1
|
Boiko NV. [Epistaxis and arterial hypertension: a pathogenic link]. Vestn Otorinolaringol 2021; 86:72-77. [PMID: 33720656 DOI: 10.17116/otorino20218601172] [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] [Indexed: 06/12/2023]
Abstract
THE AIM OF THIS RESEARCH Was to study changes in the nasal mucosa vessels in hypertensive patients suffering from recurrent epistaxis. PATIENTS AND METHODS 78 hypertensive patients aged between 50 and 70, admitted due to epistaxis were studied. Diabetic, coagulopathic patients and those taking anticoagulants were excluded from the research. All the patients were divided into 2 groups: group 1 (46 people) with a single epistaxis, group 2 (32 people) with a recurrent epistaxis. At the admission time all the patients showed elevated arterial pressure, yet the differences between the patients of group 1 and group 2 were not significant. 14 patients of group 2 did not reveal any source of hemorrhage due to a severely deviated septum. These patients underwent septoplasty followed by mucoperichondrium biopsy. Histological study of samples showed multiple erosions within the epithelial layer, as well as necrotic patches spreading to the deeper mucous coat layers. The microvasculature showed dystrophic changes in the endothelium, its focal desquamation with basal membrane exposure and thrombocytes and erythrocytes adhesion at such places, erythrocyte aggregation, plasma separation, erythrocyte and fibrinous thrombi formation. Ultrastructural investigation revealed dystrophic changes in the capillary endothelium of the nasal mucosa combined with rheological disorders expressed as erythrocytes sludge. Thus, the cause of epistaxis is not high arterial pressure, but those changes in the nasal mucosa vessels promoted by long arterial hypertension.
Collapse
Affiliation(s)
- N V Boiko
- Rostov State Medical University, Rostov-on-Don, Russia
| |
Collapse
|
2
|
Byun H, Chung JH, Lee SH, Ryu J, Kim C, Shin JH. Association of Hypertension With the Risk and Severity of Epistaxis. JAMA Otolaryngol Head Neck Surg 2020; 147:2770570. [PMID: 32910190 PMCID: PMC7489409 DOI: 10.1001/jamaoto.2020.2906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
Abstract
IMPORTANCE The association between hypertension and epistaxis has long been a subject of debate. OBJECTIVES To evaluate the risk of epistaxis in patients with hypertension using a nationwide population cohort and to assess the association of hypertension with the methods of managing cases of epistaxis. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, a hypertension cohort and comparison cohort were built using the Korean National Health Insurance Service-National Sample Cohort that represents the entire population of the Republic of Korea from January 1, 2002, to December 31, 2015. The hypertension cohort comprised 35 749 patients with a record of 3 or more prescriptions of antihypertensive medication and a diagnosis of hypertension (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I10). Patients with other diseases associated with epistaxis, such as sinonasal tumors, facial trauma, bleeding tendency, and coagulation disorder, as well as those taking anticoagulant medications, were excluded. A comparison cohort comprised 35 749 individuals without hypertension matched sociodemographically in a 1:1 ratio. Statistical analysis was performed from January 1, 2019, to March 31, 2020. MAIN OUTCOMES AND MEASURES The incidence and recurrence of epistaxis were evaluated in both cohorts. The risk factors for epistaxis and management strategies were also assessed. RESULTS Among the 35 749 patients in the hypertension cohort (20 579 men [57.6%]; median age, 52 years [interquartile range, 45-62 years]) the incidence rate (IR) of epistaxis was 32.97 per 10 000 persons (95% CI, 30.57-35.51 per 10 000 persons); among the 35 749 individuals in the comparison cohort (20 910 men [58.5%]; median age, 52 years [interquartile range, 45-62 years]), the IR of epistaxis was 22.76 per 10 000 persons (95% CI, 20.78-24.89 per 10 000 persons) (IR ratio, 1.45; 95% CI, 1.29-1.63; adjusted hazard ratio, 1.47; 95% CI, 1.30-1.66). The IR of recurrent epistaxis was 1.96 per 10 000 persons in the hypertension cohort and 1.59 per 10 000 persons in the nonhypertension cohort (IR ratio, 1.23; 95% CI, 0.77-2.00). Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69; 95% CI, 1.70-4.25; Cohen h effect size, 0.27; 95% CI, 0.16-0.39) and receive posterior nasal packing (odds ratio, 4.58; 95% CI, 1.03-20.38; Cohen h effect size, 0.15; 95% CI, 0.03-0.26) compared with the comparison cohort. CONCLUSIONS AND RELEVANCE This study suggests that patients with hypertension had an increased risk of epistaxis requiring hospital visits. In addition, epistaxis in patients with hypertension appeared to need more emergency department visits and require more posterior nasal packing procedures compared with patients without hypertension. Medical counseling about epistaxis is advisable for individuals with hypertension, and the presence of hypertension should be considered in managing nasal bleedings.
Collapse
Affiliation(s)
- Hayoung Byun
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jae Ho Chung
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Seung Hwan Lee
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jiin Ryu
- Biostatistical Consulting and Research Laboratory, Medical Research Collaborating Center, Hanyang University, Seoul, Republic of Korea
| | - Changsun Kim
- Department of Emergency Medicine, School of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jeong-Hun Shin
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Hanyang University, Seoul, Republic of Korea
| |
Collapse
|
3
|
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]
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Payne SC, Feldstein D, Anne S, Tunkel DE. Hypertension and Epistaxis: Why Is There Limited Guidance in the Nosebleed Clinical Practice Guidelines? Otolaryngol Head Neck Surg 2020; 162:33-34. [DOI: 10.1177/0194599819889972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypertension has long been thought to influence the risk and severity of epistaxis. However, evaluation of the relevant literature reveals articles with methodologic concerns or limited quality. In many instances, these studies are not adequately controlled, and lack of multivariate analyses calls into question any noted association between epistaxis and hypertension. The goal of this commentary is to explain why there is limited guidance about the management of hypertension and the possible association with nosebleed in the 2020 American Academy of Otolaryngology–Head and Neck Surgery Foundation clinical practice guideline for nosebleeds. Background on the literature that describes the association between hypertension and nosebleeds is provided.
Collapse
Affiliation(s)
- Spencer C. Payne
- Department of Otolaryngology–Head & Neck Surgery, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - David Feldstein
- Department of Internal Medicine, School of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Samantha Anne
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio, USA
| | - David E. Tunkel
- Department of Otolaryngology–Head & Neck Surgery, School of Medicine, Johns Hopkins, Baltimore, Maryland, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial. J Emerg Med 2018; 55:455-464. [PMID: 30195946 DOI: 10.1016/j.jemermed.2018.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/18/2018] [Accepted: 07/02/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Treatment for epistaxis includes application of intranasal vasoconstrictors. These medications have a precaution against use in patients with hypertension. Given that many patients who present with epistaxis are hypertensive, these warnings are commonly overridden by clinical necessity. OBJECTIVE Our aim was to determine the effects of intranasal vasoconstrictors on blood pressure. METHODS We conducted a single-center, randomized, double-blind, placebo-controlled trial from November 2014 through July 2016. Adult patients being discharged from the emergency department (ED) at Mayo Clinic (Rochester, Minnesota) were recruited. Patients were ineligible if they had a contraindication to study medications, had a history of hypertension, were currently taking antihypertensive or antidysrhythmic medications, or had nasal abnormalities, such as epistaxis. Subjects were randomized to one of four study arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine 1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and heart rate were measured every 5 min for 30 min. RESULTS Sixty-eight patients were enrolled in the study; of these, 63 patients completed the study (oxymetazoline, n = 15; phenylephrine, n = 20; lidocaine with epinephrine, n = 11; saline, n = 17). We did not observe any significant differences in mean arterial pressure over time between phenylephrine and saline, oxymetazoline and saline, or lidocaine with epinephrine and saline. The mean greatest increases from baseline in mean arterial pressure, systolic and diastolic blood pressure, and heart rate for each treatment group were also not significantly different from the saline group. CONCLUSIONS Intranasal vasoconstrictors did not significantly increase blood pressure in patients without a history of hypertension. Our findings reinforce the practice of administering these medications to patients who present to the ED with epistaxis, regardless of high blood pressure.
Collapse
|
9
|
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]
|
10
|
Aetiological profile and treatment outcomes of epistaxis at a major teaching hospital: a review of 721 cases. Ir J Med Sci 2017; 187:761-766. [PMID: 29197966 DOI: 10.1007/s11845-017-1721-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Epistaxis is the most prevalent ENT emergency and a significant burden on ENT services. Our objective was to study the incidence and outcomes of patients presenting with epistaxis at a major teaching hospital. METHODS A retrospective descriptive study of 721 patients, who presented with epistaxis over a 1-year period, was carried out. Data collected was analysed using SPSS software version 20. RESULTS Of the 721 patients, initial treatment consisted of nasal cautery (298), nasal packing (200), or no treatment (223). Fifty-nine patients were admitted. The mean age of admitted patients was 66.8 years and the male to female ratio was 2:1. 69.5% had hypertension and 78% used an antiplatelet/anticoagulation medication. The majority of admitted and return patients were out of hours referrals from ED and the mean admission duration was five nights. Surgical treatment for intractable epistaxis included arterial ligation or endovascular embolisation. Successful treatment was defined as no recurrent epistaxis following pack removal or no readmission with epistaxis within 24 h of hospital discharge. Six hundred forty-four patients had successful treatment. CONCLUSION More return and admitted patients presented at out-of-hours times with less clinical staff on site. Most non-admitted patients received no treatment. These factors possibly lead to increased stress on the ENT casualty service. Cautery and nasal packing are the most common treatment modalities in first-time and admitted patients yet result in considerable rates of representation.
Collapse
|
11
|
Côrte FC, Orfao T, Dias CC, Moura CP, Santos M. Risk factors for the occurrence of epistaxis: Prospective study. Auris Nasus Larynx 2017; 45:471-475. [PMID: 28844608 DOI: 10.1016/j.anl.2017.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/15/2017] [Accepted: 07/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Analyse and compare the characteristics of patients with epistaxis admitted to the otolaryngology emergency department with those provided by a control group. Establish a model to identify epistaxis predictive factors. METHODS Prospective analysis of 283 consecutive adults, admitted to the otolaryngology emergency department of a tertiary referral centre between 25 January and 25 February 2014. Comparison of gender, age, co-morbidities, usual medication, history of epistaxis or nasal trauma, presence of septal deviation and blood pressure value on admission, between the elements that were admitted to the emergency due to epistaxis (group 1) and a group composed of patients with other symptoms (group 2). Intergroup variations were analyzed using t student and chi-square tests. Multivariate logistic regression and a receiver operating characteristic curve were used to establish a predictive model and test its suitability. RESULTS Male gender (OR=2.57, 95% CI 1.1-6.0, p=0.029), older age (OR=1.03, 95% CI 1.0-1.1, p=0.002), existence of peripheral vascular disease (OR=13.47, 95% CI 1.9-95.3, p=0.009), cardiovascular disease (OR=3.91, 95% CI 1.6-9.7, p=0.003) and previous history of epistaxis (OR=5.53, 95% CI 2.5-12.1, p<0.001) were predictors of epistaxis when adjusted for the presence of elevated blood pressure, history of hypertension, cerebrovascular disease and chronic use of anticoagulants or antiplatelet drugs. The model revealed a good applicability (area under the curve of 0.852). CONCLUSIONS The only predictive factors of admission to the emergency department due to epistaxis were male gender, older age, peripheral vascular disease, cardiovascular disease and history of epistaxis.
Collapse
Affiliation(s)
- Filipa Camacho Côrte
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal.
| | - Tiago Orfao
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal
| | - Cláudia Camila Dias
- Centre for Research in Health Technologies and Information Systems, Porto, Portugal
| | - Carla Pinto Moura
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal; University of Porto Medical School, Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
| | - Margarida Santos
- Department of Otorhinolaryngology, Hospital de São João EPE, Porto, Portugal
| |
Collapse
|
12
|
Page RL, Bainbridge JL. Intractable Epistaxis Associated with Topiramate Administration. Ann Pharmacother 2016; 40:1462-5. [PMID: 16822894 DOI: 10.1345/aph.1h078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To report a case of a patient who experienced serious, intractable epistaxis warranting emergency department (ED) visits and hospital admission after initiation of topiramate therapy. Case Summary: A 61-year-old woman with significant cardiovascular disease was started on topiramate 25 mg daily for lower extremity neuropathy. After 7 days of treatment, she began to experience severe, intractable epistaxis that lasted 8 days, warranting an ED visit. The epistaxis resolved 1 week after topiramate discontinuation. Topiramate was restarted 3 months later, and the patient again developed intractable epistaxis. After 2 days of epistaxis, she returned to the ED with significant anginal pain and was admitted to the hospital, where she received 2 units of packed red blood cells. One week after stopping topiramate, the epistaxis stopped. At the time of writing, she had exhibited no epistaxis for 6 months. According to the Naranjo probability scale, topiramate was the probable cause of epistaxis. Discussion: Topiramate is a neuromodulatory compound approved for management of migraines, as well as partial and generalized tonic–clonic seizures. Over the past decade, its use has expanded to include many other neuropathic conditions. Currently, epistaxis has been reported in only 1–4% of patients receiving topiramate in clinical trials; however, these data were derived from a young study population. Like topiramate, calcium-channel blockers (CCBs) modulate voltage-gated L type calcium ion channels. These specific channels are located on vascular smooth muscle and non-contractile tissues such as platelets. Due to their possible antiplatelet effects, CCBs have been associated with an increased risk of hemorrhage, epistaxis, and prolonged bleeding time. The same may hold true for topiramate. Conclusions: Topiramate, particularly in combination with antiplatelet medications, may be associated with severe, intractable epistaxis. Intractable epistaxis should be added to the list of potentially serious adverse reactions that are monitored when topiramate is administered.
Collapse
Affiliation(s)
- Robert L Page
- Department of Clinical Pharmacy, Schools of Pharmacy and Medicine, University of Colorado Health Sciences Center, Denver, 80262, USA.
| | | |
Collapse
|
13
|
Chaaban MR, Zhang D, Resto V, Goodwin JS. Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis. Otolaryngol Head Neck Surg 2016; 156:81-86. [DOI: 10.1177/0194599816667295] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To determine the demographics and seasonal and geographic variation of epistaxis in the United States. Study Design Retrospective cohort analysis based on data from Medicare claims. Setting Emergency department visits. Subjects and Methods We used a 5% sample of Medicare data from January 2012 to December 2012. Our cohort included patients with an incident diagnosis of epistaxis during a visit to the emergency department, excluding those with a diagnosis in the prior 12 months. Demographics included age, sex, race, and ethnicity. We compared the rate of emergency department visits for epistaxis by geographic division and individual states. Results In the 5% sample of Medicare data, 4120 emergency department visits for incident epistaxis were identified in 2012. Our results showed an increase in the emergency department visits for epistaxis with age. Compared with patients <65 years old, patients who were 66 to 76, 76 to 85, and >85 years old were 1.36 (95% confidence interval [95% CI], 1.23-1.50), 2.37 (95% CI, 2.14-2.62), and 3.24 (95% CI, 2.91-3.62) more likely to present with epistaxis, respectively. Men were 1.24 (95% CI, 1.17-1.32) times more likely to present with epistaxis than women. Blacks were 1.23 (95% CI, 1.10-1.36) times more likely to present with epistaxis when compared with non-Hispanic whites. Epistaxis emergency department visits were 40% lower in the summer months versus winter. The seasonal variation was more pronounced in the northern versus southern United States. Conclusion Emergency department visits for epistaxis increase with age and appear to be seasonal, with a more pronounced variation in the northern versus southern United States.
Collapse
Affiliation(s)
- Mohamad R. Chaaban
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Dong Zhang
- Sealy Center on Aging, Galveston, Texas, USA
| | - Vicente Resto
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, Texas, USA
| | - James S. Goodwin
- Sealy Center on Aging, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
Kindler RM, Holzmann D, Landis BN, Ditzen B, Soyka MB. The high rate of long-term recurrences and sequelae after epistaxis treatment. Auris Nasus Larynx 2015; 43:412-7. [PMID: 26531257 DOI: 10.1016/j.anl.2015.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/14/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Epistaxis is the most frequent rhinologic emergency with a high treatment morbidity. This study assessed the long-term outcome after epistaxis treatment with regard to patient comfort during the treatment, long-term complications and rate of recurrences. METHODS A questionnaire cohort study was performed at the ENT department of the University Hospital Zurich. In April 2014, 363 patients were contacted, who were treated between March 2007 and April 2008 for the reason of epistaxis using a written questionnaire to elucidate the patients' condition after the treatment. The type of treatment, subjective discomfort as well as degree of pain, complications, permanent sequelae and recurrences were assessed. RESULTS 109 questionnaires were analyzed (response rate of 36%). The overall same-sided recurrence rate after successful treatment during the 6.4-year follow-up was 22%. Discomfort was reported in 48% after cautery, 86% after packing and in 11% after surgery. Strong or very strong pain was perceived in 8% after cautery, 26% after packing and in 0% after surgery alone. Complications consisted of nasal crusting in 15% after cautery and nasal breathing impairment in 24% after packing. Permanent harm was reported in 4% after cautery versus 20% after packing plus surgery. CONCLUSIONS The data confirm the high rate of recurrences despite adequate treatment in the long-term analysis. The rate of post-treatment complications is considerably high with nasal crusting being the main inconvenience. It further shows that patients keep a vivid memory of the treatment even many years later and that packing is extremely uncomfortable to patients.
Collapse
Affiliation(s)
- Rahel M Kindler
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Switzerland; University of Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Switzerland; University of Zurich, Switzerland
| | - Basile N Landis
- Rhinology-Olfactology Unit, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Geneva, Switzerland
| | - Beate Ditzen
- Institute of Psychology, University Zurich, Switzerland; Institute of Medical Psychology University Hospital of Heidelberg, Germany
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Switzerland; University of Zurich, Switzerland.
| |
Collapse
|
16
|
Boiko NV, Shatokhin YV. [Pathogenesis of nasal bleeding in the patients presenting with arterial hypertension]. Vestn Otorinolaringol 2015; 80:41-45. [PMID: 26525471 DOI: 10.17116/otorino201580541-45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The objective of the present work was to study the pathogenetic mechanisms underlying nasal bleeding (NB) in the patients presenting with arterial hypertension (AH). A total of 47 patients with AH suffering from NB were available for the examination of whom 28 experienced a single bleeding episode and 19 had recurrent bleeding. 11 of them were treated by endonasal surgical intervention for the achievement of hemostasis. Simultaneously, mucoperichondreal biopsies were taken from the anterior septal portions and used for histological and ultrastructural investigations. The laboratory examination of all the patients has demonstrated hyperfibrinogenemia and the enhanced level of soluble monomeric fibrin complexes in the blood (especially in the patients with recurrent nasal bleeding) despite the normal platelet levels, prothrombin and thrombin times. These findings gave reason to characterize the hemostasiological status of the patients as chronic compensated disseminated intravascular coagulation (DIC) syndrome. The histological study revealed hyaline, erythrocyte-rich and fibrin thrombi in the vessels of the microcirculatory system whereas ultrastructural studies showed desquamation of endothelial cells, massive desendothelization, and disintegration of the basal membrane with the exposure of subendothelium. It is supposed that these changes provoked the development of thrombosis and focal necrosis in nasal mucosa. The authors conclude that the cause of nasal bleeding associated with arterial hypertension is directly related to the lesions of vascular endothelial, microcirculatory disorders, and modification of the blood coagulation processes rather than to the mechanical rupture of blood vessels. These changes are believed to be responsible for the development of local intravascular coagulation.
Collapse
Affiliation(s)
- N V Boiko
- Rostov State Medical University, Russian Ministry of Health, Rostov-on-Don, Russia, 3440061
| | - Yu V Shatokhin
- Rostov State Medical University, Russian Ministry of Health, Rostov-on-Don, Russia, 3440061
| |
Collapse
|
17
|
Sarhan NA, Algamal AM. Relationship between epistaxis and hypertension: A cause and effect or coincidence? J Saudi Heart Assoc 2014; 27:79-84. [PMID: 25870500 PMCID: PMC4392352 DOI: 10.1016/j.jsha.2014.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/16/2014] [Accepted: 09/05/2014] [Indexed: 02/01/2023] Open
Abstract
Introduction Epistaxis is the most common otorhinolaryngological emergency. Whether there is an association or cause and effect relationship between epistaxis and hypertension is a subject of longstanding controversy. Objective The aim of our study is to evaluate the relationship between epistaxis and hypertension. Materials and methods This study was conducted at Olaya Medical Center (Riyadh) during the period between May 2013 and June 2014. A total of 80 patients were divided into two groups: Group A consisted of 40 patients who presented with epistaxis, and Group B consisted of 40 patients who served as a control group. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) was performed for all patients. Patients were followed up for a period of three months. Results Readings of blood pressure (BP) were similar between the two groups regarding BP at presentation, ABPM, and BP at three months. There was a higher number of attacks in patients with history of hypertension. There was highly significant positive correlation between number of attacks of epistaxis and BP readings. Systolic BP at presentation was higher in patients who needed more complex interventions such as pack, balloon or cautery than those managed by first aid. Conclusion We found no definite association between epistaxis and hypertension. Epistaxis was not initiated by high BP but was more difficult to control in hypertensive patients.
Collapse
|
18
|
Ando Y, Iimura J, Arai S, Arai C, Komori M, Tsuyumu M, Hama T, Shigeta Y, Hatano A, Moriyama H. Risk factors for recurrent epistaxis: Importance of initial treatment. Auris Nasus Larynx 2014; 41:41-5. [DOI: 10.1016/j.anl.2013.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 05/14/2013] [Accepted: 05/23/2013] [Indexed: 10/26/2022]
|
19
|
|
20
|
Kikidis D, Tsioufis K, Papanikolaou V, Zerva K, Hantzakos A. Is epistaxis associated with arterial hypertension? A systematic review of the literature. Eur Arch Otorhinolaryngol 2013; 271:237-43. [PMID: 23539411 DOI: 10.1007/s00405-013-2450-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/13/2013] [Indexed: 11/25/2022]
Abstract
Both epistaxis and hypertension are frequent problems in the adult population. The relationship between the level of arterial pressure and incidence of epistaxis in a patient with hypertension is a question that appears frequently in the clinical practice. A systematic review of the literature regarding the relation of arterial hypertension with epistaxis was performed through MEDLINE and EMBASE. All studies, whether examining the correlation of arterial pressure at presentation of a patient with nasal bleeding or the repercussion of episodes of epistaxis in hypertensive patients, were included in this review. Studies were evaluated independently by two reviewers according to a standard evaluation form. Overall, nine studies fulfilled our inclusion criteria. Five of them were single-group (patient) studies, while the remaining four included a control group. In eight studies, the patient group included patients with epistaxis, while one focused on hypertensive patients. Six out of nine studies agree that arterial pressure is higher at the time of epistaxis, as compared to the control group or to the general population. Seven out of nine studies conclude that there is cross-correlation between arterial pressure and the actual incident of epistaxis. The presence of high arterial blood pressure during the actual episode of nasal bleeding cannot establish a causative relationship with epistaxis, because of confounding stress and possible white coat phenomenon, but may lead to initial diagnosis of an already installed arterial hypertension.
Collapse
Affiliation(s)
- D Kikidis
- Department of Otorhinolaryngology - Head and Neck Surgery, National and Kapodistrian University of Athens, Hippocrateion General Hospital, 114 Vas. Sophias Avenue, 11527, Athens, Greece
| | | | | | | | | |
Collapse
|
21
|
Murer K, Ahmad N, Roth BA, Holzmann D, Soyka MB. THREAT helps to identify epistaxis patients requiring blood transfusions. J Otolaryngol Head Neck Surg 2013; 42:4. [PMID: 23663751 PMCID: PMC3646554 DOI: 10.1186/1916-0216-42-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/25/2012] [Indexed: 11/10/2022] Open
Abstract
Objective To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors. Design Retrospective cohort study. Setting A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions. Methods The clinical charts and medical histories of these patients were evaluated. Main outcome measures Common parameters that increase the risk for severe anemia due to epistaxis. Results Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach. Conclusions Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.
Collapse
Affiliation(s)
- Karin Murer
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, 8091, Switzerland.
| | | | | | | | | |
Collapse
|
22
|
Makarawo TP, Howe D, Chan SK. Is routine nasoendoscopy warranted in epistaxis patients after removal of nasal packing? ALLERGY & RHINOLOGY 2012; 2:12-5. [PMID: 22852109 PMCID: PMC3390123 DOI: 10.2500/ar.2011.2.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fiberoptic nasoendoscopy (FNE) is a powerful investigative tool in ear, nose, and throat practice in which its use in the management of epistaxis is varied among clinicians. The practice of assessing the nasal cavity after removal of nasal packs is common but its usefulness has not been evaluated. Therefore, we assessed the benefits of routine FNE after removal of nasal packs in epistaxis patients. Our study was performed retrospectively involving 62 adult patients admitted over a 6-month period between 2005 and 2006. Data regarding the emergent management of epistaxis cases on presentation, the use of FNE, and the final diagnosis and outcome of each patient were specifically investigated during the study. Anterior rhinoscopy was performed in 27 patients at initial presentation, of whom 45% (10/27) had anterior bleeding points identified. FNE examination after removal of nasal packs in eight patients yielded evidence of a posterior bleeding point in only one case (12.5%). Of those patients in whom anterior rhinoscopy revealed no anterior bleeding point at presentation (17/27), 12 patients went on to have FNE after removal of their nasal packs, and of these, 33% (4/12) of patients were found to have a posterior bleeding vessel. Overall, FNE was performed in 24 patients, of whom only 1 (1/24) had an active posterior bleeding vessel needing nasal repacking. Four patients (4/24) had prominent posterior vessels that required no intervention, 1 patient (1/24) had new pathology identified, and in the remaining 18 cases (18/24), FNE yielded no additional information to modify management. The routine performance of FNE in all epistaxis patients after pack removal does not appear to convey any additional benefit. We advocate the use of FNE when anterior bleeding has been excluded or bleeding is persistent and that careful nasal examination by anterior rhinoscopy should be the cornerstone of assessment.
Collapse
Affiliation(s)
- Tafadzwa P Makarawo
- Department of Ear, Nose, and Throat, Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, WV10 0QP, United Kingdom
| | | | | |
Collapse
|
23
|
Abstract
Epistaxis is a common medical problem that rarely requires surgical intervention. However, when medical or surgical intervention is required, epistaxis can sometimes be difficult to control. Knowledge of nasopharyngeal anatomy is absolutely essential to the proper management of epistaxis. This article begins with a discussion of the essential anatomy of the region and the basic epidemiology of epistaxis, followed by a review of initial treatment as well as devices and procedures specifically designed for the control of epistaxis. Advances and new devices for the control of epistaxis are described.
Collapse
Affiliation(s)
- Levon Nikoyan
- Oral and Maxillofacial Surgery, Department of Dentistry, Woodhull Medical and Mental Health Center, Brooklyn, NY 11206, USA.
| | | |
Collapse
|
24
|
Relationship between blood pressure and persistent epistaxis at the emergency department: a retrospective study. ACTA ACUST UNITED AC 2012; 6:291-5. [DOI: 10.1016/j.jash.2012.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/27/2012] [Accepted: 05/08/2012] [Indexed: 11/18/2022]
|
25
|
Meenakshisundaram R, Babuvinish D, Grootveld M, Rajendiran C, Thirumalaikolundusubramanian P. Status of end organs in newly detected rural essential hypertensives: a study from southern India. Clin Exp Hypertens 2011; 34:201-8. [PMID: 22150025 DOI: 10.3109/10641963.2011.618201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypertension is associated with end-organ damage (EOD). Since EOD is a risk factor for cardio- and cerebrovascular complications, it is a major requirement for these to be detected, prevented, and treated. OBJECTIVE The objectives of our study were to determine out the prevalence of EOD in newly detected rural essential hypertensives, identify the pattern of EOD involved, and also assess the interrelationship among them. METHODS A total of 147 consecutive patients with newly diagnosed essential hypertension and, attending the outpatient clinic, were included in this study based on a set of inclusion and exclusion criteria. Patients with comorbid illnesses were excluded from the investigation. The significance of a range of variables involved was evaluated using statistical software. RESULTS Amongst the cases, there were 79 males (M) and 68 females (F). Their mean and median ages were 55 (standard deviation (SD) = 9.90) and 54 years, respectively. Of these 86% (70 M and 56 F) had one or more EODs; an observation which was very close to statistically significant (P = .054). In our patients, microalbuminuria (35%), diastolic dysfunction (59%), increased left ventricular (LV) mass (68%) and retinopathy (69%) were particularly notable. Increased LV mass had a strong association with retinopathy, microalbuminuria, and diastolic dysfunction. CONCLUSION The presence of one or more EODs in newly detected hypertension indicates widespread vascular damage that carries a high risk for cardio- and cerebrovascular morbidity and mortality. Hence, there is an urgent requirement not only for complete evaluation but also to stimulate an increased awareness amongst physicians and the general public, regarding the control of blood pressure.
Collapse
|
26
|
Serious spontaneous epistaxis and hypertension in hospitalized patients. Eur Arch Otorhinolaryngol 2011; 268:1749-53. [PMID: 21656167 DOI: 10.1007/s00405-011-1659-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 05/25/2011] [Indexed: 10/18/2022]
Abstract
The aim of the study was to evaluate the role of hypertension in patients hospitalized for serious spontaneous epistaxis. This 6-year retrospective study was based on 219 patients hospitalized in a University Hospital ENT and Head and Neck surgery department for serious spontaneous epistaxis. The following parameters were recorded: length of hospital stay, history of hypertension, blood pressure (BP) recordings (on admission, during hospitalization and on discharge), epistaxis severity criteria, including medical and/or surgical management of epistaxis (blood transfusion depending on blood count, embolization, surgery), medications affecting clotting. Epistaxis was classified into two groups: serious and severe. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean arterial pressure on discharge and number of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. Overall, on univariate logistic regression analysis, no factors were independently associated with severity of epistaxis. The pathophysiology of serious spontaneous epistaxis remains to be unclear. It concerns elderly patients (>60-70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients with no history of hypertension. However, hypertension per se does not appear to be a statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis.
Collapse
|
27
|
Celik T, Iyisoy A, Yuksel UC, Karahatay S, Tan Y, Isik E. A new evidence of end-organ damage in the patients with arterial hypertension: Epistaxis? Int J Cardiol 2010; 141:105-7. [DOI: 10.1016/j.ijcard.2008.11.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Accepted: 11/16/2008] [Indexed: 10/21/2022]
|
28
|
Soyka MB, Rufibach K, Huber A, Holzmann D. Is severe epistaxis associated with acetylsalicylic acid intake? Laryngoscope 2010; 120:200-7. [PMID: 19877246 DOI: 10.1002/lary.20695] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Epistaxis represents a very common emergency in any ear, nose, and throat (ENT) department around the world. Despite other risk factors, acetylsalicylic acid (ASA) contributes to nosebleeds by its intrinsic ability to impair thrombocyte aggregation. The aim of this study was to investigate the influence of ASA on the severity of epistaxis and to compare it with other potential risk factors. STUDY DESIGN A prospective cohort study was performed at the ENT department of University Hospital Zurich. METHODS A total of 591 events were evaluated concerning surgical interventions and the length of in-hospital stay. Further analyses regarding recurrences and number of treatments and a specially designed severity score, as well as other outcome parameters, were performed. RESULTS Ninety-nine patients needed to stay in-hospital for at least 1 day. Nearly 30% of all patients had ASA intake, and only 18% were on vitamin K antagonist therapy. Patients on ASA showed significantly more surgical interventions, a higher recurrence rate, and a larger number of required treatments as well as an increased severity score. Duration of in-hospital stay and the complication rate, however, were not associated with drug intake. CONCLUSIONS We not only identified ASA to be one of the major risk factors in epistaxis, but also quantified its impact on the severity of nose bleeding. We emphasize the importance of a well-indicated antiaggregational therapy, and strongly discourage using ASA as a life-style drug for the elderly. ASA therapy needs to be discontinued whenever possible and reasonable.
Collapse
Affiliation(s)
- Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | | | | |
Collapse
|
29
|
|
30
|
Monjas-Cánovas I, Hernández-García I, Mauri-Barberá J, Sanz-Romero B, Gras-Albert JR. Epidemiology of epistaxes admitted to a tertiary hospital. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2009; 61:41-7. [PMID: 20004879 DOI: 10.1016/j.otorri.2009.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Revised: 08/20/2009] [Accepted: 09/02/2009] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Epistaxis has been known since antiquity. However, we have limited epidemiological data at our disposal. The aim of this study is to know the main epidemiological characteristics of the cases of epistaxis admitted and to determine the factors associated with the recurrence of bleeding. METHODS A retrospective study was conducted including admissions for epistaxis in the ENT department of our hospital during the period between January, 2003, and December, 2008. We analyzed the distribution by gender, age, location and time of year. The aetiological causes identified included systemic and local factors. We analyzed the variables related to bleeding recurrence. RESULTS We evaluated 178 cases of epistaxis: 68% of patients were male (121/178), compared to 32% of women (57/178). The median age (p25-p75) was 65 (53-75) years. The epistaxes were most noticeable during the months of January and April. Among the systemic causes, hypertension (56%), anti-platelet treatment (23%) and anti-coagulant therapies (18.5%) predominated. Local factors were much less numerous than general ones (11% v. 68%). Recurrent bleeding was present in 14% of cases (25/178) and only the posterior location was shown to influence this variable (P<.05). CONCLUSIONS The typical pattern of the patients admitted to our department for epistaxis is a middle-aged or elderly male with underlying co-morbidity and posterior epistaxis.
Collapse
Affiliation(s)
- Irene Monjas-Cánovas
- Servicio de Otorrinolaringología, Hospital General Universitario, Alicante, España
| | | | | | | | | |
Collapse
|
31
|
Abstract
Epistaxis can be encountered in a wide range of specialties, and it is vital that doctors and nurses can identify the causes and manage it effectively. When managed correctly the potential morbidity and mortality can be significantly reduced.
Collapse
Affiliation(s)
- Louise Melia
- North Glasgow Ear, Nose and Throat Department, Gartnavel General Hospital, Glasgow
| | | |
Collapse
|
32
|
|
33
|
Strasser JL, Hawkins EC. Clinical features of epistaxis in dogs: a retrospective study of 35 cases (1999-2002). J Am Anim Hosp Assoc 2007; 41:179-84. [PMID: 15870252 DOI: 10.5326/0410179] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Epistaxis was retrospectively evaluated in 35 dogs. Systemic disease was diagnosed in seven dogs and intranasal disease in 29. Nineteen dogs with intranasal disease had neoplasia. Dogs with neoplasia were older (mean 10.0 years) than dogs with nonneoplastic intranasal disease (mean 5.6 years). Signs persisting for >1 month occurred more often in dogs with intranasal than systemic disease. Unilateral epistaxis did not distinguish intranasal from systemic disease. Only dogs with intranasal disease had facial deformity, decreased airflow, or regional sub-mandibular lymphadenopathy. Dogs with systemic disease had a lower packed cell volume (mean 31.8%) than dogs with intranasal disease (mean 42.7%).
Collapse
Affiliation(s)
- Jennifer L Strasser
- Veterinary Medical Teaching Hospital, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina 27606, USA
| | | |
Collapse
|
34
|
Affiliation(s)
- Matthew I Trotter
- University Hospital Birmingham Queen Elizabeth, Edgbaston, Birmingham B15 2TH
| | | | | |
Collapse
|
35
|
Lubianca JN, Moreira LB, Gus M, Fuchs FD. Stopping oral contraceptives: an effective blood pressure-lowering intervention in women with hypertension. J Hum Hypertens 2005; 19:451-5. [PMID: 15759027 DOI: 10.1038/sj.jhh.1001841] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The association of combined oral contraceptives (OC) with higher blood pressure (BP) may be attenuated with pills with smaller doses of oestrogen. The effect of stopping OC on BP of patients with hypertension was not described to date. In a cohort study of patients with hypertension, we identified 72 women using OC among 2112 patients seen from 1989 to 2002. Stopping hormonal contraception was recommended to all. The main outcome measurement was BP change in women who stopped (n=44) and who did not stop (n=28) OC, adjusting for baseline BP and age. Odds ratio for having a reduction of at least 20 mmHg in systolic blood pressure (SBP) or 10 mmHg in diastolic blood pressure (DBP), adjusting for age, change in weight and prescription of BP-lowering drugs, were calculated. The mean follow-up time was 6.6+/-7.5 months. Participants who stopped and did not stop OC had similar baseline characteristics. The deltas of SBP (adjusted) were 15.1+/-2.6 mmHg in patients who stopped and 2.8+/-3.2 mmHg in patients who did not stop OC (P=0.004). The corresponding values for DBP were 10.4+/-1.8 and 2.7+/-2.2 mmHg (P=0.008), respectively. The odds ratio (adjusted) for having a decrease of at least 20 mmHg in SBP or 10 mmHg in DBP was 0.28 (95% CI 0.08-0.90) in patients who stopped OC. Stopping OC is an effective antihypertensive intervention in a clinical setting.
Collapse
Affiliation(s)
- J N Lubianca
- Programa de Pós-Graduação em Medicina:Ciências Médicas, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | | |
Collapse
|
36
|
Fuchs FD, Moreira LB, Pires CP, Torres FS, Furtado MV, Moraes RS, Wiehe M, Fuchs SC, Lubianca Neto JF. Absence of association between hypertension and epistaxis: a population-based study. Blood Press 2004; 12:145-8. [PMID: 12875475 DOI: 10.1080/08037050310001750] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The association between epistaxis and hypertension is still disputed. In a cross-sectional study, we evaluated this association in a sample of 1174 individuals older than 18 years, representative of inhabitants of Porto Alegre, RS, Brazil. Epistaxis was defined as any episode of non-traumatic nosebleeding after 18 years of age. Hypertension was defined as the mean of two blood pressure readings > or = 160/95 mmHg or the use of antihypertensive drugs. The prevalence of epistaxis and hypertension were 14.7% (95% confidence interval, CI 12.7-16.7) and 24.1% (95% CI 21.7-26.6), respectively. History of epistaxis in the adulthood (risk ratio = 1.24, 95% CI 0.83-1.85), and in the previous 6 months (risk ratio 0.79, 95% CI 0.40-1.56; p = 0.510) were not associated with hypertension after controlling for gender, age, race, history of allergic rhinitis or nasal abnormalities, alcohol abuse, smoking and years of study. History of epistaxis was positively associated with history of allergic rhinitis and inversely associated with years at school. In conclusion, we demonstrated that hypertension is not associated with history of epistaxis in the adulthood in free-living individuals.
Collapse
Affiliation(s)
- Flávio D Fuchs
- Division of Cardiology, Hospital de Clínicas Porto Alegre, Porto Alegre, RS, Brazil.
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Fuchs FD, Gus M, Moreira LB, Moreira WD, Gonçalves SC, Nunes G. Headache is not more frequent among patients with moderate to severe hypertension. J Hum Hypertens 2003; 17:787-90. [PMID: 14578919 DOI: 10.1038/sj.jhh.1001621] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The association between hypertension and headache has been a contentious issue. Most studies have showed that mild hypertension and headache are not associated, but this may not be the case in patients with hypertension classified at more severe stages. We investigated the association between hypertension classified at moderate to severe stages and headache in a cross-sectional study conducted in the hypertension clinic of a tertiary care University hospital. In total, 1763 referred patients with a medical diagnosis of hypertension in most cases (95.7%) were evaluated by an extensive protocol questionnaire, detailed physical examination, laboratory examination, and had their blood pressure classified according to the VI Joint National Committee (JNC-VI) recommendation. Logistic regression models were used to explore the association between severity of hypertension and pulse pressure with the presence of headache, controlling for several potential confounders. The complaint of headache was referred by 903 (51.3% of whole sample), and a total of 378 patients (21.4%) were classified at the moderate to severe stage (stage III of the JNC-VI report). The diagnosis of moderate to severe hypertension was not associated with the complaint of headache (OR 1.02, 95% CI from 0.79 to 1.30). Pulse pressure and headache were inversely associated (OR 0.91, 95% CI from 0.86 to 0.97, for 10 mmHg). We concluded that headache and hypertension classified at moderate to severe stages were not associated in patients attending to a hypertension clinic. The novel finding of an inverse association between pulse pressure and headache should be addressed in further investigations.
Collapse
Affiliation(s)
- F D Fuchs
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil.
| | | | | | | | | | | |
Collapse
|
38
|
Nakada H, Kase Y, Matsunaga T, Komoda T, Iinuma T. Caspase 3 Activation in Nasal Capillary in Patients with Epistaxis. Otolaryngol Head Neck Surg 2003; 128:632-9. [PMID: 12748555 DOI: 10.1016/s0194-59980300085-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: We investigated whether an apoptosis of nasal microvessels contributes to probable mechanism of the onset of epistaxis.
STUDY DESIGN AND SETTING: Nasal septal mucosa of Little's areas taken from patients without (n = 19) and with (n = 26) epistaxis were examined. Active caspase-3 in the mucosa was detected according to the methods of immunohistochemistry and Western blotting. On Western blot analysis of the homogenates of the mucosa, we also sought probable signaling factors after caspase-3 activation.
RESULTS: Marked activation of caspase-3 was detected in the capillaries and its neighboring muscle cells of Little's area from patients with epistaxis, and the activation was due to enhanced expression of procaspase-3 protein and progressive cleavage of the precursor. As a result of Western blotting of signaling factors, enhanced expressions of caspase-9 and Bax protein in the homogenates of Little's area in epistaxis group were found compared with those in control group. Increased levels of cytochrome c released into a cytosol were also detected in the capillaries in epistaxis group.
CONCLUSION: In the present study, caspase-3 activation was found in the capillaries of Little's area from patients with epistaxis, suggesting that an apoptosis of capillaries may contribute to a mechanism of the onset of epistaxis. Moreover, alterations of some apoptotic factors such as caspase-9, Bax, and cytochrome c in the tissues demonstrated participation of mitochondrial disturbance in one of the apoptotic mechanisms.
SIGNIFICANCE: Further explorations of the pathobiologic mechanism of capillary apoptosis can lead not only to an identification of risk factors in the onset of epistaxis but also to the development of medical therapy of epistaxis.
Collapse
Affiliation(s)
- Hiroto Nakada
- Department of Otorhinolaryngology, Saitama Medical School, 38 Morohongo, Moroyama, Iruma-gun, Saitama 350-0495, Japan.
| | | | | | | | | |
Collapse
|
39
|
Herkner H, Havel C, Müllner M, Gamper G, Bur A, Temmel AF, Laggner AN, Hirschl MM. Active epistaxis at ED presentation is associated with arterial hypertension. Am J Emerg Med 2002; 20:92-5. [PMID: 11880870 DOI: 10.1053/ajem.2002.31577] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Epistaxis and hypertension are frequent in the general population, but an association is still controversial. Aim of this retrospective cohort study was to test if active epistaxis at emergency department (ED) presentation is associated with hypertension. Patients with active epistaxis at ED presentation (n = 271; 73%) were compared with controls without active bleeding (n = 101; 27%). By multivariate logistic regression modeling we found that active epistaxis was independently associated with history of hypertension (odds ratio 2.8 [95% CI 1.4 to 5.6; P =.004] adjusted for age, gender, rhinitis, diffuse bleeding, and malignant diseases). Patients with active epistaxis had higher blood pressure at presentation compared with controls (systolic blood pressure 165 v 153 mmHg, P <.001, diastolic blood pressure 85 v 77 mmHg, P <.001). Active epistaxis at ED presentation is associated with arterial hypertension.
Collapse
Affiliation(s)
- Harald Herkner
- Department of Emergency Medicine, University of Vienna-Medical School, Vienna General Hospital, Vienna, Austria.
| | | | | | | | | | | | | | | |
Collapse
|