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Jacobs D, Wang VJ, Chao JR, Manes RP, Lee YH. Treatment, Management, and Otolaryngology Consultation for Epistaxis in the Emergency Room: An Institutional Experience. Am J Rhinol Allergy 2024; 38:102-107. [PMID: 38155492 DOI: 10.1177/19458924231223348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
BACKGROUND Epistaxis is a common reason for emergency department (ED) visits, accounting for approximately 1 of every 200 ED visits in the United States annually and up to one-third of all otolaryngology (ENT)-related ED encounters. OBJECTIVES To detail reasons for ENT consultation for epistaxis in the ED, understand how consultation impacts patient care, assess follow-up patterns after emergency care, and study patient care after transfer or referral into the ED. METHODS Retrospective chart review of 592 adult patients with epistaxis managed in a tertiary care ED setting between 2017 and 2018. Patients with known follow-up, ENT consult in the ED, or admission were included, while patients with trauma, recent head and neck surgery, or abnormal anatomy were excluded. RESULTS The most common reasons for ENT consultation for epistaxis were for advanced management, referral to the ED from an outside facility or provider, and recent head and neck surgery. In total, 48.2% of patients treated for epistaxis in the ED received an ENT consultation. ENT consultation was associated with a higher likelihood of receiving absorbable or nonabsorbable packing (92.4% vs 36.1%). In total, 40.4% of patients referred into the ED from an outside facility or provider had no change in their management after receiving an ENT consult. Patients referred to the ED and White patients were significantly more likely to receive an ENT consult. Secondary analyses revealed that more White patients had an established outpatient ENT provider than patients of other races. On multivariate analysis, patients who received an ENT consult spent 75.2 min longer in the ED. CONCLUSION The high percentage of patients referred or transferred to the ED for epistaxis management with no change in interventions after ENT consultation indicates a continued need to develop more precise clinical care pathways. Additionally, there may be gaps between White and non-White patients in access to ENT care.
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Affiliation(s)
- Daniel Jacobs
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vickie J Wang
- Yale University School of Medicine, New Haven, CT, USA
| | - Janet R Chao
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - R Peter Manes
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Yan H Lee
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Rosario E, Sharma E, Patel A, Guvensen G, Ashroff R, McClenaghan F, Hariri A, Joseph J. Use of tranexamic acid-soaked NasoPore® in the emergency department, to reduce epistaxis admissions. Clin Otolaryngol 2023; 48:909-914. [PMID: 37614122 DOI: 10.1111/coa.14093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 07/25/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES The aim of this study was to assess the efficacy of a new emergency department (ED) intervention for the management of non-traumatic, anterior epistaxis in adult patients, aiming to reduce epistaxis admissions. DESIGN A new epistaxis pathway was introduced for use by ED practitioners. This was disseminated in ED through an educational campaign by the ear, nose and throat team. A tranexamic acid (500 mg/5 mL)-soaked NasoPore® packing step was introduced for epistaxis which did not terminate following 10 min of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation periods were defined, and all adults attending ED with non-traumatic, anterior epistaxis were included. Pre- and post-implementation epistaxis treatment interventions, admission rates and re-attendance rates were recorded by retrospective audit and compared. RESULTS In the post-implementation group, epistaxis admissions were 51.7% (p < .05) lower than in the pre-implementation group, as a proportion of the total number attending ED with epistaxis during these periods. CONCLUSIONS The significant reduction in epistaxis admissions demonstrates that this ED intervention is beneficial for patient outcomes.
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Affiliation(s)
- Eleanor Rosario
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ekta Sharma
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ankit Patel
- Department of Otolaryngology, University College London Hospitals, UK
| | | | - Rizal Ashroff
- Accident & Emergency Department, University College London Hospitals, UK
| | - Fiona McClenaghan
- Department of Otolaryngology, University College London Hospitals, UK
| | - Ahmad Hariri
- Department of Otolaryngology, University College London Hospitals, UK
| | - Jonathan Joseph
- Department of Otolaryngology, University College London Hospitals, UK
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Randhawa A, Randhawa KS, Tseng CC, Fang CH, Baredes S, Eloy JA. Racial Disparities in Charges, Length of Stay, and Complications Following Adult Inpatient Epistaxis Treatment. Am J Rhinol Allergy 2022; 37:51-57. [PMID: 36221850 DOI: 10.1177/19458924221130880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although recent studies have identified an association between race and adverse outcomes in head and neck surgeries, there are limited data examining the impact of racial disparities on adult inpatient outcomes following epistaxis management procedures. OBJECTIVE To analyze the association between race and adverse outcomes in hospitalized patients undergoing epistaxis treatment. METHODS This retrospective cohort analysis utilized the 2003 to 2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify cases with a primary diagnosis of epistaxis that underwent a procedure for epistaxis control. Cases with missing data were excluded. Higher total charges and prolonged length of stay (LOS) were indicated by values greater than the 75th percentile. Demographics, hospital characteristics, Elixhauser comorbidity score, and complications were compared among race cohorts using univariate chi-square analysis and one-way analysis of variance (ANOVA). The independent effect of race on adverse outcomes was analyzed using multivariate binary logistic regression while adjusting for the aforementioned variables. RESULTS Of the 83 356 cases of epistaxis included, 80.3% were White, 12.5% Black, and 7.2% Hispanic. Black patients had increased odds of urinary/renal complications (odds ratio [OR] 2.148, 95% confidence interval [CI] 1.797-2.569, P < .001) compared to White patients. Additionally, Black patients experienced higher odds of prolonged LOS (OR 1.227, 95% CI 1.101-1.367, P < .001) and higher total charges (OR 1.257, 95% CI 1.109-1.426, P < .001) compared to White patients. Similarly, Hispanic patients were more likely to experience urinary/renal complications (OR 1.605, 95% CI 1.244-2.071, P < .001), higher total charges (OR 1.519, 95% CI 1.302-1.772, P < .001), and prolonged LOS (OR 1.157, 95% CI 1.007-1.331, P = .040) compared to White patients. CONCLUSION Race is an important factor associated with an increased incidence of complications in hospitalized patients treated for epistaxis.
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Affiliation(s)
- Avneet Randhawa
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Karandeep S Randhawa
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Christopher C Tseng
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Christina H Fang
- Department of Otorhinolaryngology - Head and Neck Surgery, 2013Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, 12286Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Neurological Surgery, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Ophthalmology and Visual Science, 12286Rutgers New Jersey Medical School, Newark, New Jersey.,Department of Otolaryngology and Facial Plastic Surgery, Saint Barnabas Medical Center - RWJBarnabas Health, Livingston, New Jersey
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Lelegren M, Bhat K, Sheehan B, Lamichhane R, Han JK, Lam KK. Variations in utilization and clinical outcomes for endoscopic sphenopalatine artery ligation and endovascular arterial embolization in a single multi-hospital network. Am J Otolaryngol 2021; 42:103066. [PMID: 33934006 DOI: 10.1016/j.amjoto.2021.103066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Endoscopic sphenopalatine artery ligation (ESPAL) and endovascular arterial embolization (EAE) are increasingly common treatment options for patients with refractory epistaxis. The objective of this study was to compare the utilization pattern and clinical outcomes between these interventions within our single multi-hospital network. MATERIALS AND METHODS A retrospective study of all patients undergoing ESPAL and/or EAE within any of the hospitals in a single healthcare network between 2008 and 2017 was conducted. We compared differences in procedure utilization with various hospital characteristics. Secondarily, we evaluated clinical outcomes and costs associated with each procedure. RESULTS Forty-three ESPAL and 33 EAE procedures were performed across 7 hospitals, with the majority of procedures being performed at teaching institutions (65% and 91%, p = .013). The majority of both interventions were performed in larger hospitals and EAE patients were more likely to undergo inter-hospital transfer compared to ESPAL patients (48.5% and 16.3%, p = .02). Success rates for ESPAL and EAE were comparable (95% and 93%); however, the median direct cost of treatment for EAE was significantly higher than the cost for ESPAL ($12984.89 and $5002.02, p < .0001). CONCLUSIONS The majority of both ESPAL and EAE interventions were performed at teaching and larger hospitals. Transfers occurring prior to EAE may have been due to the limited availability of interventional radiology services, and likely contributed to the increased cost of treatment. ESPAL is a known cost-effective management strategy and should be considered early in treatment algorithms of refractory epistaxis.
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Anti-thrombotics and their impact on inpatient epistaxis management: a tertiary centre experience. Ir J Med Sci 2021; 191:1621-1629. [PMID: 34562192 PMCID: PMC9308617 DOI: 10.1007/s11845-021-02790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/18/2021] [Indexed: 11/03/2022]
Abstract
Introduction Epistaxis represents a massive burden upon NHS resources. Despite being an extremely common reason for emergency ENT admissions, there remains significant variation in its management. Although the evidence base is continually growing, there appears to be a lack of guidance towards managing anti-coagulants and anti-platelet medications and identifying patient-specific outcomes in this setting. Epistaxis has long been associated with a multitude of risk factors but none have shown consistent, direct correlation. Materials and methods We aimed to identify if the use of anti-thrombotic medication was associated with a longer length of hospital admission or conferred a higher requirement for nasal packing, re-packing, surgery or re-admission. We conducted a retrospective analysis of 100 consecutive adult patients admitted over a 6-month period. Statistical analysis was conducted using SPSS software. Results Sixty-five percent of patients were taking anti-thrombotic medication. The variability of admission INR values in those taking warfarin did not relate with any outcome measure. There was no statistical difference between patients taking anti-thrombotic medication and those who do not, with regards to our primary outcome measures. Re-admission rates within 28 days were found to be 13%, with anti-thrombotic medication use and pre-existing cardiovascular disease recognised as commonly encountered risk factors. Three percent of patients required surgical intervention. Eight percent of patients required re-packing, with a Rapid Rhino chosen in all instances. Conclusion The use of anti-thrombotic medication is not associated with increased morbidity or increased rate of complications. Anti-thrombotic usage and more than one medical co-morbidity increase the risk of re-admission within 28 days.
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Richardson C, Abrol A, Cabrera CI, Goldstein J, Maronian N, Rodriguez K, D'Anza B. The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation. Am J Otolaryngol 2021; 42:102941. [PMID: 33592555 DOI: 10.1016/j.amjoto.2021.102941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.
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Management of ENT emergencies during the coronavirus disease 2019 pandemic. The Journal of Laryngology & Otology 2021; 135:117-124. [PMID: 33612142 PMCID: PMC7900667 DOI: 10.1017/s0022215121000530] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre. Methods After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019. Results An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients. Conclusions Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns.
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8
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Singh AK, Kasle DA, Torabi SJ, Manes RP. Adverse Events Associated With ClariFix Posterior Nasal Nerve Cryoablation: A MAUDE Database Analysis. Otolaryngol Head Neck Surg 2021; 165:597-601. [PMID: 33528303 DOI: 10.1177/0194599820986581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis. The purpose of this study is to review the medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events related to the use of ClariFix, a device designed for office-based cryosurgical ablation of the PNN. A total of 12 adverse events associated with ClariFix from January 2017 to August 2020 were identified and analyzed. The most common adverse events associated with ClariFix PNN cryoablation include epistaxis and nasal swelling. Further studies are needed to clarify whether PNN cryoablation is associated with epistaxis in certain populations.
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Affiliation(s)
- Amrita K Singh
- Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David A Kasle
- Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sina J Torabi
- Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - R Peter Manes
- Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
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9
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg 2020; 162:S1-S38. [PMID: 31910111 DOI: 10.1177/0194599819890327] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Abstract
Epistaxis is not uncommon, with up to 60% of the population suffering from at least one episode in their lifetime and as many as 6% presenting for medical attention. An analysis of emergency room (ER) visits in the United States between 2009 and 2011 identified 1.2 million encounters for epistaxis, accounting for 0.32% of ER visits. Approximately 6% of patients will require more aggressive, invasive management in the form of transnasal ligation of the sphenopalatine artery or endovascular embolization. This article reviews the epidemiology, rationale for endovascular treatment, strategy for treatment, endovascular technique, postprocedural follow-up, and complications and their management.
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Affiliation(s)
- Joan C Wojak
- Department of Radiology, Our Lady of Lourdes Regional Medical Center, Lafayette, Louisiana.,Department of Radiology, Louisiana State University School of Medicine, New Orleans, Louisiana
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11
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngol Head Neck Surg 2020; 162:8-25. [PMID: 31910122 DOI: 10.1177/0194599819889955] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, a Division of Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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12
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Usefulness of computed tomography in predicting ethmoidal arterial bleeding in refractory epistaxis. Eur Arch Otorhinolaryngol 2020; 277:1969-1975. [PMID: 32170420 DOI: 10.1007/s00405-020-05914-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Epistaxis that is refractory to conservative management can be treated with endoscopic sphenopalatine artery ligation (ESPAL). Although rare, ethmoidal artery (EA) bleeding can be a cause of rebleeding after successful ESPAL. EA bleeding is diagnosed by angiography and can also be identified during surgical exploration. However, since the angiographic embolization of the EA is contraindicated, surgical hemostasis is mandatory. This study investigated whether paranasal sinus (PNS) CT could provide information for predicting EA bleeding without angiography in patients with refractory epistaxis requiring ESPAL. METHODS Forty-seven patients, who were surgically treated [with ESPAL or EA ligation (EAL)] for refractory epistaxis from March 2010 to June 2019, were retrospectively analyzed. A positive PNS CT finding for EA bleeding was defined as the presence of soft tissue densities having continuity with the EA pathway, accompanied by a partially deficient surrounding bony canal. These findings as well as soft tissue densities in each paranasal sinus were compared between the ESPAL and EAL groups. RESULTS All patients in the EAL group had positive CT findings of EA bleeding, compared to only 12.2% in the ESPAL group (P < 0.001). The rate of soft tissue densities within the frontal and sphenoid sinuses were noted in 26.8% and 17.1% of patients in the ESPAL group, compared to 83.3% and 83.3% of patients in the EAL group (P = 0.013 and P = 0.003, respectively). CONCLUSION PNS CT might be useful for predicting EA bleeding in patients with refractory epistaxis requiring surgical hemostasis.
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13
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Nithianandan H, Thavorn K, Banaz F, Macdonald K, Lasso A, Kilty SJ. Determining the hospital cost of anterior epistaxis treatment modalities at a Canadian tertiary care centre. World J Otorhinolaryngol Head Neck Surg 2020; 5:193-199. [PMID: 32083246 PMCID: PMC7015865 DOI: 10.1016/j.wjorl.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/31/2019] [Accepted: 11/27/2019] [Indexed: 11/05/2022] Open
Abstract
Objective To estimate the hospital costs of managing anterior epistaxis in the Emergency Department at a Tertiary Care centre in Canada. Material and methods A cost analysis was conducted based on a retrospective review of Emergency Department visits from January 2012 to May 2014. A consecutive sample of adult patients with a diagnosis of anterior epistaxis was included. Anterior epistaxis was managed via one of: Nasal clip, Merocel®, Silver Nitrate cautery, Vaseline packing, other treatment or no treatment. Both the direct and indirect hospital costs ($CDN) for anterior epistaxis treatment were calculated from the hospital's perspective. Generalized linear models were used to assess the association between treatment modalities and total hospital costs while controlling for potential confounding factors. Results Three hundred and fifty-three patients (49% female) with a mean age of (69.9 ± 18.5) years were included in the analysis. The median (interquartile ranges) costs of treatment ranged from C$227.83 (C$167.96, C$328.69) for observation to C$763.98 (C$632.25,C$830.23) for Merocel®. The overall median total hospital costs incurred across all modalities was C$566.24 (C$459.61, C$753.46) for the management of anterior epistaxis. Silver Nitrate, nasal clip, and observation were statistically associated with a lower cost when compared to Merocel® (P < 0.001) even after potential confounding factors were controlled. Conclusions Our results show wide difference in the hospital cost of epistaxis across treatment modalities. These cost estimates can help inform future economic evaluation studies aiming to guide the allocation of health care resources for patients with epistaxis.
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Affiliation(s)
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Institute for Clinical and Evaluative Sciences, ICES uOttawa, Ottawa, Ontario, Canada
| | - Fatmahalzahra Banaz
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, The University of Ottawa, Ottawa, Ontario, Canada
| | - Kristian Macdonald
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, The University of Ottawa, Ottawa, Ontario, Canada
| | - Andrea Lasso
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Shaun J Kilty
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, The University of Ottawa, Ottawa, Ontario, Canada.,Dr. S. Kilty Medicine Prof. Corp., Ottawa, ON, Canada
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14
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Lin Y, Yasheng M, Zhang H, Rouzi M, Zunong M, Wu X. Characteristics and treatment of patients with epistaxis over the last 5 years in Guangzhou. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919892150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Epistaxis is one of the most common emergencies in the department of otolaryngology, which gives a burden to the health care system. Objectives: This study aimed to investigate the patients’ characteristics of hospital admission with epistaxis and provide an optimized protocol. Methods: This study was a retrospective analysis of patients with epistaxis admitted to The Third Affiliated Hospital of Sun Yat-sen University in Guangzhou, China. The data were analyzed in terms of gender, age, seasonal differences, length and expenses of hospitalization, pathogenesis of epistaxis, primary medical management before hospital admission, bleeding sites, and treatment. Results: A total of 387 patients were included, which consisted of 270 males and 117 females with an average of 43 years. Most patients could be identified with underlying diseases, and the most commonly observed bleeding site was Little area (n = 164). Most patients received electrocauterization as a precision medical treatment (n = 288). The duration of hospitalization length ranged from a mean of 5.17–4.48 days, and the expenses of hospitalization ranged from a mean of RMB 4881–4951 yuan over the last 5 years. Conclusion: Most patients with epistaxis could be treated as outpatients by endoscopic electrocauterization, and hospitalization is indicated when patients need improvement of poor general condition, posterior packing, embolization, or surgery. This study enables to provide an optimized protocol for patient with epistaxis.
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Affiliation(s)
- Yong Lin
- Department of Otolaryngology Head and Neck Surgery, The First People’s Hospital of Kashi District, Kashi, China
| | - Maimaitiyiming Yasheng
- Department of Otolaryngology Head and Neck Surgery, The First People’s Hospital of Kashi District, Kashi, China
| | - Heyue Zhang
- Department of Otolaryngology Head and Neck Surgery, The First People’s Hospital of Kashi District, Kashi, China
| | - Mireguli Rouzi
- Department of Otolaryngology Head and Neck Surgery, The First People’s Hospital of Kashi District, Kashi, China
| | - Mierban Zunong
- Department of Otolaryngology Head and Neck Surgery, The First People’s Hospital of Kashi District, Kashi, China
| | - Xifu Wu
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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15
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Kunz SM, Holzmann D, Waser Y, Meerwein C, Deggeller M, Soyka MB. Does Length Matter? A Comparison of Rapid Rhino™ Nasal Packings for the Treatment of Epistaxis. Am J Rhinol Allergy 2019; 33:723-729. [DOI: 10.1177/1945892419864799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BackgroundEpistaxis is the most common otorhinolaryngologic emergency around the world. A broad variety of treatment options is available; ranging from conservative measures such as cauterization and nasal packings to surgery. For posterior epistaxis, nasal packings are usually the preferred initial treatment method. There are 2 different models of the widely used Rapid Rhino™ packing available at our department; the 7.5 cm, single-lumen, and the 9 cm, double-lumen variant with 2 separately inflatable balloons. Identifying whether one packing is superior to the other will help with the choice of the best possible treatment.ObjectiveThe goal of this study was to determine whether the new, double-lumen model had advantages compared to its shorter counterpart.MethodsAll patients treated with Rapid Rhino™ packings for spontaneous epistaxis between December 2005 and October 2017 were analyzed for various parameters such as recurrence rates, hospitalization rate, and duration of in-patient stay. The groups were divided by model and whether patients were treated before or after the introduction of the double-lumen version (December 2010).ResultsA total of 865 cases of patients treated with Rapid Rhino™ packs were analyzed. Before December 2010, 210 of 372 cases (56%) were hospitalized, whereas afterwards it was only 48% (235/493; P = .01). The duration of the in-patient stay decreased from 3.7 to 3.1 days ( P < .01). There was no difference in recurrence rates.ConclusionThe introduction of the double-lumen, 9 cm Rapid Rhino™ packing has led to a decrease of in-patient time and to less hospitalizations. Therefore, it should be preferred to the shorter, single-lumen model in the treatment of posterior epistaxis.
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Affiliation(s)
- Seraina M. Kunz
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Yves Waser
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christian Meerwein
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Deggeller
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael B. Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
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Richardson C, Abrol A, Hamill CS, Maronian N, Rodriguez K, D'Anza B. Improving efficiency in epistaxis transfers in a large health system: Analyzing emergency department treatment variability as pretext for a clinical care pathway. Am J Otolaryngol 2019; 40:530-535. [PMID: 31036416 DOI: 10.1016/j.amjoto.2019.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Epistaxis is a common condition with an estimated $100 million in health care costs annually. A significant portion of this stems from Emergency Department (ED) management and hospital transfers. Currently there is no data in the literature clearly depicting the differences in treatment of epistaxis between Emergency Medicine (EM) physicians and Otolaryngologists. Clinical care pathways (CCP) are a way to standardize care and increase efficiency. Our goal was to evaluate the variability in epistaxis management between EM and Otolaryngology physicians in order to determine the potential impact of a system wide clinical care pathway. MATERIALS AND METHODS A retrospective case study was conducted of all patients transferred between emergency departments for epistaxis over an 18-month period. Exclusion criteria comprised patients under 18 years old, recent sinonasal surgery, bleeding disorders, and recent facial trauma. RESULTS 73 patients met inclusion criteria. EM physicians used nasal cautery in 8%, absorbable packing in 1% and non-absorbable packing in 92% (with 33% being bilateral). In comparison, Otolaryngologists used nasal cautery in 37%, absorbable packing in 34%, and non-absorbable packing in 23%. Eighty percent of patients treated by an Otolaryngology physician required less invasive intervention than previously performed by EM physicians prior to transfer. CONCLUSIONS Epistaxis management varied significantly between Emergency Medicine and Otolaryngology physicians. Numerous patients were treated immediately with non-absorbable packing. On post-transfer Otolaryngology evaluation, many of these patients required less invasive interventions. This study highlights the variability of epistaxis treatment within our hospital system and warrants the need for a standardized care pathway.
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17
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Smith J, Hanson J, Chowdhury R, Bungard TJ. Community-based management of epistaxis: Who bloody knows? Can Pharm J (Ott) 2019; 152:164-176. [PMID: 31156729 DOI: 10.1177/1715163519840380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jenna Smith
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Jennifer Hanson
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Raiyan Chowdhury
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
| | - Tammy J Bungard
- Alberta Health Services (Smith), University of Alberta Hospital.,Anticoagulation Management Services (Hanson), University of Alberta Hospital.,Division of Otolaryngology Head and Neck Surgery (Chowdhury), University of Alberta, Edmonton, Alberta.,Division of Cardiology (Bungard), University of Alberta, Edmonton, Alberta
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18
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Balakrishnan K, Moriarty JP, Rosedahl J, Driscoll CL, Borah BJ. Predictors of High Costs of Care among Otolaryngology Patients. Otolaryngol Head Neck Surg 2019; 161:271-277. [DOI: 10.1177/0194599819838843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Identify predictors of high-cost otolaryngology care. Study Design Cross-sectional. Setting Tertiary academic multispecialty hospital. Subjects/Methods All patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. “Outliers” were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status. Results In total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers. Conclusion This is the first large-scale study of high-cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high-cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.
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Affiliation(s)
- Karthik Balakrishnan
- Department of Otorhinolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Mayo Clinic Children’s Center, Rochester, Minnesota, USA
| | - James P. Moriarty
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jordan Rosedahl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin L. Driscoll
- Department of Otorhinolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Bijan J. Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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19
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Zhou AH, Chung SY, Sylvester MJ, Zaki M, Svider PS, Hsueh WD, Baredes S, Eloy JA. To Pack or Not to Pack: Inpatient Management of Epistaxis in the Elderly. Am J Rhinol Allergy 2018; 32:539-545. [PMID: 30270635 DOI: 10.1177/1945892418801259] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Epistaxis is common in elderly patients, occasionally necessitating hospitalization for the management of severe bleeds. In this study, we aim to explore the impact of nasal packing versus nonpacking interventions (cauterization, embolization, and ligation) on outcomes and complications of epistaxis hospitalization in the elderly. METHODS The 2008-2013 National Inpatient Sample was queried for elderly patients (≥65 years) with a primary diagnosis of epistaxis and accompanying procedure codes for anterior and posterior nasal packing or nonpacking interventions. RESULTS A total of 8449 cases met the inclusion criteria, with 62.4% receiving only nasal packing and 37.6% receiving nonpacking interventions. On average, nonpacking interventions were associated with a 9.9% increase in length of stay and a 54.0% increase in hospital charges. Comorbidity rates did not vary between cohorts, except for diabetes mellitus, which was less common in the nonpacking cohort (26.6% vs 29.0%; P = .014). Nonpacking interventions were associated with an increased rate of blood transfusion (24.5% vs. 21.8%; P = .004), but no significant differences in rates of stroke, blindness, aspiration pneumonia, infectious pneumonia, thromboembolism, urinary/renal complications, pulmonary complications, cardiac complications, or in-hospital mortality. Comparing patients receiving ligation or embolization, no differences in length of stay, complications, or in-hospital mortality were found; however, embolization patients incurred 232.1% greater hospital charges ( P < .001). CONCLUSION Nonpacking interventions in the elderly do not appear to be associated with increased morbidity or mortality when compared to nasal packing only but appear to be associated with increased hospital charges and length of stay. Embolization in the elderly results in greater hospital charges but no change in outcome when compared to ligation.
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Affiliation(s)
- Albert H Zhou
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sei Y Chung
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Michael J Sylvester
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Michael Zaki
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter S Svider
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Wayne D Hsueh
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- 2 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Soly Baredes
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- 2 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- 1 Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- 2 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
- 3 Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
- 4 Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey
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20
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Ni JS, Kohn J, Levi JR. Inpatient Pediatric Epistaxis: Management and Resource Utilization. Ann Otol Rhinol Laryngol 2018; 127:829-835. [DOI: 10.1177/0003489418797946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Epistaxis is a common condition that rarely warrants hospital admission in the pediatric population, making its inpatient management difficult to study. This study aims to use a nationwide database to analyze trends in the treatment of pediatric patients admitted with epistaxis and determine factors impacting total charges. Methods: The latest (2012) version of the Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality was used to identify weighted discharges with the primary diagnosis of epistaxis. Information regarding demographics, comorbidities, treatment, hospital burden, and other admission details were obtained. Linear regression was used to analyze factors suspected to increase cost. Results: Among 372 weighted discharges, the mean age was 9.68 years (SD = 5.79), and 60.0% were male. The most common comorbidities were thrombocytopenia, von Willebrand disease, and chronic sinusitis. The majority of admissions with epistaxis (56.7%) did not undergo any procedure to control epistaxis. Mean total charges was $30 208 (SD = $62 683) with a mean length of stay of 2.46 days (SD = 3.31). Independent predictors of increased charges included longer length of stay, admission from the emergency department, and median household income within the third quartile for patients’ ZIP codes. Midwest hospital region independently predicted decreased charges. Having a procedure to control epistaxis did not significantly impact cost. Conclusions: Pediatric epistaxis admissions often do not require long hospital stays or procedural control of the bleed. However, significant charges are incurred treating epistaxis. Awareness of factors impacting these charges can potentially improve resource utilization.
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Affiliation(s)
- Jonathan S. Ni
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jocelyn Kohn
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Jessica R. Levi
- Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Otolaryngology–Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA
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Douglas CM, Tikka T, Broadbent B, Calder N, Montgomery J. Patterns of hospital admission in 54 501 patients with epistaxis over a 20-year period in Scotland, UK. Clin Otolaryngol 2018; 43:1465-1470. [PMID: 29953726 DOI: 10.1111/coa.13178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 06/22/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Epistaxis affects most people over their lifetime. It is the commonest ear, nose and throat emergency. Hospital admission and socio-economic deprivation have been associated with mental health disorders, respiratory illness and with emergency hospital admissions. Low socio-economic status has never previously been associated with epistaxis, a common reason for admission to ear, nose and throat departments throughout the UK. METHODS Demographics from Information Services Division Scotland were analysed over a period of 20 years. This focused on gender, number of admissions, number of bed days, socio-economic deprivation (Scottish Index of Multiple Deprivation) and mortality within 1 year. RESULTS Data from 54 501 patients were assessed. Admission numbers and length of stay have significantly decreased (P < 0.0001). Males are more frequently affected (P = 0.001). Admission numbers were higher for patients in more deprived areas (P < 0.001). Mean duration of stay has decreased by 1 bed day. Surgical intervention of epistaxis has increased significantly (P < 0.001). There is an associated 1-year mortality rate of 9.8% following epistaxis. CONCLUSION There has been a significant decrease in hospital admissions and length of hospital stay in patients admitted with epistaxis over the past 20 years. There is a significant association with deprivation and epistaxis admission.
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Affiliation(s)
- Catriona M Douglas
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Theofano Tikka
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Benedict Broadbent
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
| | - Nick Calder
- Department of Otolaryngology - Head and Neck Surgery, Monklands Hospital, Airdrie, ML6 0BG, UK
| | - Jenny Montgomery
- Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK
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22
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Initial assessment in the management of adult epistaxis: systematic review. The Journal of Laryngology & Otology 2017; 131:1035-1055. [DOI: 10.1017/s0022215117002031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:The initial assessment of epistaxis patients commonly includes: first aid measures, observations, focused history taking, and clinical examinations and investigations. This systematic review aimed to identify evidence that informs how the initial assessment of these patients should be conducted.Method:A systematic review of the literature was performed using a standardised methodology and search strategy.Results:Seventeen articles were included. Factors identified were: co-morbidity, intrinsic patient factors, coagulation screening and ice pack use. Hypertension and anticoagulant use were demonstrated to adversely affect outcomes. Coagulation screening is useful in patients on anticoagulant medication. Four studies could not be accessed. Retrospective methodology and insufficient statistical analysis limit several studies.Conclusion:Sustained ambulatory hypertension, anticoagulant therapy and posterior bleeding may be associated with recurrent epistaxis, and should be recorded. Oral ice pack use may decrease severity and can be considered as first aid. Coagulation studies are appropriate for patients with a history of anticoagulant use or bleeding diatheses.
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23
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Shay S, Shapiro NL, Bhattacharyya N. Epidemiological characteristics of pediatric epistaxis presenting to the emergency department. Int J Pediatr Otorhinolaryngol 2017; 103:121-124. [PMID: 29224751 DOI: 10.1016/j.ijporl.2017.10.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/10/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Investigate the epidemiological characteristics of pediatric epistaxis in the emergency department setting. STUDY DESIGN Cross-sectional study using national databases. METHODS Children (age <18 years) presenting with a diagnosis of epistaxis were extracted from the State Emergency Department Databases for New York, Florida, Iowa, and California for the calendar year 2010. Associated diagnoses, procedures, encounter characteristics, and demographic data were examined. RESULTS There were 18,745 cases of pediatric epistaxis (mean age 7.54 years, 57.4% male). Overall, 6.9% of patients underwent procedures to control epistaxis, of which 93.5% had simple anterior epistaxis control. The distribution of pediatric epistaxis was highest in spring and summer months (p < 0.001). Children from the lowest income quartile comprised a higher proportion of epistaxis presentations (38.8%, p < 0.001), yet were least likely to have an epistaxis control procedure performed (p < 0.001). Most patients had either Medicaid (43.8%) or private insurance (41.3%). Patients with Medicaid and those without healthcare coverage were least likely to undergo an epistaxis control procedure (p < 0.001). White children were more likely to undergo an epistaxis control procedure compared to those of minority backgrounds (p < 0.001). CONCLUSIONS Most emergency department presentations of pediatric epistaxis are uninvolved cases that do not require procedural intervention. The overrepresentation of low socioeconomic status patients may suggest an overutilization of emergency services for minor cases of epistaxis, and perhaps a lack of access to primary care providers. This is the first study to evaluate racial and socioeconomic factors in relationship to pediatric epistaxis. Further investigation is needed to better elucidate these potential disparities.
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Affiliation(s)
- Sophie Shay
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 550, Los Angeles, CA 90095, USA.
| | - Nina L Shapiro
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 550, Los Angeles, CA 90095, USA.
| | - Neil Bhattacharyya
- Department of Otology & Laryngology, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA.
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24
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Rudmik L, Mattos JL, Stokken JK, Soler ZM, Manes RP, Higgins TS, Setzen M, Lee J, Schneider J. Rhinology-specific priority setting for quality improvement: a modified Delphi study from the Quality Improvement Committee of the American Rhinologic Society. Int Forum Allergy Rhinol 2017; 7:937-944. [PMID: 28799731 DOI: 10.1002/alr.21998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Improving the quality of healthcare is a complex and resource intensive process. To optimize the allocation of scarce resources, quality improvement (QI) should focus on high-value diseases that will produce the largest improvement in health system performance. Given the breadth and multidisciplinary nature of sinonasal disease management, the purpose of this study was to transparently develop a prioritized list of sinonasal diseases for QI from the perspective of the specialty of rhinology and the American Rhinologic Society (ARS). METHODS The RAND modified Delphi methodology was used to rank the priority of nine sinonasal disease categories from 1 (lowest priority) to 9 (highest priority). Two rounds of ranking along with a teleconference meeting was performed by a panel of 9 experts from the ARS Quality Improvement Committee. RESULTS The final QI-prioritized list of sinonasal diseases are as follows: chronic rhinosinusitis (CRS) (mean score = 8.9), recurrent acute rhinosinusitis (RARS) (mean score = 7.9), sinonasal neoplasms (mean score = 7.0), anatomic nasal obstruction (mean score = 5.9), refractory epistaxis (mean score = 5.2), complicated acute rhinosinusitis (mean score = 5.2), chronic nonallergic rhinitis (mean score = 4.4), orbital disease (mean score = 4.3), uncomplicated acute rhinosinusitis (mean score = 4.1), and allergy/allergic rhinitis (mean score = 3.7). CONCLUSION The three most important disease categories for QI from the perspective of the specialty of rhinology were CRS, RARS, and sinonasal neoplasms. Future studies need to define and validate quality metrics for each of these important disease categories in order to facilitate appropriate measurement and improvement initiatives.
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Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Jose L Mattos
- Department of Otolaryngology-Head and Neck Surgery; University of Virginia School of Medicine, Charlotteville, VA
| | - Janalee K Stokken
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - R Peter Manes
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Thomas S Higgins
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, Louisville, KY
| | - Michael Setzen
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY
| | - Jivianne Lee
- Department of Otolaryngology-Head and Neck Surgery University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - John Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St. Louis, MO
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25
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Cohen O, Shoffel-Havakuk H, Warman M, Tzelnick S, Haimovich Y, Kohlberg GD, Halperin D, Lahav Y. Early and Late Recurrent Epistaxis Admissions: Patterns of Incidence and Risk Factors. Otolaryngol Head Neck Surg 2017; 157:424-431. [PMID: 28463569 DOI: 10.1177/0194599817705619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Epistaxis is a common complaint, yet few studies have focused on the incidence and risk factors of recurrent epistaxis. Our objective was to determine the patterns of incidence and risk factors for recurrent epistaxis admission (REA). Study Design Case series with chart review. Settings Single academic center. Subjects and Methods The medical records of patients admitted for epistaxis between 1999 and 2015 were reviewed. The follow-up period was defined as 3 years following initial admission. REAs were categorized as early (30 days) and late (31 days to 3 years) following initial admission. Logistic regression was used to identify potential predictors of REAs. Results A total of 653 patients were included. Eighty-six patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late. Nonlinear incidence curve was demonstrated for both early and late REAs. Based on logistic regression, prior nasal surgery and anemia were independent risk factors for early REAs. According to multivariate analysis, thrombocytopenia was significantly associated with late REAs. Conclusion Early and late REAs demonstrate different risk predictors. Knowledge of such risk factors may help in risk stratification for this selected group of patients. All patients at risk should be advised on possible preventive measures. Patients at risk for early REA may benefit from a more proactive approach.
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Affiliation(s)
- Oded Cohen
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Hagit Shoffel-Havakuk
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Meir Warman
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Sharon Tzelnick
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Yaara Haimovich
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Gavriel D Kohlberg
- 3 Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Columbia and Weill Cornell Campuses, New York, New York, USA
| | - Doron Halperin
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Yonatan Lahav
- 1 Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.,2 Hadassah Medical School, Hebrew University, Jerusalem, Israel
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26
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Sylvester MJ, Chung SY, Guinand LA, Govindan A, Baredes S, Eloy JA. Arterial ligation versus embolization in epistaxis management: Counterintuitive national trends. Laryngoscope 2016; 127:1017-1020. [DOI: 10.1002/lary.26452] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/31/2016] [Accepted: 11/10/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Michael J. Sylvester
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
| | - Sei Y. Chung
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
| | - Luis A. Guinand
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
| | - Aparna Govindan
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
| | - Soly Baredes
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New JerseyRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology–Head and Neck SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New JerseyRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
- Department of Neurological SurgeryRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
- Department of Ophthalmology and Visual ScienceRutgers New Jersey Medical SchoolNewark New Jersey U.S.A
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