What should be done for a patient with recurring epistaxis (nosebleeds) and eye deviation, who has a history of Cushing's syndrome?

Management of Recurring Epistaxis in a Patient with Cushing's Syndrome

For a patient with recurring epistaxis and eye deviation with a history of Cushing's syndrome, referral to an otolaryngologist is strongly recommended for comprehensive evaluation and management, as this combination of symptoms suggests potential serious underlying pathology requiring specialist care. 1

Initial Assessment and Management

First-Line Measures for Epistaxis Control

• Instruct the patient to:
  • Sit with head slightly forward
  • Apply firm sustained compression to the lower third of the nose for 10-15 minutes
  • Breathe through the mouth and spit out any blood 1
• After compression, perform anterior rhinoscopy to identify the bleeding site after removing blood clots 1
• Apply topical tranexamic acid (TXA) if available, which can control bleeding within 10 minutes in 71% of patients 1

Special Considerations for Cushing's Syndrome

• Patients with Cushing's syndrome have increased risk factors for epistaxis including:
  • Hypertension (common in Cushing's syndrome)
  • Easy bruising and skin fragility
  • Potential immunosuppression increasing infection risk 2, 3
• The eye deviation requires urgent neurological evaluation as it may indicate:
  • Possible intracranial pathology
  • Potential carotid artery aneurysm (reported in Cushing's disease) 4

Specialist Referral and Advanced Management

Otolaryngology Evaluation

• Nasal endoscopy to precisely identify the bleeding site 1
• Assessment for:
  • Posterior epistaxis (which has higher risk and may require hospitalization)
  • Local anatomical factors contributing to recurrent bleeding
  • Evidence of systemic causes related to Cushing's syndrome 1

Treatment Options

1. Cauterization:

   • If bleeding site is clearly identified, apply cautery after local anesthesia
   • Restrict cautery application only to the active or suspected bleeding site 1

2. Nasal Packing:

   • Consider if bleeding continues despite first-line measures
   • Options include non-absorbable and absorbable materials
   • Monitor for complications, especially in immunocompromised patients with Cushing's syndrome 1, 5

3. Surgical Options (for persistent/recurrent bleeding):

   • Endoscopic arterial ligation (97% success rate)
   • Endovascular embolization (~80% success rate) 1

Neurological Evaluation for Eye Deviation

• MRI of brain and orbits to evaluate for:
  • Pituitary tumor extension (if Cushing's disease is the cause)
  • Intracranial aneurysm (reported in Cushing's disease patients) 4
  • Other intracranial pathology that might explain both symptoms

Follow-up and Prevention

• Schedule follow-up within 3-5 days to assess for recurrence 1
• Provide patient education on:
  • Proper nasal moisturization techniques
  • Home treatment methods
  • When to seek emergency care (bleeding >30 minutes, signs of hypovolemia) 1
• Consider optimization of Cushing's syndrome management to reduce associated risk factors:
  • Control hypertension
  • Address hypercoagulability
  • Manage immunosuppression 2, 3

Important Cautions and Pitfalls

• Do not delay specialist referral - the combination of recurrent epistaxis and eye deviation in a patient with Cushing's syndrome warrants prompt specialist evaluation
• Monitor for infection - patients with Cushing's syndrome are at increased risk for opportunistic infections, which can complicate management 5
• Consider hospitalization for:
  • Posterior epistaxis
  • Bleeding not controlled with anterior packing
  • Significant hemodynamic instability
  • Need for blood transfusion 1
• Avoid routine imaging for uncomplicated epistaxis, but in this case with eye deviation and Cushing's syndrome, imaging is indicated 1