Controversies in the specialist management of adult epistaxis: an evidence-based review

Posterior epistaxis management: review of the literature and proposed guidelines of the hellenic rhinological-facial plastic surgery society

PURPOSE

Posterior epistaxis is a common emergency in ENT practice varying in severity and treatment. Many management guidelines have been proposed, all of which are a product of retrospective analyses due to the nature of this pathology, as large-scale double-blind studies are impossible-even unethical-to conduct. The purpose of this review is to perform a thorough analysis and comparison of every treatment plan available and establish guidelines for the best possible outcome in accordance to every parameter studied. Given the extensive heterogeneity of information and the multitude of studies on this topic, along with the comparison of various treatment options, we opted for a literature review as our research approach.

METHODS

A review of the literature was performed using PubMed Database and search terms included "posterior epistaxis", "treatment", "management", "guidelines", "algorithm" "nasal packing", "posterior packing", "surgery", "SPA ligation", "embolization", "risk factors" or a combination of the above.

RESULTS

Initial patients' assessment invariably results in most cases in posterior packing. There seems to be a superiority in recent literature of early surgery over nasal packing as a definitive treatment. Embolization is usually used after surgery failure, except for specific occasions.

CONCLUSION

Despite the vast heterogeneity of information, there seems to be a need for re-evaluation of the well-established treatment plans according to more recent studies.

Risk Factors for Severe Clinical Course in Epistaxis Patients

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.

Risk factors and management outcomes in epistaxis: a tertiary centre experience

BACKGROUND

Risk factors and outcomes associated with severe epistaxis are not well understood. This study explores the associations between epistaxis severity, comorbidities, use of antiplatelets or anticoagulants and management outcomes.

METHODS

This is a retrospective cross-sectional study of all epistaxis cases presenting to the emergency department at a tertiary academic hospital from January 2016 to December 2019. Epistaxis severity was defined as mild (no intervention), moderate (required cautery and/or packing) and severe (clinical instability with reversal products, surgical or radiological intervention). Univariable and multivariable regression analyses were undertaken, with risk factors and management outcomes analysed according to severity.

RESULTS

A total of 543 patients with epistaxis (54.2% male, mean age 74.4 ± 15.7 years) were included in this study, with 14.7% (80) having severe epistaxis. Of these presentations 216 (39.8%) were on antiplatelets, while 207 (38.1%) were on anticoagulants. In univariate analyses, clopidogrel use, hereditary haemorrhagic telangiectasia (HHT), haematological malignancy, bleeding disorders and chronic liver disease (CLD) were associated with moderate to severe epistaxis (P < 0.05), while the use of rivaroxaban was inversely associated severity (P = 0.002). Only HHT, haematological malignancy and CLD remained significant in multivariate models. Cautery as first-line management was infrequently utilized while anticoagulation was frequently withheld. A longer length of stay (1.1 days vs. 4.3 days; P < 0.001) and higher 2-week readmission rates (2.2% vs. 12.5%; P < 0.001) were noted with severe epistaxis compared with mild presentations.

CONCLUSION

Epistaxis severity is associated with certain clinical conditions and poor outcomes. Despite recommended guidelines, variations in first-line management were evident.

Peri-operative complications of sphenopalatine artery ligation: a 10-year series from two secondary care centres

Background

There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed.

Methods

A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0–2657 days).

Results

Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0–8 times).

Conclusion

Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

Nasal Packing in the Emergency Department: A Practical Review for Emergency Providers

We performed a narrative review of epistaxis management in the emergency department. First, we examined the pathophysiology, the current types of treatment that are available to emergency clinicians. When nasal packing is indicated, we examined the efficacy of nasal packing in addition to other topical treatment such as tranexamic acid and the evidence of prophylactic antibiotics. We detailed current studies involving tranexamic acid and prophylactic antibiotics for nasal packing. Finally, we introduced an epistaxis clinical care pathway, based on current evidence, to aid emergency clinicians with their clinical decision-making processes.

Management of epistaxis in patients on novel oral anticoagulation therapy

BACKGROUND

Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy.

OBJECTIVE

This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management.

METHOD

A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019.

RESULTS

Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined.

CONCLUSION

Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

Role of age and anticoagulants in recurrent idiopathic epistaxis

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.

Bilateral nasal septal chemical cautery: a safe and effective outpatient procedure for control of recurrent epistaxis, our experience in 134 patients

PURPOSE

To assess the effectiveness and complications of bilateral nasal septal cautery using silver nitrate in anterior nasal epistaxis.

METHODS

This prospective study was carried out on 180 consecutive patients presenting with epistaxis to a general ENT clinic. Local anaesthetic cautery was performed using 5% lidocaine hydrochloride and 0.5% phenylephrine hydrochloride spray in all the patients except eight children that were 4 years or younger that were done under general anaesthetic. Visible vessels in Little's areas were cauterised using two silver nitrate sticks each side. Patients were prescribed naseptin cream and followed-up. We classified re-bleeds as follow: 0-1 episodes: significant improvement, 2-3 episodes: moderate improvement, 4 + episodes: no improvement.

RESULTS

We analysed 134 (74%) patients who were seen at follow-up. Age range was 5-88 years (mean 25, median 15), there were 89 (67%) males. Children made up 60% (81) of the study population (aged 16 years and under), of these 56 (69%) were male. Significant improvement was seen in 93% (124) of the study population, but there were relapses in two children (1.5%) and only moderate improvement in eight patients (6%). There was no significant complication in the study population, but 11 patients had crusting at the sites of cautery at follow-up.

CONCLUSIONS

Bilateral silver nitrate cauterisation is an effective method of treating recurrent epistaxis with low risk of complications.

Severe spontaneous epistaxis: retrospective study in a tertiary ENT centre

PURPOSE

To investigate the clinical profile and outcomes of different treatment strategies in patients hospitalized for spontaneous severe epistaxis.

METHODS

This is a retrospective descriptive study of a case series of patients hospitalized for epistaxis in the University Hospital of Ghent between 2005 and 2012.

RESULTS

124 patients with, respectively, 132 episodes were included. 64% were male. The mean age was 65 years. 73% had comorbidities of which arterial hypertension was the most common. 61% were taking one or more antithrombotics and in 25.7% a recent change in the medication schedule took place. 47% of the episodes necessitated a vascular intervention. The most performed surgery was endoscopic sphenopalatine artery ligation. The 1-year success rate of conservative treatment was 47% and of vascular intervention 81%. No significant difference between the recurrence rates and need for vascular intervention of the different comorbidities and medications was detected using Pearson chi-squared and Fisher's exact testing. The overall 5-year survival rate was 83.6%.

CONCLUSIONS

The typical pattern of a patient presenting with severe epistaxis was a patient in the sixth decade, male, suffering from comorbidities and taking one or more antithrombotic agents. Based on the above-mentioned success rates of the different treatment options, we think all centres treating epistaxis should apply a well-defined protocol to guide the decision when to proceed with surgery. Furthermore, prospective research needs to precisely investigate the role played by comorbidities and their treatment in the occurrence of epistaxis and to test the effectiveness of proposed algorithms.

Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED

BACKGROUND

Emergency Department (ED) patients presenting with spontaneous epistaxis who have anterior nasal packing are routinely prescribed systemic prophylactic antibiotics in spite of the lack of supporting evidence-based literature. Although there is literature that discusses infection rates with nasal packing for epistaxis and prophylactic antibiotics prescribing practices of otolaryngologists, this is the first study to our knowledge that examines the practices of emergency physicians.

OBJECTIVES

The main objective of this study was to compare the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontaneous epistaxis and to examine current management practices of antibiotic prescribing for these patients.

METHODS

A retrospective review of ED patients ≥ 18 years old with the discharge diagnosis of epistaxis was performed over a 5-year period. Patients who had multiple visits to the ED for epistaxis or recent nasal or sinus surgery were excluded.

RESULTS

Over half of the patients, 57/106 (53.7%), who had anterior packing were prescribed prophylactic systemic antibiotics. Of these patients, 69/106 (65%) returned for a follow-up visit. There were no documented infections for any of these patients regardless of whether or not they were prescribed antibiotics. There was no significant difference with respect to rate of infection found between these two groups (the p-value = 0.263).

CONCLUSION

The absence of infection supports previous findings and suggests that prophylactic antibiotic use for nasal packing in spontaneous epistaxis patients is not necessary. Further randomized controlled studies are necessary to definitively support this practice change.

Management of epistaxis in patients with ventricular assist device: a retrospective review

Background

Patients with a ventricular assist device (VAD) are at risk for epistaxis due to the need for anticoagulation. Additionally, these patients develop acquired von Willebrand syndrome (AvWS) due to these devices. Management is complicated by the risk of thrombosis if anticoagulation is reversed. This study sought to characterize the clinical features and management of epistaxis in this high-risk population.

Methods

Retrospective review of adults with VAD and epistaxis necessitating inpatient consultation with the otolaryngology service were included.

Results

49 patients met inclusion criteria. All patients had a presumed diagnosis of AvWS. An elevated INR (> 2.0) was present in 18 patients (36.7%). Anticoagulation was held in 14 (28.6%) patients, though active correction was not necessary. Multiple encounters were required in 16 (32.7%) patients. Spontaneous epistaxis was associated with multiple encounters (p = 0.02). The use of hemostatic material was associated with a lower likelihood of bleeding recurrence (p = 0.05), whereas cauterization with silver nitrate alone was associated with a higher likelihood of re-intervention (p = 0.05). Surgery or embolization was not required urgently for any patient. Endoscopy under general anesthesia was performed for one patient electively. Mean follow up time was 16.6 months (σ = 6.3). At six months, 18 (36.7%) patients were deceased.

Conclusion

While these patients are at risk for recurrent spontaneous epistaxis, nonsurgical treatment without active correction of INR or AvWS was largely successful. Placement of hemostatic material, as opposed to cautery with silver nitrate, should be considered as a first-line treatment in this group. Multidisciplinary collaboration is critical for successful management.

The role of oral anticoagulants in epistaxis

Purpose

The purpose of this retrospective study was to identify the impact of oral anticoagulants on epistaxis with the focus on new oral anticoagulants.

Methods

The study was conducted at the Department  for Ear- Nose- and Throat (ENT), Head and Neck Surgery, Technical University Munich, Germany. All patients presenting in 2014 with the diagnosis of epistaxis to a specialized ENT accident and emergency department were identified and analyzed in clinical data and medication.

Results

600 adult cases, with a median age of 66.6 years were identified with active bleeding. 66.8% of all cases were anticoagulated. Classic oral anticoagulants (COAC) were three times more common in patients than new-generation oral anticoagulants (NOAC). Recurrent bleeding was significantly associated with oral anticoagulants (OAC) (p = 0.014) and bleeding location was most often anterior (p = 0.006). In contrast, severe cases, which required surgery or embolization were significantly more likely in non-anticoagulated middle-aged patients with posterior bleedings (p < 0.05). In our epistaxis cohort, OAC were highly overrepresented (40%) when compared to the general German population (1%) but COAC as well as NOAC played only a minor role in severe courses of epistaxis.

Conclusion

Oral anticoagulation, especially with new-generation drugs, is not associated with more complicated and severe courses of epistaxis, but rather with recurrent bleeding. One should keep this information in mind when triaging the patient in the emergency room and when planning further procedures.

Intractable epistaxis: which arteries are responsible? An angiographic study

PURPOSE

Epistaxis constitutes a significant proportion of the Otolaryngologist's emergency workload. Optimal management differs in relation to the anatomic origin of the bleeding. The outcome of our study was to determine which artery(ies) could be considered as the cause of severe bleeding in the context of severe epistaxis.

METHODS

Fifty-five procedures of embolization preceded by angiography were reviewed. Medical records of interventionally treated patients were analysed for demographics, medical history, risk factors and clinical data. Angiographic findings were also assessed for active contrast extravasation (blush), vascular abnormality and embolised artery.

RESULTS

Previous angiography showed an active contrast extravasation in only 20 procedures. The most common bleeding source was the sphenopalatine artery (SPA) followed by anterior ethmoïdal artery (AEA) and facial artery. Majority of multiple or bilateral extravasations occured in patients with systemic factors.

CONCLUSIONS

A better understanding of the potential bleeding source might help and limit the risk of treatment failures. Our study confirms that the SPA is the most common cause of severe bleeding. We also emphasise the role of the AEA not only in traumatic context. Others arteries are rarely involved except in patients with comorbidities or frequent recurrences.

Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

BACKGROUND

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

OBJECTIVES

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Emergency Department care of childhood epistaxis

OBJECTIVE

The aim of this review is to determine an efficient and safe primary strategy care for paediatric epistaxis.

DATA SOURCES

We searched PubMed and Cochrane databases for studies referenced with key words 'epistaxis AND childhood'. This search yielded 32 research articles about primary care in childhood epistaxis (from 1989 to 2015). Bibliographic references found in these articles were also examined to identify pertinent literature. We compared our results to the specific management of adult epistaxis classically described in the literature.

RESULTS

Epistaxis is one of the most common reasons for referral of children to a hospital ENT outpatient department. The bleeding usually originates from the anterior septum, as opposed to adults. Crusting, digital trauma, foreign bodies and nasal colonisation with Staphylococcus aureus have been suggested as specific nosebleed factors in children. Rare aetiologies as juvenile nasopharyngeal angiofibroma appear later during adolescence. There are different modes of management of mild epistaxis, which begin with clearing out blood clots and bidigital compression. An intranasal topical local anaesthetic and decongestant can be used over 6 years of age. In case of active bleeding, chemical cauterisation is preferred to anterior packing and electric cauterisation but is only feasible if the bleeding site is clearly visible. In case of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, antiseptic cream is easy to apply and can avoid 'acrobatic' cauterisation liable to cause further nasal cavity trauma.

CONCLUSIONS

Aetiologies and treatment vary with patient age and the existence or not of active bleeding at the time of the examination. Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know paediatric epistaxis specificities.

The use of FloSeal haemostatic sealant in the management of epistaxis: a prospective clinical study and literature review

INTRODUCTION It is standard practice in the UK that if conservative measures or chemical cautery fail to control epistaxis, patients receive nasal packing which is often uncomfortable, requires admission and has well documented associated morbidity. Our study aims to evaluate the use of FloSeal haemostatic sealant in managing patients with epistaxis. MATERIALS AND METHODS Patients were identified from those referred with active epistaxis. A successful outcome was defined as complete haemostasis with FloSeal alone, with no further significant bleeding requiring admission or further interventions in the subsequent 7 days. Patients reported satisfaction using a ten-point visual analogue scale. Ear, nose and throat doctors recorded patient demographics, time to prepare FloSeal, length of stay, need for further treatment and adverse events on an electronic database. RESULTS 30 patients were enrolled in the study. The mean time to prepare FloSeal was 5 minutes. The success rate of FloSeal was 90%. The mean length of stay was 2.75 hours. The mean patient satisfaction with FloSeal was 8.4/10. No adverse events occurred. DISCUSSION FloSeal was found to be effective in controlling anterior epistaxis. There was a single case of posterior epistaxis which required operative management. The literature largely supports FloSeal in anterior epistaxis, but indicates sphenopalatine artery ligation as the definitive management of posterior epistaxis. CONCLUSIONS Our data support the use of FloSeal in patients with anterior epistaxis not controlled with conservative measures or chemical cautery. It was found to be easy to use, is well tolerated by patients and is efficient in financial terms.

A prospective pilot study comparing nasal blood sampling and venipuncture for the assessment of hemoglobin levels and INR

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.

A study to determine the benefits of bilateral versus unilateral nasal packing with Rapid Rhino ® packs

There is little evidence to suggest that bilateral nasal packing increases intra-nasal pressures compared to a single pack (or is well tolerated) for uncontrolled unilateral epistaxis, but it is often performed and justified on those grounds. 15 volunteers were recruited according to strict criteria. Rapid Rhino(®) 5.5 cm anterior packs were inserted bilaterally following topical nasal preparation with co-phenylcaine. The first pack was inflated to a pre-determined pressure. The contralateral pack was inflated to match, and any intra-nasal pressure change on the first side was measured. The subject's level of discomfort was scored on a visual analogue scale. This procedure was repeated at incremental pressures. Higher ipsilateral intra-nasal pressures are achieved when additional contralateral nasal packs are inflated. This change in ipsilateral intra-nasal pressure is greater at higher total inflation pressures. At higher pressures, the subjects reported lower mean pain scores when bilateral packs were used compared to unilateral. This effect was only statistically significant at intra-nasal pressures of 140 mmHg and above (Wilcoxon Signed-Rank test, p < 0.02). It is possible to increase the ipsilateral nasal cavity pressure by inserting a contralateral nasal pack. Although this extra pressure may be enough to tamponade further venous bleeding without significantly increasing a subject's discomfort, the high levels of pack pressure required, make this unlikely to be of significant use in the clinical setting.