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Shalakya Tantra
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Category : Nasachikitsa (Rhinology)
Forign bodies are commen cause of intermittant unilateral epistaxis with serosangeous discharge. Both animate and inanimate forign bodies can be encountered but leeche as a cause of epistaxis is not that much commen.
A 35 yrs old male, otherwise apperantly healthy, reported to my E.N.T. O.P.D. with complaint of unilateral blood stained discharge, odd sensation of something creeping in the nose and slight occasional unlilateral blockage since a week. He was suspecting a leech in his nasal cavity as he had a history of drinking water from an open stream in an area where leeches are quite commen. The patient belonged to a hilly area of Distt. Sirmour from Himachal Pradesh and particularly some shaddy moist ares in this region have abundent leeches, particularly harbouring the open water springs.
On examination by anterior rhinoscopy no apparent forign body was seen in thenasal cavity. The right nostril was full of blood strained mucoid discharge. As he was an adult male, the secretions were removed with the help of suction and again the cavity was examined but no forign body could be visualised. Posterior rhinoscopy was also apparently normal. A diagnostic nasal endoscopy with a 4 mm 00 endoscope was performed after topical anesthesia with nasal spray. A blackish brown mass was seen moving high up on the septum and hidden behind the middle turbinate.The upper attachement could not be seen . A cupped endoscopic forceps was introduced in the nasal cavity and the forign body was grabbed and brought out. This turned out to be a leech, which was still alive and measured about 3 inches long. Xylometazoline drops were instilled and the patient had no bleeding and was relived of his symptoms.
A similar case of 7 yrs old girl, with similar complaints and no finding on anterior and posterior rhinoscopy, when examined endoscopically revealed a live leech in nasalcavity which was removed after topical anesthesia, with no post operative sequlae.
I also encountered a case of leech sticking to the upper fornix of the eyelid about five years back in a child of about 3 yrs age which was sucessfuly removed after topical anesthesia.
Among the animate forign bodies most books report nasal myiasis as the commenest cause of unilateral epistaxis. Leech infestation has not been reported as a commen cause of epistaxis in books. However, Manson Bahr has mentioned leech as the cause of epistaxis. Leeches can enter the maxillary sinus through the natural or the acessory ostia and then they can be very difficult to remove. They can get dislodged from nasal cavity and enter the subglotic area causing dyspnoea and cough and can be life threatning.
Leeches are annelids belonging to subgroup Hirudinea. They can be classified into fresh water, terrestrial and marine leeches according to there habitat. A few of them are haemorrhagic parasites feeding on blood of animals. They are hermephrodites. Hirudiniasis is the term used to indicate the invasion of body cavity by leeches. The species Dinobdella ferox ( furocious leech / nasal leech) are known to invade the nasal cavities.
Leeches attach themselves to the human beings either on skin or the mucous membrane with the help of their caudal end and suck blood by there sucker. A single leech can suck ten times the blood of its size. The saliva of leech contains a local anesthetic that limits the sensation to the host, thus the the host does not attempt to remove it. The saliva also contains a potent vasodilator and also an Anticoagulant called hirudin. Thus the dilated vessels enable the leech to suck more and more blood without clotting.
Though, simple methods like instilation of saline drops, citric acid or 50% alcohol gargeling can be of some use but they should be avoided as these can lead to the accidental passage of leech into airway with life threatning sequalae. Such cases are best left to otolaryngologist and this applies to all the nasal forign bodies.
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ANIMATE FORIGN BODY IN NASAL CAVITY and ROLE OF ENDOSCOPY : A LIVE LEECH CASE REPORT
ABSTRACT: Forign bodies in the nasal cavity are commen presentation in E.N.T. O.P.D. but animate forign bodies are less frequently encountered. Leech infestation of nasal cavity are rare,here are two case reports.INTRODUCTION and CASE REPORT
Forign bodies inside the nasal cavity are commen preentation in E.N.T. clinics. Usally it is the children who present with forign bodies in the nose but adults are no exceptions particularly those with mental retardation and depressive patients. Seldom will one keep a record of number and kind of forign bodies encountered. But forign bodies in the nasal cavity can be a great challange and the management will require great skill.Forign bodies are commen cause of intermittant unilateral epistaxis with serosangeous discharge. Both animate and inanimate forign bodies can be encountered but leeche as a cause of epistaxis is not that much commen.
A 35 yrs old male, otherwise apperantly healthy, reported to my E.N.T. O.P.D. with complaint of unilateral blood stained discharge, odd sensation of something creeping in the nose and slight occasional unlilateral blockage since a week. He was suspecting a leech in his nasal cavity as he had a history of drinking water from an open stream in an area where leeches are quite commen. The patient belonged to a hilly area of Distt. Sirmour from Himachal Pradesh and particularly some shaddy moist ares in this region have abundent leeches, particularly harbouring the open water springs.
On examination by anterior rhinoscopy no apparent forign body was seen in thenasal cavity. The right nostril was full of blood strained mucoid discharge. As he was an adult male, the secretions were removed with the help of suction and again the cavity was examined but no forign body could be visualised. Posterior rhinoscopy was also apparently normal. A diagnostic nasal endoscopy with a 4 mm 00 endoscope was performed after topical anesthesia with nasal spray. A blackish brown mass was seen moving high up on the septum and hidden behind the middle turbinate.The upper attachement could not be seen . A cupped endoscopic forceps was introduced in the nasal cavity and the forign body was grabbed and brought out. This turned out to be a leech, which was still alive and measured about 3 inches long. Xylometazoline drops were instilled and the patient had no bleeding and was relived of his symptoms.
A similar case of 7 yrs old girl, with similar complaints and no finding on anterior and posterior rhinoscopy, when examined endoscopically revealed a live leech in nasalcavity which was removed after topical anesthesia, with no post operative sequlae.
I also encountered a case of leech sticking to the upper fornix of the eyelid about five years back in a child of about 3 yrs age which was sucessfuly removed after topical anesthesia.
DISCUSSION
Forign bodies in the nasal cavity can be catagorised into animate forign bodies and inanimate forign bodies. The inanimate forign bodies can be either organic or nonorganic. Among inanimate forign bodies, endogenous materials like bones or peices of cartilages can be left behind following surgical intranasal interventions. Innumerable materials like beans, peas, chalk, beads, drawing pins, peices of rubber errasers, washers, eyelets, nuts, buttons, brass studs, sponges, corks and cardboard discs have gained enterance into nasal cavity. Even a door handle, bullets, thimble, iron bolts, corks, coins and a pencile have been recovered from nose.Among the animate forign bodies most books report nasal myiasis as the commenest cause of unilateral epistaxis. Leech infestation has not been reported as a commen cause of epistaxis in books. However, Manson Bahr has mentioned leech as the cause of epistaxis. Leeches can enter the maxillary sinus through the natural or the acessory ostia and then they can be very difficult to remove. They can get dislodged from nasal cavity and enter the subglotic area causing dyspnoea and cough and can be life threatning.
Leeches are annelids belonging to subgroup Hirudinea. They can be classified into fresh water, terrestrial and marine leeches according to there habitat. A few of them are haemorrhagic parasites feeding on blood of animals. They are hermephrodites. Hirudiniasis is the term used to indicate the invasion of body cavity by leeches. The species Dinobdella ferox ( furocious leech / nasal leech) are known to invade the nasal cavities.
Leeches attach themselves to the human beings either on skin or the mucous membrane with the help of their caudal end and suck blood by there sucker. A single leech can suck ten times the blood of its size. The saliva of leech contains a local anesthetic that limits the sensation to the host, thus the the host does not attempt to remove it. The saliva also contains a potent vasodilator and also an Anticoagulant called hirudin. Thus the dilated vessels enable the leech to suck more and more blood without clotting.
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Though, simple methods like instilation of saline drops, citric acid or 50% alcohol gargeling can be of some use but they should be avoided as these can lead to the accidental passage of leech into airway with life threatning sequalae. Such cases are best left to otolaryngologist and this applies to all the nasal forign bodies.
CONCLUSION
Hence, leech as an animate forign body should always be kept in mind while treating a patient with features suggestive of forign body reporting from an area where springs and ponds are commen. A thorough search should be made and if anterior rhinoscopy is negative a diagnostic endoscopy should be performed as leechs are known to attach to posterior part or high up on the nasal septum or the lateral nasal wall. In such cases this could be the most rewarding procedure for diagnosis and management.Newer Articles:
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