides, A. : Tears of blood. Ann. Ocul. 160:705, 1923. 20. Abel, S. : Haemorrhage from the lacrimal punctum. Brit. J. Ophth. 34:754, 1950. 21. Jongkees, L. B. W. : Bleeding from lacrimal duct during nasal hemorrhage. Nederl. T. Geneesk. 85:2695, 1941. 22. Konikow, M. J. : A case of bloody tears. Bos ton Med. Surg. J. 175 :607, 1916. 23. Messner, F. : Profuse bloody tears associated with nasal tamponade for epistaxis. Wien Klin. Wschr. 59:469, 1947. 24. Schenk, G. : Bloody tears from bleeding through the nasolacrimal duct. Klin. Mbl. Augen heilk. 41:481,1903.