[Severe epistaxis caused by carotid artery rupture].

Epistaxis due to rupture of the carotid, usually occurs as a result of cranial or closed cranio-facial traumatism. Heamorrhage is secondary to the formation of post-traumatic arterial aneurysms or arterio-venous fistulas. Frequently, the lesion is along the intra-cavernous pathway of the internal carotid. Rupture of a spontaneous arterial aneurysm in the sphenoidal sinus is, however, extremely rare. Carotid arteriography is the main method of investigation, and this method alone is capable of detecting the carotid lesion. In addition to obvious cases, it should be requested in cases of severe, copious and recurrent epistaxis when interrogation of the patient reveals the merest hint of trauma, often a long time previously. Immediate treatment consists of anterior bilateral and naso-pharyngeal tampnage. This allows enough time for arteriography to be carried out under the most favourable conditions and also testing for carotid substitution. In order to ensure permanent thrombosis of the aneurysmal pocket or the arteriovenous fistula, most methods resolve themselves into occlusion of the carotid axis. Cervical ligature of the carotid on its own, and isolated trapping have given way to techniques employing either a combination of trapping and embolization, or the placing of a balloon probe without trapping. At present, Serbinenko is advocating using balloons released when arteriography is carried out, obliterating the fistula and left in position permanently. Finally, there is the method by which the sphenoidal sinus is approached para-lateronasally after ethmoidectomy: this is an effective method which is much less incursive than the endo-cranial approach.