This paper presents a case of a patient with a 3-month history of recurrent right-sided epistaxis with heavy bleeding for 4-days. Leech infestation in the nasal cavity was found to be the main cause of the epistaxis via endoscopic examination. Epistaxis caused by leech infestation although rare, can cause serious problems. When the clinicians meet the patients with unexplained intermittent epistaxis, leech infections must be taken into consideration. In this case, a 5-cm in length dark brown leech was removed with ethmoid forceps under local anesthesia by nasal endoscopy.
Intranasal foreign bodies are a common disease in the otolaryngology department and it is a required skill for doctors in the ENT to diagnosis the disease and remove the foreign body. The foreign body in the nasal cavity may cause epistaxis, nasal obstruction, rhinocnesmus, and so on. It is necessary to remove foreign bodies in time to prevent from causing severe complications. However, leech infections is rare and easily ignored by clinicians that mainly occurring in backward developing countries or areas.
A previously healthy 73-year-old man presented with a 3-month history of intermittent epistaxis to the otolaryngology department of our hospital. The patient developed right-sided nose bleeds with nasal obstruction prior to 3-months.The exact amount of bleeding is unclear. The bleeding stopped after the patient used cold water on his forehead. The patient was asymptomatic 3 months prior to his presentation with the right-sided epistaxis. And then the patient sought a doctor at the local township hospital to seek care and was diagnosed as epistaxis with an unknown cause. During the 3-months, the symptom of intermittent right-sided epistaxis could be stopped on its own. Hence, he did not pay attention to it. The patient had another occurrence of epistaxis before 4- days prior and felt a sensation of a foreign body moving inside the his nasal cavity. He removed a segment of a foreign body with his hand. The surface of foreign body was smooth. The patient still had the symptom of intermittent epistaxis along with an itchy nose during the 4 days. So he eventually proceeded with care in the otolaryngology department of our hospital for further treatment. Anterior rhinoscopy revealed hyperemia of the right nasal mucosa and numerous secretions in the nasal meatus, which was bloody, without pus or odor. A dark-brown “leech” shaped foreign body with peristalsis movement the leech was endoscopically visualized in the nasal septum ( Fig. 1 ). Then we immediately obstructed the postnaris with gauze firstly.2% pontocaine was sprayed in nasal cavity to anesthetize leech. A few seconds later, the leech paralyzed. Ethmoid forcep was immediately used to grasp the front of the leech and removed the alive leech via rhinoscopy which measures 5 cm in length ( Fig. 2 ). The nasal cavity was examined again for no foreign body remnants or active bleeding.
Intranasal foreign bodies are a common cause of epistaxis [ , ]. The common foreign bodies include beads, peanuts, rubbers or small parts of toys, etc [ ]. Epistaxis caused by parasitic infections is so rare that it has not been mentioned as a cause of epistaxis in standard textbooks [ ]. Parasitic infections has been very rare in developed countries such as Europe and the United States. But it is still common in developing countries, especially in backward rural areas [ , ]. Farmers work in the fields all year round and are often exposed to unsanitary water. And many farmers have a bad habit of drinking unsafe water in field and using it to wash face, which may lead to parasitic infections [ ]. This phenomenon is usually common in Southern China. Consequently, if the clinicians encounter patients with unexplained epistaxis, parasitic infections must be taken into consideration especially when the patients come from such endemic areas.
Leeches are hermaphroditic parasites inhabiting in fresh water and the length of leeches removed from the nasal cavities are reported to be 2–12 cm [ ]. The leech eggs are discharged out of body 1 month later of internal mating. It take about 16–25 days to develop from eggs to larvae in wet mud. Among the different developmental stages of leech, leech larvae are the most common foreign bodies infecting human [ ]. Leeches are annelids or segmented worms. They have a powerful muscular sucker at each end [ , ]. Leeches attach to the tissue or skin by the suckers and use three teeth inside their suckers to bite [ ]. The hosts usually feel unpainful and are not aware of the presence of leeches when bited because leeches can secret the anesthetic chemical [ ]. Leeches can remain in the nasal cavity for a long time until the hosts have symptoms. The common symptoms of patients are recurrent epistaxis, nasal obstruction and sensation of a moving foreign body in the nose. Leeches can even move to trachea and bronchi and cause hemoptysis, pain and suffocation [ ]. Moreover, cases have been reported with involvement of the nasopharynx, larynx,oesophagus, vagina and urethra [ , , ].
The saliva of a leech also contains hirudin and histamine like substances. Hirudin inhibits thrombin in the clotting process and histamine prevents closure of capillaries, which may cause massive blood loss [ , , ]. Meanwhile, they ingest an amount of blood equivalent to 8.9 times their weight [ , ]. Leech infection may cause severe anemia and even need blood transfusion. Consequently, it is very important to diagnose and remove the leech in time.
It is easy to misdiagnosis when a leech is not in the nasal cavity. This is partly because the disease is so rare that clinicians tend to ignore it. When leech is located in nasopharynx, it is easy to be misdiagnosed as nasopharyngeal malignant tumor. Therefore, it is particularly important to collect the medical history carefully, including the patient’s living environment and living habits. In addition, the nasal cavity has a special anatomical and complicated structure, with four pairs of sinuses. When living leeches move into the sinus cavity, it is difficult to be found by rhinoscopy. In this case, the leech was just located in the position of common meatus, and can be discovered by rhinoscopy. However, in cases that are difficult to be confirmed by rhinoscopy, relevant imaging examinations can be further completed, such as CT,MR,etc.Imaging examination can not only help to diagnose the disease, but also locate the leech and judge the degree of damage of the nasal cavity and paranasal sinus, which is helpful for the clinician to remove the leech. Clinicians need to collect medical history and physical examination carefully and comprehensively, and complete the relevant imaging examination to diagnosis leech infection in time.
There are various methods to remove leeches. It is difficult to remove leeches directly because it has a soft and slippery skin, which slip away easily. Removing leeches under general anesthesia may be required for small children. In this case, we obstructed the postnaris with gauze. Then we sprayed 2% pontocaine into nasal cavity. A few seconds later, the leech paralyzed. We immediately used the dentate forcep to grasp the leech head to remove it. Some experience may be concluded from this case that the postnaris can be blocked with gauze to prevent the leech pass to the larynx or lower respiratory tract before removing the live leech. Moreover, dentate forcep may be selected to prevent the leech from sliping away and tetracaine may be selected as anesthetic to anesthetize leech. Clinician should try to avoid movement of leech in nasal cavity and aggravating the damage of nasal mucosa, and reduce the pain of patients. Adrenaline or ephedrine can contract the nasal mucosa, which may weaken the adhesion of leech suckers in the nasal cavity and help to remove leech. Another method is irrigation with strong saline, vinegar, turpentine, or alcohol.
In conclusion, this paper describes the process of removing living leech from nasal cavity and summarizes its experience to provide the information for otolaryngologist and emergency department doctor. Living in rural areas where leeches are endemic and swimming in or drinking polluted water may provide clues for clinicians when the clinicians meet the patients with unexplained intermittent epistaxis.
Credit author statement
Hou Nan: Conceptualization, Writing – review & editing, Funding acquisition. Lv Die: Writing – original draft preparation. Zhao Kai: Resources. Xu Xiaoli: Data curation. Yang Wenbin: Visualization. Wang Yi: Supervision
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
This research was supported by grant from the Foundation of the Sichuan Science and Technology Department , No. 19ZDYF0944 .