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Kil HK, Ahn JC. Intractable epistaxis requiring surgical exploration or arterial embolization; Associated comorbidities and locations of the bleeder. Auris Nasus Larynx 2024; 51:797-802. [PMID: 38964029 DOI: 10.1016/j.anl.2024.06.001] [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: 01/27/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE This study aimed to determine which comorbidities were associated with intractable epistaxis requiring electrocauterization or embolization, and to identify the location where intractable epistaxis frequently occurred. METHODS The patients were divided into two groups: patients with epistaxis successfully controlled in outpatient department (OPD) and those with intractable epistaxis in OPD which was controlled by surgical exploration or arterial embolization (OP/EM). Evaluations of the bleeding locations, related vessels, and patient's comorbidities were conducted. RESULTS A total of 41 patients from the OP/EM group and 725 patients from the OPD group were enrolled. The following comorbidities showed elevated risks of the intractable epistaxis (p< 0.05) in multivariate analysis; hypertension (OR 1.089, 95% CI 1.049 - 1.132), dyslipidemia (1.132, 1.041 - 1.232), liver cirrhosis (1.272, 1.152 - 1.406), chronic obstructive pulmonary disease (1.234, 1.078 - 1.412) and asthma (1.205, 1.053 - 1.379). Inferior and middle turbinate were equally the most common location of the intractable bleeding. CONCLUSION In patients with epistaxis requiring hemostatic treatments, comorbidities such as hypertension, dyslipidemia, liver diseases, COPD, and asthma were associated with intractable epistaxis. The main bleeding sites of intractable epistaxis were the middle and inferior turbinate.
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Affiliation(s)
- Hong-Kwon Kil
- Department of Otorhinolaryngology-Head and Neck Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jae-Cheul Ahn
- Department of Otorhinolaryngology-Head and Neck Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea.
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Hovgaard LH, Grønlund C, Homøe P. Risk factors of epistaxis in rural Denmark: a cross-sectional population-based survey of data from the Lolland-Falster health study. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08762-2. [PMID: 38914819 DOI: 10.1007/s00405-024-08762-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/26/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Epistaxis is a common condition that affects about 60% of the population in their lifetime, with 6% needing medical attention. Little is known about the epidemiology and risk factors of epistaxis outside the health care system. This study aimed to investigate the prevalence and risk factors of epistaxis in a rural Danish population using data from the Lolland-Falster Health Study (LOFUS). METHODS We conducted a cross-sectional survey based on data from LOFUS, a household-based, prospective cohort study in the rural provincial area of Lolland-Falster, Denmark. We enrolled 10,065 participants (≥ 50 years) and collected data on demographics, comorbidities, medication, lifestyle factors, and laboratory parameters. Logistic regressions were used to test for correlations between epistaxis and different risk factors. RESULTS In total 5.3% of the participants had experienced epistaxis within the past 30 days, and 7.9% had sought medical attention for epistaxis at some point in their lives. We identified several factors that were significantly correlated with increased odds of epistaxis, such as male gender, age group 50-59 years, high BMI (> 25), allergy, diabetes, hypertension, atherosclerosis, angina, and anticoagulant treatment. Excellent or good self-reported health was correlated to significantly lower odds of epistaxis. CONCLUSION This study provides a comprehensive overview of the prevalence and risk factors of epistaxis outside the health care system. Our study suggests that preventive measures targeting these risk factors may reduce the incidence and severity of epistaxis in this population.
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Affiliation(s)
- Lisette Hvid Hovgaard
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Lykkebaekvej 1, Køge, 4600, Denmark.
| | - Casper Grønlund
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Lykkebaekvej 1, Køge, 4600, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Preben Homøe
- Department of Otorhinolaryngology and Maxillofacial Surgery, Zealand University Hospital, Lykkebaekvej 1, Køge, 4600, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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van der Zaag PD, Geurts S, Rozema R, Reininga IHF, van Minnen B. Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics. Eur J Trauma Emerg Surg 2024; 50:543-550. [PMID: 38197899 PMCID: PMC11035474 DOI: 10.1007/s00068-023-02428-0] [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: 11/04/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE To investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures. METHOD A prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures. RESULTS Out of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors. CONCLUSION Maxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.
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Affiliation(s)
- Pieter Date van der Zaag
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stephanie Geurts
- Faculty of Dentistry and Oral Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Romke Rozema
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Inge H F Reininga
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Emergency Care Network Northern Netherlands (AZNN), Northern Netherlands Trauma Registry, Groningen, The Netherlands
| | - Baucke van Minnen
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Papazoglou AS, Athanaseas I, Fousekis K, Kasotakis N, Kolokouris S, Zisakis T, Kyriakoulis KG. Diagnostic and Therapeutic Challenges in a Military Recruit Training Center of the Hellenic Navy: A Retrospective Analysis of the Poros Registry Serving as a Quality Improvement Project for Medical Officers. Mil Med 2024; 189:e166-e175. [PMID: 37399317 DOI: 10.1093/milmed/usad243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/30/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Basic military training (BMT) has been associated with increased morbidity burden. Nevertheless, the exact epidemiology of the encountered cases in the BMT of Greek recruits has never been assessed. The aim of this quality improvement project was to investigate for the first time the clinical patterns, rates, and severity of symptoms leading recruits to visit the infirmary of a recruit training center and use this knowledge to provide a practical guidance for the physicians in charge. MATERIALS AND METHODS All medical cases which were consecutively examined for the time range from November 2021 to September 2022 at the infirmary of the Hellenic Naval recruit training center in Poros, Greece, were retrospectively analyzed. Logistic regression analyses were performed to identify independent predictors of "severe clinical status" (i.e., overnight sick bay confinement and/or transfer to a tertiary hospital within 24 h) and absence from BMT for at least 1 day. RESULTS A total of 2,623 medical cases were examined during four recruit seasons from November 2021 to September 2022. Upper respiratory tract infections (URTIs) and musculoskeletal injuries were the most frequent reasons for a recruit's visit to the infirmary (33.9% and 30.2%, respectively). 6.7% of the total cases were identified as having "severe clinical status." Specifically, in psychiatric, urological, and cardiovascular cases, febrile events were all independently associated with increased risk of "severe clinical status." There was a positive association between training week and absence from BMT, while febrile events and spring recruit season were also independently linked with increased probability of absence from BMT for at least 1 day. CONCLUSIONS URTIs and musculoskeletal complaints were the primary reasons for recruits' presentation at the infirmary of a Greek recruit training center, leading to severe rates of attrition. Further registries and quality improvement projects are warranted to reach specific conclusions and reduce BMT-related morbidity and its subsequent implications.
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Schmid FA, Mergen V, Bärlocher T, Kaufmann B, Epprecht L, Soyka MB, Eberli D, Hötker AM. Atherosclerosis of the iliac arteries for the prediction of erectile dysfunction and epistaxis in men undergoing abdominal CT scan. BMC Urol 2023; 23:173. [PMID: 37891557 PMCID: PMC10612309 DOI: 10.1186/s12894-023-01340-4] [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: 12/01/2022] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND To investigate the association between erectile dysfunction (ED) as well as epistaxis (ES) in relation to the extent of iliac atherosclerosis. METHODS In this retrospective cross-sectional study, all consecutive male patients treated at our institution from 01/2016 to 12/2020 undergoing abdominal CT scan were evaluated. Patients (n = 1272) were invited by mail to participate in the study in returning two questionnaires for the evaluation of ED (IIEF-5) and ES. Patients who returned filled-in questionnaires within a 3-month deadline were included in the study. The extent of atherosclerosis in the common iliac artery (CIA) and the internal iliac artery (IIA) was assessed by calcium scoring on unenhanced CT. Stratification of results was performed according to reported IIEF-5 scores and consequential ED groups. RESULTS In total, 437 patients (34.4% of contacted) met the inclusion criteria. Forty-two patients did not fulfill predefined age requirements (< 75 years) and 120 patients had to be excluded as calcium scoring on nonenhanced CT was not feasible. Finally, 275 patients were included in the analysis and stratified into groups of "no-mild" (n = 146) and "moderate-severe" (n = 129) ED. The calcium score (r=-0.28, p < 0.001) and the number of atherosclerotic lesions (r=-0.32, p < 0.001) in the CIA + IIA showed a significant negative correlation to the IIEF-5 score, respectively. Patients differed significantly in CIA + IIA calcium score (difference: 167.4, p < 0.001) and number of atherosclerotic lesions (difference: 5.00, p < 0.001) when belonging to the "no-mild" vs. "moderate-severe" ED group, respectively. A multivariable regression model, after adjusting for relevant baseline characteristics, showed that the number of atherosclerotic CIA + IIA lesions was an independent predictor of ED (OR = 1.05, p = 0.036), whereas CIA + IIA calcium score was not (OR = 1.00031, p = 0.20). No relevant correlation was found between ES episodes and IIEF-5 scores (r=-0.069, p = 0.25), CIA + IIA calcium score (r=-0.10, p = 0.87) or number of atherosclerotic CIA + IIA lesions (r=-0.032, p = 0.60), respectively. CONCLUSIONS The number of atherosclerotic lesions in the iliac arteries on nonenhanced abdominal CT scans is associated with the severity of ED. This may be used to identify subclinical cardiovascular disease and to quantify the risk for cardiovascular hazards in the future. TRIAL REGISTRATION BASEC-Nr. 2020 - 01637.
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Affiliation(s)
- Florian A Schmid
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich, 8091, Switzerland.
| | - Victor Mergen
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Timo Bärlocher
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich, 8091, Switzerland
| | - Basil Kaufmann
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich, 8091, Switzerland
| | - Lorenz Epprecht
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich, 8091, Switzerland
| | - Andreas M Hötker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Hadar A, Shaul C, Ghantous J, Tarnovsky Y, Cohen A, Zini A, Peleg U. Risk Factors for Severe Clinical Course in Epistaxis Patients. EAR, NOSE & THROAT JOURNAL 2023:1455613231189056. [PMID: 37496443 DOI: 10.1177/01455613231189056] [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: 07/28/2023] Open
Abstract
Purpose: Epistaxis is a common medical emergency that may require admission to the emergency department (ED) and treatment by an otolaryngologist. Currently, there are no widely accepted indications for hospitalization, and the decision is based on personal experience. Methods: A retrospective study of 1171 medical records of patients with epistaxis treated at our tertiary medical center ED from 2013 to 2018 with no age limit. The presence of recurrent epistaxis, a posterior source of bleeding, the need for hospitalization, the need for blood transfusion, or surgical intervention defined severe clinical course. Results: The 1171 admissions included 230 recurrent admissions for a total of 941 patients (60% males) who were treated by an otolaryngologist. The average age was 57.6 in the adult population (>15) and 6.6 in the pediatric population (≤15). Of all patients, 39% had hypertension; 39% took antiplatelet/anticoagulation therapy; 63% came during winter-a significant risk factor; 34 (2.9%) had reduced hemoglobin levels of >1gr%, but only 7 received a blood transfusion; 131 (11%) were hospitalized, and 21 (1.8%) required surgical control of the bleeding. Age (OR 1.02; CI 1.01-1.023), male sex (OR 2.07; CI 1.59-2.69), hypertension (OR 1.76; CI 1.27-2.45), and antiplatelet/anticoagulation therapy (OR 2.53; CI 1.93-3.33, OR 1.65; CI 1.11-2.44, respectively), were significantly correlated with severe clinical course. Conclusion: Epistaxis is significantly more common and severe in older male patients with hypertension or antiplatelet/anticoagulation therapy. However, few need a blood transfusion or surgical intervention. In borderline cases with no definitive indication for hospitalization, we suggest adopting these factors as indications for hospitalization due to their marked influence on the clinical course. Routine coagulation tests are indicated in patients treated with warfarin or combined antiplatelet + anticoagulation therapy.
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Affiliation(s)
- Ayalon Hadar
- Department of Otolaryngology, Head and Neck Surgery, Shaare-Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Chanan Shaul
- Department of Otolaryngology, Head and Neck Surgery, Shaare-Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Jameel Ghantous
- Department of Otolaryngology, Head and Neck Surgery, Shaare-Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Yehuda Tarnovsky
- Department of Otolaryngology, Head and Neck Surgery, Shaare-Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Adiel Cohen
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avraham Zini
- Faculty of Dental Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uri Peleg
- Department of Otolaryngology, Head and Neck Surgery, Shaare-Zedek Medical Center, The Hebrew University, Jerusalem, Israel
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Fridie L, Michael Tzizik D. Traumatic Injuries of the Eye, Ear, Nose, and Throat. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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DİKİCİ O, DURGUT O. Effects of Nasal Pathologies in Paediatric Epistaxis. ACTA MEDICA ALANYA 2022. [DOI: 10.30565/medalanya.1127833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives: The aim of this study was to investigate the effects of nasal pathologies in paediatric patients with recurrent epistaxis.
Methods: A total of 100 (61 boys, 39 girls) patients aged 2–17 years (mean age: 8.9 ± 3.6 years) were included in this study. Anterior rhinoscopy and flexible nasal endoscopy were used to examine all the patients. The epistaxis duration, treatment in active epistaxis by parents, medical history, medical treatment and interventions were recorded. The location of the epistaxis site, nasal mucosa type, the presence of nasal vestibulitis, nasal septum deviation location and type, adenoid size and the degree of inferior turbinate hypertrophy were recorded.
Results: The deviation was present in 31 (62%) patients with recurrent epistaxis and in 14 (28%) patients without epistaxis. The presence of deviation was significantly higher in the epistaxis group than control group (p = 0.001). The nasal mucosa type was friable mucosa in 37 (74%) patients, vascularised mucosa in 11 (22%) patients and friable – vascularised mucosa in 2 (4%) patients in recurrent epistaxis group. A significant relationship was detected between nasal mucosa type and age, the presence of the deviation, deviation location, Mladina type in epistaxis group (p = 0.005, p = 0.004, p = 0.008, p = 0.015).
Conclusion: Nasal septum deviation, inferior turbinate hypertrophy and nasal mucosa type are associated with paediatric recurrent epistaxis.
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Affiliation(s)
- Oğuzhan DİKİCİ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, KULAK-BURUN-BOĞAZ HASTALIKLARI ANABİLİM DALI
| | - Osman DURGUT
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, BURSA YÜKSEK İHTİSAS SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, KULAK-BURUN-BOĞAZ HASTALIKLARI ANABİLİM DALI
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Zieliński K, Pracoń R, Konka M, Kruk M, Kępka C, Trochimiuk P, Dębski M, Kaczmarska E, Przyłuski J, Kowalik I, Dzielińska Z, Kurowski A, Witkowski A, Demkow M. Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13802. [PMID: 36360682 PMCID: PMC9658798 DOI: 10.3390/ijerph192113802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC. METHODS Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014-11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure. RESULTS Among 195 patients (age 74 (68-80), 43.1% females, HAS-BLED score 2.0 (2.0-3.0)), during median follow-up of 370 (IQR, 358-392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16-60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81-210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37-84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32-25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20-17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01-11.08, p = 0.048) predicted post-LAAC CSB. CONCLUSIONS Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.
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Affiliation(s)
- Kamil Zieliński
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marek Konka
- Department of Congenital Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Kruk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Cezary Kępka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Piotr Trochimiuk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Dębski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Edyta Kaczmarska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Jakub Przyłuski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Ilona Kowalik
- Clinical Research Support Center, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Zofia Dzielińska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Andrzej Kurowski
- Department of Anesthesiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
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Ari K, Collins R. Outpatient Management of Epistaxis During COVID-19 to Reduce Inpatient Stay: A Quality Improvement Project. Cureus 2022; 14:e30858. [PMID: 36457605 PMCID: PMC9706149 DOI: 10.7759/cureus.30858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 06/17/2023] Open
Abstract
Introduction In March 2020, new guidelines allowed patients with epistaxis to be discharged home with nasal packs in situ to reduce the risk of inpatient coronavirus disease 2019 (COVID-19) transmission rates. Our objective is to review how successful these new guidelines have been and whether they could be safely maintained in future practice. Methods This was a retrospective data analysis at a local tertiary ENT referral hospital. The study group consisted of patients admitted with epistaxis over one year. The "Pack and Home" criteria pathway was implemented. We reviewed this pathway six months pre- (loop 1) and six months post- (loop 2) introduction. Primary outcome measures included compliance with the "Pack and Home" criteria and length of inpatient admissions. Results A total of 131 patients required nasal packing, with 72 patients (55%) in loop 1 and 59 patients (45%) in loop 2. In loop 1, all 72 patients (100%) were admitted for inpatient care. However, in loop 2, 21 patients (36%) were discharged home with nasal packs in situ and 59 patients (64%) were admitted. Of those discharged, two patients were represented after 48 hours with rebleeding. The average total length of inpatient stay in loop 1 was significantly higher at 45.7 hours and 29.6 hours in loop 2 (p<0.05). All discharged patients attended their outpatient appointment in under three days. Conclusion The "Pack and Home" criteria can successfully identify patients who are suited for an outpatient management pathway. This could reduce surgical inpatient stay and the way we manage epistaxis.
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Affiliation(s)
- Kaso Ari
- General Surgery, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Rachael Collins
- Otolaryngology, James Paget University Hospital, Great Yarmouth, GBR
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Ross A, Engebretsen S, Mahoney R, Bathula S. Risk Factors and Management for Epistaxis in a Hospitalized Adult Sample. Spartan Med Res J 2022; 7:37760. [PMID: 36128022 PMCID: PMC9448657 DOI: 10.51894/001c.37760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Epistaxis is a common otolaryngologic problem that affects most of the general population. Common risk factors for epistaxis include nasal irritants, nasal/facial oxygen use, certain systemic conditions (e.g., hypertension and coagulopathies) and medication use (e.g., anticoagulants and intranasal medications). This study examined risk factors for and management of epistaxis in patients admitted for other medical conditions who developed an episode of epistaxis during their hospital admission. METHODS Patients were included in the study if they were older than 18, admitted for medical illnesses other than epistaxis and developed an episode of epistaxis during their admission during calendar year 2020 at the authors' institution's hospitals. Electronic health record data regarding sociodemographic characteristics, common risk factors (e.g. oxygen use, anticoagulant use, history of hypertension) and treatment for epistaxis (e.g. holding anticoagulation therapy, administration of oxymetazoline, nasal cautery, nasal packing) were extracted from each chart. Patients were split into otolaryngologic treatment versus no treatment groups and risk factors were compared between sample subgroups. RESULTS A total of 143 sample patients were included, with most common reason for admission being cardiovascular related, 48 (33.6%). Most patients, 104 (72.7%), did not have a previous diagnosis of epistaxis, were positive for anticoagulant use, 106 (74.1%) and were positive for hypertension, 95 (66.4%). Oxygen use showed a significantly decreased risk for intervention (OR 0.45, 95% CI: 0.23-0.894; p = 0.028). Most patients required changes in medical management (e.g., holding anticoagulation or starting nasal saline sprays/emollients). CONCLUSION These results demonstrate the common risk factors for epistaxis in patients admitted for other clinical diseases. Identifying at-risk patients for epistaxis at hospital admission can help to initiate measures to prevent epistaxis episodes. Future studies are needed to study epistaxis risk factors and identify effective preventative measures for epistaxis among hospital populations.
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Affiliation(s)
- Andrew Ross
- Otolaryngology-Head and Neck Surgery, Detroit Medical Center
| | | | - Rebecca Mahoney
- Otolaryngology-Head and Neck Surgery, Detroit Medical Center
| | - Samba Bathula
- Otolaryngology-Head and Neck Surgery, Detroit Medical Center
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Oley MC, Oley MH, Pelealu OCP, Tangkudung G, Grimaldy G, Faruk M. Massive recurrent epistaxis in traumatic pseudoaneurysm of sphenopalatine artery: Report of 2 cases. Radiol Case Rep 2022; 17:2963-2967. [PMID: 35755108 PMCID: PMC9217997 DOI: 10.1016/j.radcr.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Maximillian Christian Oley
- Neurosurgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Neurosurgery Division, Department of Surgery, Kandou Hospital, Manado, Indonesia
- Corresponding author: Neurosurgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University. Jalan Raya Tanawangko No.56, Malalayang Satu Barat, Malalayang, Manado, North Sulawesi, 95162, Indonesia.
| | - Mendy Hatibie Oley
- Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Kandou Hospital, Manado, Indonesia
| | - Olivia Claudia Pingkan Pelealu
- Department of Ear Nose and Throat, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Department of Ear Nose and Throat, Kandou Hospital, Manado, Indonesia
| | - Gilbert Tangkudung
- Interventional Neurology Division, Neurology Department, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Interventional Neurology Division, Neurology Department, Kandou Hospital, Manado, Indonesia
| | - Garry Grimaldy
- Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
| | - Muhammad Faruk
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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13
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AlJhani SA. Escitalopram-induced epistaxis: A case report. J Taibah Univ Med Sci 2021; 16:938-942. [PMID: 34899137 PMCID: PMC8626811 DOI: 10.1016/j.jtumed.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/09/2021] [Accepted: 06/13/2021] [Indexed: 12/01/2022] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are a group of drugs used to treat various psychiatric disorders such as major depression, generalised anxiety, and obsessive-compulsive syndrome. Although generally safe, SSRIs can lead to various adverse effects, including an increased risk of bleeding due to their effect on platelet activation and aggregation. Unexpected bleeding can occur at different sites, in people of different age groups, and in combination with other medications. The commonly reported risk factors associated with medication-induced bleeding in patients with mental disorders include co-administration of other drugs and liver cirrhosis or failure. We report a relatively less common adverse effect of SSRIs. This is the case of a Middle Eastern man, known to have seasonal allergic rhinitis, who developed self-limiting epistaxis following the use of escitalopram for a depressive disorder. Since a history of seasonal allergy can precipitate bleeding when using SSRIs, risk factors for bleeding associated with SSRIs, excluding the common causes, should be explored for better management and prevention.
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Affiliation(s)
- Sumayah A AlJhani
- Department of Psychiatry, College of Medicine, Qassim University, Qassim, KSA
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Liao Z, Guo J, Mi J, Liao W, Chen S, Huang Y, Xu Y, Zhang J, Yang Q, Hong H. Analysis of Bleeding Site to Identify Associated Risk Factors of Intractable Epistaxis. Ther Clin Risk Manag 2021; 17:817-822. [PMID: 34413648 PMCID: PMC8370109 DOI: 10.2147/tcrm.s301706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/25/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Intractable epistaxis refers to deep occult bleeding and uncontrolled persistent bleeding. Effective treatment can only be implemented if the bleeding site is quickly identified and the underlying disease controlled. Objective The relationship between the bleeding site and the pathogenic factors of intractable epistaxis was analyzed to further strengthen the prevention and treatment of intractable epistaxis by outpatient doctors, family doctors and otolaryngologists. Through accurate search and minimally invasive hemostasis, it helped optimize the treatment plan for intractable epistaxis. Methods This study retrospectively analyzed the clinical data of 90 patients with intractable epistaxis who were admitted to hospital from January 2016 to December 2017. Chi-square test was used to analyze the relationship between intractable epistaxis site with underlying disease, gender and age. Results The distribution of intractable epistaxis was associated with hypertension (χ2=13.76, P=0.017). The incidence of hypertension was the highest in the olfactory sulcus of the middle turbinate region at about 60%. In addition, age was also identified as a factor that affects the distribution of intractable epistaxis (χ2=21.95, P=0.02). The incidence of intractable epistaxis on the vault of inferiornasal meatus region was highest (63%) in young patients. On the other hand, the olfactory sulcus of the middle turbinate region accounted for the highest incidence in the middle-aged and elderly group (66.7%). There was no obvious relation between the bleeding site of intractable epistaxis with diabetes, cardiovascular disease, chronic sinusitis and allergic rhinitis. Conclusion The bleeding site of intractable epistaxis is related to hypertension and age. This may improve the identification of the site of intractable epistaxis for timely implementation of treatment and can further strengthen the prevention and treatment of intractable epistaxis in outpatients or family doctors.
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Affiliation(s)
- Zhenpeng Liao
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Jianling Guo
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Jiaoping Mi
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Wei Liao
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Shulin Chen
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Yili Huang
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Yingxiang Xu
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Jun Zhang
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
| | - Qintai Yang
- Department of Otolaryngology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Haiyu Hong
- Allergy Center, Department of Otolaryngology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, People's Republic of China
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Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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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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Hur K, Badash I, Talmor G, Ference EH, Wrobel BB. Geographic Variation in Epistaxis Interventions Among Medicare Beneficiaries. Ann Otol Rhinol Laryngol 2020; 129:878-885. [PMID: 32390453 DOI: 10.1177/0003489420923380] [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: 11/16/2022]
Abstract
OBJECTIVES To quantify the utilization of epistaxis procedures in the elderly population and assess whether the geographic variability of these procedures is associated with hypertension and direct oral anticoagulant (DOAC) use. METHODS A cross-sectional study was performed on publicly available Medicare procedure and beneficiary data from 2013 to 2016 for all epistaxis procedures categorized by Common Procedural Terminology (CPT). Epistaxis procedures were analyzed by state, complexity, and provider type. Pearson's correlation coefficient was calculated. RESULTS Over 4 years, 2 19 827 epistaxis procedures were performed on Medicare patients, 44.3% of which were categorized as simple (control of nasal hemorrhage: anterior simple or posterior primary). Otolaryngologists performed 92.6% of all epistaxis procedures. The frequency of epistaxis procedures performed by state ranged from 0.99 procedures per 10 000 Medicare beneficiaries (PP10K) in Hawaii to 25.7 PP10K in New Jersey. The percentage of epistaxis interventions categorized as complex (anterior complex, posterior subsequent, with nasal endoscopy, or open procedures) in each state varied from 0% in North Dakota to 72.6% in Hawaii. Epistaxis procedure utilization was weakly correlated with the prevalence of hypertension (R2 = 0.08, P = .04) and higher percentage of DOAC among all anticoagulants prescribed (R2 = 0.08, P = .04) in a state's Medicare population. Utilization of complex epistaxis interventions was not correlated with the prevalence of hypertension or DOAC use. CONCLUSIONS Otolaryngologists perform the vast majority of epistaxis procedures in the Medicare population. However, practice patterns vary across the United States. Hypertension and DOAC use are weakly associated with the utilization of epistaxis interventions.
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Affiliation(s)
- Kevin Hur
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ido Badash
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Guy Talmor
- Department of Otolaryngology-Head and Neck Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - Elisabeth H Ference
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Bozena B Wrobel
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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18
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Role of age and anticoagulants in recurrent idiopathic epistaxis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020. [DOI: 10.1016/j.otoeng.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bedel C, Korkut M, Karancı Y, Duyan M. Can We Estimate the Recurrence of Epistaxis with Simple Blood Tests? JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2020. [DOI: 10.5799/jcei/7839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Lee CJ, Seak CJ, Liao PC, Chang CH, Tzen IS, Hou PJ, Lin CC. Evaluation of the Relationship Between Blood Pressure Control and Epistaxis Recurrence After Achieving Effective Hemostasis in the Emergency Department. J Acute Med 2020; 10:27-39. [PMID: 32995152 PMCID: PMC7517968 DOI: 10.6705/j.jacme.202003_10(1).0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 08/22/2019] [Accepted: 10/19/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND Epistaxis is the most common cause of otorhinolaryngologic emergencies. There is a longstanding controversy regarding the relationship between epistaxis and hypertension (HTN), in terms of blood pressure (BP) control in the emergency department (ED) setting. The objective of this study is to evaluate the association between HTN, BP control, and recurrent epistaxis among patients initially admitted to the ED for epistaxis. METHODS This retrospective cohort study was conducted in the EDs of three different hospitals in Taiwan and included a total of 739 patients admitted for epistaxis. RESULTS Among ED patients with epistaxis, older age was significantly associated with a history of HTN, and a statistically significant difference in age was noted between groups classified according to the systolic BP/diastolic BP (SBP/DBP) at triage. Patients with a history of HTN had higher BP values at triage than did patients without a history of HTN (SBP: 175.68 ± 32.30 mmHg vs. 148.00 ± 26.26 mmHg, DBP: 95.04 ± 20.98 mmHg vs. 83.30 ± 16.65 mmHg; p < 0.0001). Antihypertensive medications were more commonly administered to patients with a history of HTN (p < 0.0001) and in those patients with SBP/DBP: ≥ 140/≥ 90 mmHg at triage (p < 0.0001). Among patients receiving antihypertensive medications, reductions in SBP by the time of discharge were significantly greater in patients with a history of HTN and in patients with SBP/DBP: ≥ 160/≥ 100 mmHg at triage. ED revisits due to recurrent epistaxis within 72 hours were significantly associated with male sex, a positive history of HTN, level of GOT, observation for recurrent epistaxis at ED, and duration of recurrent bleeding. CONCLUSIONS A positive history of HTN is related to recurrent epistaxis among ED patients. The effectiveness of administering antihypertensive agents before achieving hemostasis in patients admitted to the ED for epistaxis warrants further study.
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Affiliation(s)
- Cheng-Jung Lee
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
| | - Chen-June Seak
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Pin-Chieh Liao
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
| | - Chia-Hsun Chang
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
| | - I-Shiang Tzen
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
| | - Po-Jen Hou
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
| | - Chih-Chuan Lin
- Linkou Medical Center, Chang Gung Memorial Hospital Department of Emergency Medicine Taoyuan Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
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Bui R, Doan N, Chaaban MR. Epidemiologic and Outcome Analysis of Epistaxis in a Tertiary Care Center Emergency Department. Am J Rhinol Allergy 2019; 34:100-107. [DOI: 10.1177/1945892419876740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The association between hypertension and recurrent epistaxis is controversial. The objective of this study is to examine the factors associated with recurrent epistaxis visits to the emergency department (ED) and establish an otolaryngology (ENT [ear, nose, and throat]) consult algorithm to optimize treatment and minimize unnecessary consultation. Methods A retrospective review of 100 patients presenting to the ED for epistaxis requiring ENT consult from 2013 to 2018 was conducted. Patient demographics, comorbidities, epistaxis etiology, blood pressure measurements during admission, and treatment methods were analyzed. Patient charts were reviewed for ED admissions, complications, and procedures. A consult algorithm was subsequently devised and retrospectively applied to our cohort. Results Patients who required more than one ED visit for epistaxis were more often males (77.8% vs 49.3%, P = .01), required posterior packing (51.9% vs 17 .8%, P < .001), and had more comorbid hypertension (66.7% vs 38.4%, P = .01) compared to patients who had 1 visit. Compared to patients presenting during summer and fall (May–October), patients presenting during winter and spring (November–April) were more often treated for anterior epistaxis with Surgicel®/Surgifoam® rather than posterior nasal packing (57.4% vs 37.0%, P = .04). Application of our consult algorithm decreased consultation by 78% and liberated 58.5 hours of ENT resident time. Conclusion Patients with recurrent epistaxis tended to be male and had more comorbid hypertension. Further prospective studies are warranted to ascertain the factors associated with recurrent epistaxis. Our consult algorithm for epistaxis helped reduce unnecessary ENT consultation and facilitated reallocation of valuable resident work hours.
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Affiliation(s)
- Roger Bui
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Nicolette Doan
- School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Mohamad R. Chaaban
- Department of Otolaryngology, University of Texas Medical Branch at Galveston, Galveston, Texas
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Gomes P, Salvador P, Lombo C, Caselhos S, Fonseca R. Role of age and anticoagulants in recurrent idiopathic epistaxis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019; 71:160-165. [PMID: 31521240 DOI: 10.1016/j.otorri.2019.05.003] [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: 03/13/2019] [Revised: 05/03/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Epistaxis is one of the commonest causes of attendance of Otolaryngology emergency rooms. Given its incidence, potential severity and high recurrence rate, a systematic and careful management is mandatory. This work aims to define prognostic factors of epistaxis recurrence. MATERIAL AND METHODS Retrospective review of medical records of patients with epistaxis admitted to our emergency department from January 2012 to December 2016. Data of 1005 patients with idiopathic epistaxis were analysed and independent risk factors for recurrence were determined by multiple logistic regression analysis. RESULTS Recurrence of epistaxis was found in 303 (30.1%) patients. Patients with recurrent epistaxis were older (p<.001) and more commonly had a history of hypertension (p=.001) and antiplatelet (p=.048) and anticoagulant (p=.001) use than those with episodic epistaxis. Age (adjusted OR 1.21, 95%CI 1.08-1.32, p=.003) and anticoagulant use (adjusted OR 2.68, 95%CI 1.94-3.70, p=.009) were predictors of increased risk of recurrent epistaxis. Gender, alcohol abuse, medical history, active bleeding at admission, unidentified bleeding point or treatment modalities were not associated with recurrence. CONCLUSION Age and use of anticoagulation drugs were risk factors for recurrence of epistaxis. None of the previously described risk factors for episodic epistaxis were found to increase the risk of recurrence. Knowledge of factors involved in recurrence might provide important information for assessment and management of increased risk patients.
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Affiliation(s)
- Patrícia Gomes
- Department of Otorhinolaryngology, Hospital Senhora da Oliveira, Guimarães, Portugal.
| | - Pedro Salvador
- Department of Otorhinolaryngology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Catarina Lombo
- Department of Otorhinolaryngology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Sérgio Caselhos
- Department of Otorhinolaryngology, Hospital Senhora da Oliveira, Guimarães, Portugal
| | - Rui Fonseca
- Department of Otorhinolaryngology, Hospital Senhora da Oliveira, Guimarães, Portugal
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Kunz SM, Holzmann D, Soyka MB. Association of epistaxis with atherosclerotic cardiovascular disease. Laryngoscope 2018; 129:783-787. [PMID: 30549051 DOI: 10.1002/lary.27604] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the association between epistaxis and atherosclerotic cardiovascular disease. STUDY DESIGN Case-control cohort study. METHODS This study included patients from the tertiary-care ear, nose, and throat department at the University Hospital of Zurich between December 1, 2016 and June 1, 2017. We assessed the cardiovascular risk profiles in a group of 41 patients presenting with epistaxis, and a group of 41 matched controls, focusing on a surrogate parameter for atherosclerosis: the carotid intima-media thickness (CIMT). RESULTS With a mean of 1.06 mm (standard deviation [SD] = 0.17), CIMT values were on average 26% higher in epistaxis patients than in their controls, with a mean of 0.84 mm (SD = 0.14; P < .001). Occurrence of severe epistaxis was also associated with lower ankle-brachial index values at 0.96 (SD = 0.12) versus 1.05 (SD = 0.17) (P < .001) and significantly higher QRISK2 relative risks (an algorithm for predicting cardiovascular risk) than found in the control group (1.81, SD = 0.97 vs. 1.35, SD = 0.28; P = .028). A binary logistic regression model, adjusted for possible confounders, showed an odds ratio of 2.5 for the occurrence of epistaxis per increase in CIMT of 0.1 mm in the study population (95% confidence interval: 1.56-4.11; P < .001). CONCLUSIONS The occurrence of severe epistaxis was shown to be closely associated with the prevalence of atherosclerotic cardiovascular disease. Accordingly, patients affected by epistaxis should be regarded as at an elevated cardiovascular risk, which indicates the need for appropriate further medical assessment and preventive measures. LEVEL OF EVIDENCE 3b TRIAL REGISTRATION: Clinical trials NCT03092973 Laryngoscope, 129:783-787, 2019.
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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
| | - Michael B Soyka
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
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Abstract
Most anterior epistaxis originates primarily from the Kiesselbach plexus, whereas posterior epistaxis is less common and originates from branches of the sphenopalatine artery. Risk factors include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies. Assessment of airway, breathing, and circulation precedes identification of bleeding source, pain control, and achieving hemostasis. Management options include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention. Specialty consultation may be pursued if interventions fail. Disposition is typically to home unless posterior epistaxis or significant comorbidities exist that warrant admission.
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Affiliation(s)
- Neil Alexander Krulewitz
- Division of Emergency Medicine, University of Utah, 30 North 1900 East, Room 1C26, Salt Lake City, UT 84132, USA.
| | - Megan Leigh Fix
- Division of Emergency Medicine, University of Utah, 30 North 1900 East, Room 1C26, Salt Lake City, UT 84132, USA
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Svider P, Arianpour K, Mutchnick S. Management of Epistaxis in Children and Adolescents: Avoiding a Chaotic Approach. Pediatr Clin North Am 2018; 65:607-621. [PMID: 29803286 DOI: 10.1016/j.pcl.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation.
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Affiliation(s)
- Peter Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, 4102 St. Antoine, 5E-UHC, Detroit, MI 48201, USA.
| | - Khashayar Arianpour
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, 4102 St. Antoine, 5E-UHC, Detroit, MI 48201, USA
| | - Sean Mutchnick
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, 4102 St. Antoine, 5E-UHC, Detroit, MI 48201, USA
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26
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Cardiovascular risk and severity factors in patients admitted to hospital for spontaneous epistaxis. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:119-122. [DOI: 10.1016/j.anorl.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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28
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Chaaban MR, Zhang D, Resto V, Goodwin JS. Factors influencing recurrent emergency department visits for epistaxis in the elderly. Auris Nasus Larynx 2017; 45:760-764. [PMID: 29208334 DOI: 10.1016/j.anl.2017.11.010] [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: 07/06/2017] [Revised: 09/26/2017] [Accepted: 11/14/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Our objective is to determine the risk factors associated with recurrent epistaxis requiring emergency department (ED) visits in the elderly. METHODS We used a 5% national sample of Medicare data from January 2012 through December 2013. Our cohort included patients with a new diagnosis of epistaxis in the ED, defined as no epistaxis in the prior 12 months. We assessed the rates of ED visits for recurrent epistaxis in the 12 months following the incident visit. Our variables included demographics, geographic location, procedures performed during the incident visit and comorbidities. RESULTS Out of the 4120 patients with incident epistaxis, 775 were readmitted with recurrent epistaxis within 12 months. 60% presented in the first 30days and 75% within 90 days. There was a significant increase in ED visits for patients over 75 years of age and in men compared to women. Recurrent ED visits for epistaxis was higher in patients with congestive heart failure, diabetes mellitus, and obstructive sleep apnea compared to those without these comorbidities. CONCLUSION Additional ED visits for epistaxis are more common in the elderly and in males. Congestive heart failure, diabetes mellitus and obstructive sleep apnea were found to be independent risk factors.
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Affiliation(s)
- Mohamad R Chaaban
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, United States.
| | - Dong Zhang
- Sealy Center on Aging, Galveston, TX, United States
| | - Vicente Resto
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, United States
| | - James S Goodwin
- Sealy Center on Aging, Galveston, TX, United States; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
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29
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Masoudian P, McDonald JT, Lasso A, Kilty SJ. Socioeconomic status and anterior epistaxis in adult population. World J Otorhinolaryngol Head Neck Surg 2017; 4:263-267. [PMID: 30564789 PMCID: PMC6284191 DOI: 10.1016/j.wjorl.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 11/09/2022] Open
Abstract
Objective Little was known about the role of socioeconomic status as a risk factor for epistaxis in adult population. The objective of this study was to determine whether socioeconomic status influences the presentation to emergency department for anterior epistaxis in an adult population. Methods Retrospective review of emergency department visits from January 2012 to May 2014. The setting is in an emergency department of a Canadian tertiary care centre. Adult patients with primary diagnosis of anterior epistaxis in the emergency department were included in this study. The main outcome was emergency department visits for anterior epistaxis visits. Results A total of 351 cases of anterior epistaxis were included. The mean age was 70 years and 51% of patients were male. The patients were stratified into two groups based on whether their age was equal to and above, or below 75 years. Our analysis indicated that those 75 years or older in higher income quintiles have an increased risk of anterior epistaxis compared to the subjects in the lower income quintiles (P < 0.05). This association did not hold true for those younger than 75 years or for all age groups combined. Conclusion There is an association between higher socioeconomic status and the presentation to the emergency department with anterior epistaxis in the population older than 75 years but not in younger patients.
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Affiliation(s)
| | - J Ted McDonald
- Department of Economics, University of New Brunswick, Fredericton, NB, Canada
| | - Andrea Lasso
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Shaun J Kilty
- The Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, The University of Ottawa, Ottawa, ON, Canada
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Mohamed OM, Govindan A, Filimonov A, Sylvester MJ, Zaki M, Baredes S, Eloy JA. Impact of liver disease on outcomes of patients hospitalized for epistaxis. Laryngoscope 2017; 127:2691-2697. [PMID: 28555879 DOI: 10.1002/lary.26624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/13/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Liver disease (LD) often results in coagulation abnormalities that may predispose to more severe epistaxis. The purpose of this analysis was to examine characteristics of patients hospitalized for epistaxis with LD and explore the impact of LD on patient outcomes. METHODS The 2002 to 2013 National Inpatient Sample was queried for cases with a primary diagnosis of epistaxis. Cases with additional codes meeting the Agency for Healthcare Research and Quality's definition of LD were identified and compared to the non-LD cohort. RESULTS Out of 39,879 cases meeting inclusion criteria, 3.6% had LD. LD was associated with younger age (55.7 years vs. 67.5 years; P < 0.001), longer hospital stay (3.9 days vs. 3.2 days; P < 0.001), and greater hospital charges ($26,141 vs. $18,200; P < 0.001) compared to the non-LD cohort. LD patients had higher rates of alcohol abuse, coagulopathy, chronic blood loss anemia, and renal failure. LD patients also had higher rates of sepsis, urinary/renal complications, respiratory failure, and infectious pneumonia. LD was associated with decreased rates of aggressive management (defined as ligation or embolization) (6.6%-9.0%; P < 0.002) and anterior or posterior nasal packing. In our multivariate logistic regression model correcting for age, gender, race, and significant comorbidities, LD was associated with 1.520 (1.336-1.729; P < 0.001) greater odds of transfusion and 2.264 (1.372-3.736; P = 0.001) greater odds of in-hospital mortality. CONCLUSION Among patients hospitalized for epistaxis, LD resulted in greater morbidity and mortality. Clinicians should be aware of the particular risk that LD bears on the hospitalized epistaxis patient. LEVEL OF EVIDENCE 2C. Laryngoscope, 127:2691-2697, 2017.
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Affiliation(s)
- Omar M Mohamed
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Aparna Govindan
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Andrey Filimonov
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Michael J Sylvester
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Michael Zaki
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Soly Baredes
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
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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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Yukitatsu Y, Tsuzuki K, Takebayashi H, Sakagami M. Clinical Study of 1,515 Patients Presenting with Epistaxis Over the Last 6 Years. ORL J Otorhinolaryngol Relat Spec 2016; 78:232-40. [PMID: 27438263 DOI: 10.1159/000446187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022]
Abstract
AIM This study reviews our clinical experience of patients with epistaxis and discusses proper management. PATIENTS AND METHODS We retrospectively investigated 1,515 patients with epistaxis treated in our department between 2005 and 2010. RESULTS Men over 50 years old predominated. More than half of the patients (n = 828) first visited after consultation hours, and 40% (n = 606) were brought by ambulance. The most common underlying diseases were circulatory diseases (69%, n = 1,047). Antithrombotics were being administered to 23% (n = 345). Kiesselbach's plexus was the most commonly observed bleeding site (51%, n = 769). In 20% (n = 297), no bleeding point was confirmed because hemostasis had been achieved on arrival. Anterior packing was the most common primary treatment, followed by electrocauterization. Hospitalization was required in 2% (n = 30). Re-bleeding occurred within 14 days after primary treatment in 14% (n = 206). Surgical treatment was performed for 5% (n = 11). CONCLUSIONS Patients showing repeated pulsatile arterial bleeding require hospitalization for surgical therapy, although outpatient therapy is sufficient in most cases. A risk of re-bleeding should be considered if patients show unclarified bleeding points and circulatory diseases.
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Affiliation(s)
- Yoriko Yukitatsu
- Department of Otolaryngology-Head and Neck Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Stadler RR, Soyka MB. A prospective pilot study comparing nasal blood sampling and venipuncture for the assessment of hemoglobin levels and INR. Laryngoscope 2016; 127:577-581. [PMID: 27076256 DOI: 10.1002/lary.26002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/20/2016] [Accepted: 02/29/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study is a pilot study evaluating the feasibility of sampling nose blood during an emergency using a commercially available rapid test device. It also compares the accuracy of rapid nasal blood test results to the results of standard laboratory methods using venous blood sampling. METHODS Nose blood was collected in patients suffering from active epistaxis. In an emergency setting, hemoglobin levels and the international normalized ratio (INR) were assessed using a rapid point-of-care test device. These results were compared to standard laboratory analyses from venous blood taken at the same time from the same patient. Twenty patients consented to and participated in these assessments. RESULTS Linear regression comparing venous and nasal samples revealed strong correlations between the two methods for both hemoglobin and INR measurement. A Bland-Altman analysis showed the mean difference to be 2.3 g/L when comparing hemoglobin measurements made using the rapid point-of-care device to hemoglobin measurements made using conventional lab assessment. The corresponding mean difference for INR measurements was 0.14. CONCLUSION The results of this pilot study support the use of point-of-care test devices using nasal blood sampling and provide preliminary data demonstrating that a rapid testing method can be reliable, practicable, and time-efficient. In our opinion, rapid hematologic screening for nasal and capillary blood should be available in emergency wards that treat epistaxis. LEVEL OF EVIDENCE 4. Laryngoscope, 127:577-581, 2017.
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Affiliation(s)
- Rafael R Stadler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich USZ, University of Zurich UZH, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich USZ, University of Zurich UZH, Zurich, Switzerland
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34
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Stadler RR, Kindler R, Holzmann D, Soyka MB. The long-term fate of epistaxis patients with exposure to antithrombotic medication. Eur Arch Otorhinolaryngol 2016; 273:2561-7. [PMID: 26861546 DOI: 10.1007/s00405-016-3913-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 01/28/2016] [Indexed: 11/25/2022]
Abstract
UNLABELLED The goal of this study was to evaluate independent risk factors for long-term epistaxis recurrences and their severity. Individual retrospective cohort study-2b level of evidence. The medical information of 603 emergency epistaxis patients was acquired during a former study. This cohort has been contacted 6 years later by conventional mail and asked to answer a specific paper questionnaire. The following parameters were evaluated: recurrent epistaxis episodes, need for a surgical intervention to stop the recurrent bleeding, patient's history for hypertension and diabetes, intake of hemostasis impairing medication now and in the past. One hundred and six (106) patients were included in the study (35.8 % response rate). The mean observation period was 76.58 months. Almost half of the patients (41.5 % = 44/106) reported at least one recurrent epistaxis episode. Patients with exposure to VKA (vitamin K antagonists) showed significantly more frequently a recurrent epistaxis episode. The binary logistic regression confirmed the intake of VKA as an independent and significant risk factor with an odds ratio of 11.6. Every single patient who had to undergo a surgical intervention to stop a recurrent bleeding stated ASA (Acetylsalicylic Acid) intake. We provide evidence that the intake of a vitamin K antagonist is an independent long-term risk factor for recurrent epistaxis episodes. The intake of ASA is a risk factor for the severity of recurrent epistaxis with the increased need for a surgical intervention not only in a short- but also in a long-term perspective. LEVEL OF EVIDENCE This prognostic investigation, designed as a combined prospective and retrospective cohort study, reaches level 2b level of evidence as it includes retrospective aspects.
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Affiliation(s)
- Rafael R Stadler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich USZ, University of Zurich UZH, 8091, Zurich, Switzerland
| | - Rahel Kindler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich USZ, University of Zurich UZH, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich USZ, University of Zurich UZH, 8091, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Zurich USZ, University of Zurich UZH, 8091, Zurich, Switzerland.
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Goljo E, Dang R, Iloreta AM, Govindaraj S. Cost of management in epistaxis admission: Impact of patient and hospital characteristics. Laryngoscope 2015; 125:2642-7. [DOI: 10.1002/lary.25374] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/06/2015] [Accepted: 04/21/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Erden Goljo
- Department of Otolaryngology-Head and Neck Surgery; Icahn School of Medicine at Mount Sinai; New York New York U.S.A
| | - Rajan Dang
- Department of Otolaryngology-Head and Neck Surgery; Icahn School of Medicine at Mount Sinai; New York New York U.S.A
| | - Alfred M. Iloreta
- Department of Otolaryngology-Head and Neck Surgery; Icahn School of Medicine at Mount Sinai; New York New York U.S.A
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery; Icahn School of Medicine at Mount Sinai; New York New York U.S.A
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Goh S, Ritchie L, Joseph T, Brookes J. Spontaneous sphenopalatine pseudoaneurysm: recurrent epistaxis in a patient with cryptogenic vasculopathy. BMJ Case Rep 2015; 2015:bcr-2015-210159. [PMID: 26113592 DOI: 10.1136/bcr-2015-210159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a unique case of recurrent epistaxis secondary to a spontaneous sphenopalatine artery aneurysm in a young woman. This was investigated with an external carotid artery angiogram and subsequently treated successfully with endovascular embolisation of the aneurysm.
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Affiliation(s)
- Samantha Goh
- Department of ENT, Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Louisa Ritchie
- Department of ENT, Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Theo Joseph
- Department of ENT, Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jocelyn Brookes
- Department of Interventional Radiology, University College London Hospitals NHS Foundation Trust, London, UK
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