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Zloczower E, Pinhas S, Allon R, Syn-Hershko A, Raz Yarkoni T, Marom M, Kiderman D, Cohen O, Warman M. The impact of different anticoagulants and antiplatelets regimens on acute epistaxis outcomes. Eur Arch Otorhinolaryngol 2024; 281:4863-4871. [PMID: 38782795 PMCID: PMC11393048 DOI: 10.1007/s00405-024-08718-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The impact of anticoagulants (AC) and antiplatelets (AP) on the management of acute epistaxis remains unclear. This study investigated the association between AC/AP therapy and treatment outcomes in patients with acute epistaxis. METHODOLOGY A retrospective analysis of patients presented to the otolaryngology emergency room with acute epistaxis (2014-2022). Patients were categorized based on their regular medications: AP, dual AP therapy (DAPT), new oral anticoagulants (NOAC), vitamin K antagonists (VKA), or no regular AC/AP use (control group). Outcome measures included rates of minor interventions (chemical or electrical cautery, nasal tamponade), major interventions (endoscopic ligation, embolization), recurrent emergency department visits, admission rates, and duration. RESULTS 786 patients were included with an average follow-up period of 52.56 ± 20.4 months. Compared to the control group, patients on AP, DAPT, or VKA had significantly higher rates of minor interventions (63.1% vs. 74.4%, 79.6%, and 77.3%, respectively, p < 0.05). DAPT users exhibited a higher rate of major interventions than the control (5.6% vs. 1.3%, p = 0.053). NOAC users showed no significant difference in minor interventions compared to control and required no major interventions. Both NOAC and VKA users had significantly higher rates of recurrent epistaxis events and prolonged hospitalization compared to the control (p < 0.01 and p < 0.05, respectively). CONCLUSIONS NOAC demonstrated more favorable outcomes than VKA in patients with acute epistaxis, and DAPT use was associated with an increased need for major interventions. These findings suggest a more conservative approach in NOAC users than other AC/AP agents.
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Affiliation(s)
- Elchanan Zloczower
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel.
| | - Sapir Pinhas
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Raviv Allon
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Adi Syn-Hershko
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Tom Raz Yarkoni
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Maayan Marom
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Kiderman
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
| | - Oded Cohen
- Joyce and Irvin Goldman Medical School, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheba, Israel
- Division of Otorhinolaryngology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheba, Israel
| | - Meir Warman
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel
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van der Zaag PD, Geurts S, Rozema R, Reininga IHF, van Minnen B. Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics. Eur J Trauma Emerg Surg 2024; 50:543-550. [PMID: 38197899 PMCID: PMC11035474 DOI: 10.1007/s00068-023-02428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE To investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures. METHOD A prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures. RESULTS Out of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors. CONCLUSION Maxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.
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Affiliation(s)
- Pieter Date van der Zaag
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stephanie Geurts
- Faculty of Dentistry and Oral Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Romke Rozema
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Inge H F Reininga
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Emergency Care Network Northern Netherlands (AZNN), Northern Netherlands Trauma Registry, Groningen, The Netherlands
| | - Baucke van Minnen
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Hughes JM, Teh BM, Hart CJ, Gibbs HH, Aung AK. Risk factors and management outcomes in epistaxis: a tertiary centre experience. ANZ J Surg 2023; 93:555-560. [PMID: 36539988 DOI: 10.1111/ans.18179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Jed M Hughes
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Bing Mei Teh
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
- Department of Otolaryngology, Head and Neck Surgery, Monash Health; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Cameron J Hart
- Department of ENT, Head Neck Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Harry H Gibbs
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Ingason AB, Rumba E, Hreinsson JP, Agustsson AS, Lund SH, Palsson DA, Reynisson IE, Gudmundsdottir BR, Onundarson PT, Tryggvason G, Bjornsson ES. Warfarin is associated with higher rates of epistaxis compared to direct oral anticoagulants: A nationwide propensity score-weighted study. J Intern Med 2022; 292:501-511. [PMID: 35411982 DOI: 10.1111/joim.13498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC). OBJECTIVE To compare rates of clinically relevant epistaxis between OAC. METHODS Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression. RESULTS During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001). CONCLUSION Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants.
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Affiliation(s)
- Arnar B Ingason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Johann P Hreinsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnar S Agustsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Daniel A Palsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Brynja R Gudmundsdottir
- Department of Laboratory Hematology and Coagulation Center, Landspitali University Hospital, Reykjavik, Iceland
| | - Pall T Onundarson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Laboratory Hematology and Coagulation Center, Landspitali University Hospital, Reykjavik, Iceland
| | - Geir Tryggvason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Otolaryngology - Head and Neck Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Einar S Bjornsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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Maina G, Ooi E. A retrospective review of spontaneous epistaxis outcomes for patients on novel oral anticoagulants compared to antiplatelets and warfarin. Am J Otolaryngol 2022; 43:103488. [PMID: 35537230 DOI: 10.1016/j.amjoto.2022.103488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/01/2022] [Indexed: 11/01/2022]
Abstract
AIMS The incidence of epistaxis-related admissions amongst elderly patients is rising due to the increasing use of anticoagulants and antiplatelet agents. This retrospective study evaluates the differences in outcomes for patients on warfarin, novel anticoagulants (NOACs) and antiplatelets over two different time periods. METHODOLOGY Retrospective case-control study with data from patients admitted with epistaxis through the Flinders Medical Centre Emergency Department in the first six months of 2013 and compared to the same period in 2018. The latter coincides with integration of NOACs into Australian prescribing practices. Included participants were ≥50 years with spontaneous epistaxis which coincides with peak incidence in adults. Exclusion criteria were epistaxis due to trauma, intrinsic coagulopathy, or recent post-surgery. Linear regression and binary logistic regression models were the statistical methods used. RESULTS Data from 85 patients were analysed for length of stay (LOS), readmission rates and method of haemostasis. In 2013, 41 patients were included compared to 44 in 2018, suggesting a 7% increase in admissions rates but this was not statistically significant (p = 0.96). The proportion of patients admitted with epistaxis while taking an anticoagulant or antiplatelet agent increased from 66% in 2013 to 93% in 2018. Thirty six percent of patients in 2018 were taking NOACs, however, LOS was 2 times shorter (mean ratio = 2.08 days, 95% CI: 1.03, 4.19). Seven percent of patients in 2018 had bleeding requiring surgery or interventional radiology, compared to 12% in 2013, but this was not statistically significant. There was no statistically significant difference in readmission rates (p = 0.82) or intervention required (p = 0.74) between the two time periods. CONCLUSIONS Epistaxis admissions at our institution have increased since the introduction of NOACs. However, most patients can be managed successfully with intranasal packing and cautery alone. NOACs are not associated with increased rated of invasive haemostatic measures and patients have a shorter LOS.
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6
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Stanković P, Hoch S, Rudhart S, Obradović D, Dagres N, Wilhelm T. Direct oral anticoagulants versus vitamin K antagonists in epistaxis patients: A systematic review and meta-analysis. Clin Otolaryngol 2021; 47:255-263. [PMID: 34812585 DOI: 10.1111/coa.13898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/28/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiological and haematological guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome. DESIGN/SETTING A systematic review and meta-analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data were analysed and standardised mean difference (SMD) was calculated according to Hedges' g. Dichotomous data were analysed, and the Mantel-Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I2 statistics. MAIN OUTCOME/RESULTS A total of eight reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD = -0.22, 95% CI-0.42 to -0.02, p = .03) and a significantly higher rate of posterior bleeding in the VKA group (OR = .39, 95% CI 0.23 to 0.68, p = .001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion or surgical intervention (p = .57, .12, .57 and .38 respectively) were found. CONCLUSION According to this meta-analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs.
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Affiliation(s)
- Petar Stanković
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Borna, Germany
| | - Stephan Hoch
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Philipps-University Marburg, Marburg, Germany
| | - Stefan Rudhart
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Philipps-University Marburg, Marburg, Germany
| | - Danilo Obradović
- Department of Cardiology, Heart Centre, University of Leipzig, Leipzig, Germany
| | - Nikolaos Dagres
- Department of Cardiology, Heart Centre, University of Leipzig, Leipzig, Germany
| | - Thomas Wilhelm
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Borna, Germany.,Medical Faculty, Philipps-University, Marburg, Germany
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Anti-thrombotics and their impact on inpatient epistaxis management: a tertiary centre experience. Ir J Med Sci 2021; 191:1621-1629. [PMID: 34562192 PMCID: PMC9308617 DOI: 10.1007/s11845-021-02790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/18/2021] [Indexed: 11/03/2022]
Abstract
Introduction Epistaxis represents a massive burden upon NHS resources. Despite being an extremely common reason for emergency ENT admissions, there remains significant variation in its management. Although the evidence base is continually growing, there appears to be a lack of guidance towards managing anti-coagulants and anti-platelet medications and identifying patient-specific outcomes in this setting. Epistaxis has long been associated with a multitude of risk factors but none have shown consistent, direct correlation. Materials and methods We aimed to identify if the use of anti-thrombotic medication was associated with a longer length of hospital admission or conferred a higher requirement for nasal packing, re-packing, surgery or re-admission. We conducted a retrospective analysis of 100 consecutive adult patients admitted over a 6-month period. Statistical analysis was conducted using SPSS software. Results Sixty-five percent of patients were taking anti-thrombotic medication. The variability of admission INR values in those taking warfarin did not relate with any outcome measure. There was no statistical difference between patients taking anti-thrombotic medication and those who do not, with regards to our primary outcome measures. Re-admission rates within 28 days were found to be 13%, with anti-thrombotic medication use and pre-existing cardiovascular disease recognised as commonly encountered risk factors. Three percent of patients required surgical intervention. Eight percent of patients required re-packing, with a Rapid Rhino chosen in all instances. Conclusion The use of anti-thrombotic medication is not associated with increased morbidity or increased rate of complications. Anti-thrombotic usage and more than one medical co-morbidity increase the risk of re-admission within 28 days.
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8
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Send T, Bertlich M, Eichhorn KW, Ganschow R, Schafigh D, Horlbeck F, Bootz F, Jakob M. Etiology, Management, and Outcome of Pediatric Epistaxis. Pediatr Emerg Care 2021; 37:466-470. [PMID: 30624421 DOI: 10.1097/pec.0000000000001698] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Epistaxis in children is one of the most common causes for seeking professional medical help. Patients may be treated by several disciplines with various approaches to pediatric epistaxis. We reviewed cases of pediatric epistaxis from an otorhinolaryngologist's point of view. METHODS A retrospective chart review was performed on all patients younger than 18 years presenting with epistaxis to the Department of Otorhinolaryngology at the University of Bonn, Germany. RESULTS Sixty episodes of epistaxis in 58 patients were included in the study. Mean age was 10.1 ± 4.5 years. In terms of risk factors, 3 patients had a hemorrhagic diathesis, 3 had taken medication that interfered with hemostasis, and 8 had a history of previous trauma, most of which was digital manipulation. Twenty-six patients did not need invasive therapy. Twenty-six patients received cauterization to control the bleeding, and 4 patients needed surgery. The necessity for surgery was mainly noncooperation. CONCLUSIONS Epistaxis in children is seldom serious. However, hemorrhagic diathesis needs to be kept in mind as a potential cause of epistaxis. In most cases, careful instruction of the patients and the relatives concerning nasal mucosal care is sufficient. If cauterization is necessary, silver nitrate coagulation should be preferred over electrocoagulation.
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Affiliation(s)
- Thorsten Send
- From the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Bonn
| | - Mattis Bertlich
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Munich
| | - Klaus Wolfgang Eichhorn
- From the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Bonn
| | | | - Darius Schafigh
- From the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Bonn
| | - Fritz Horlbeck
- Internal Medicine II-Department of Cardiology, Angiology and Pneumology, University Hospital Bonn, Bonn, Federal Republic of Germany
| | - Friedrich Bootz
- From the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Bonn
| | - Mark Jakob
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Munich
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Yaniv D, Zavdy O, Sapir E, Levi L, Soudry E. The Impact of Traditional Anticoagulants, Novel Anticoagulants, and Antiplatelets on Epistaxis. Laryngoscope 2021; 131:1946-1951. [PMID: 33533493 DOI: 10.1002/lary.29417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/29/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE/HYPOTHESIS Anticoagulant and antiplatelet medications (ACAP) are known to be associated with an increased risk for epistaxis. There are conflicting results regarding the impact of Novel Oral Anticoagulants (NOAC) on epistaxis and its severity. STUDY DESIGN Retrospective chart review of patients who were admitted to the ED in our tertiary level hospital with a diagnosis of epistaxis during the years 2012 to 2018. METHODS Retrospective analysis of patients presenting to tertiary level emergency otolaryngological care during the years 2012 to 2018. The impact of various ACAP medications on epistaxis severity, hospital admission, and recurrence was analyzed. RESULTS A total of 470 patients were identified. Two hundred and twenty-nine patients (49%), were not on any anticoagulant/antiplatelet (ACAP) medications (controls) and 241 patients (51%) were taking at least one ACAP medication (ACAP group). Patients in the ACAP group were at a higher risk for severe epistaxis (OR = 1.8, P < .05) and were more likely to be hospitalized (OR = 2.17, P < .05). Surprisingly, the risk for recurrence was similar in the ACAP and control groups (15%, P > .05). Compared to controls, Warfarin and Enoxaparin increased the overall risk for severe epistaxis (OR = 4.4, P < .05) and for hospital admission (OR = 2.1, P < .05). Specifically, an increased risk for posterior tamponade (OR = 19, P < .001), significant blood loss (OR = 4.4, P = .032), and blood transfusion (OR = 4.7, P = .007) were identified as well. Interestingly, NOACs were not associated with increased risk for severe epistaxis, hospital admission, tamponade, and significant blood loss or blood transfusion compared to controls. CONCLUSIONS Compared to older generation anticoagulants and antiplatelet medications, NOACs demonstrated an improved safety profile, in terms of epistaxis severity, need for hospital admission and outcomes. These results may suggest a more conservative approach and less hospitalization when treating epistaxis in patients receiving NOACs. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1946-1951, 2021.
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Affiliation(s)
- Dan Yaniv
- Department of Otolaryngology -Head and neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Zavdy
- Department of Otolaryngology -Head and neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einav Sapir
- Department of Otolaryngology -Head and neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lirit Levi
- Department of Otolaryngology -Head and neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ethan Soudry
- Department of Otolaryngology -Head and neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Ameya G, Biresaw G, Mohammed H, Chebud A, Meskele M, Hussein M, Endris M. Epistaxis and Its Associated Factors Among Precollege Students in Southern Ethiopia. J Blood Med 2021; 12:1-8. [PMID: 33442314 PMCID: PMC7797310 DOI: 10.2147/jbm.s285403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Epistaxis is one of the most common otorhinolaryngological emergencies affecting the majority of the population in their lifetime, with some of them requiring serious medical attention. This study aimed to assess the prevalence and associated factors of epistaxis among pre-college students in Wolaita Sodo, Ethiopia. Methods An institution-based cross-sectional study was conducted. Data were collected using a pre-tested interviewer administered questionnaire. The study participants were selected by systematic random sampling technique. A logistic regression analysis was employed to assess the presence and strength of association factors with epistaxis. An adjusted odds ratio with 95% confidence interval was used to determine the presence and strength of the association at 0.05 level of significance. Results Of 387 participants, 57.1% of them were male, and the mean age of all participant was 18.05±1.401 SD years. The overall epistaxis prevalence was 108 (27.9%). Blood group O, which accounted for about 43.4% was more prevalent. Blood group O (AOR=3.96, 95% CI=1.5-10.4), participants who drink coffee daily (AOR=2.75, 95% CI=1.0-7.4), and participants who took a bath frequently with both hot and cold-water (AOR=4.55, 95% CI=1.1-18.6) were significantly associated with epistaxis. Conclusion The type of blood group, interval of coffee drinking, and type of bathing were significantly associated with epistaxis. Working on the identified associated factor and increased awareness about epistaxis for the students with effective first aid training is mandatory.
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Affiliation(s)
- Gemechu Ameya
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Kotebe Metropolitan University, Addis Ababa, Ethiopia
| | - Gelila Biresaw
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Hayat Mohammed
- Department of Medical Laboratory Science, College of Medicine and Health Science, Jimma University, Jimma, Ethiopia
| | | | - Melese Meskele
- Worabe Comprehensive Specialized Hospital, Worabe, Ethiopia
| | | | - Muktar Endris
- Galikoma Health Center, Afar Region, Galikoma, Ethiopia
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Martín-Bailón M, López-Mesa P, Dios-Loureiro C. Manejo de epistaxis en pacientes con terapia antitrombótica. REVISTA ORL 2020. [DOI: 10.14201/orl.24097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción y objetivo: la epistaxis es una de las urgencias otorrinolaringológicas más frecuentes. Una de sus causas son las alteraciones de la hemostasia provocadas por fármacos antitrombóticos. El objetivo del estudio es determinar si existen diferencias en el manejo de epistaxis entre pacientes con terapia antitrombótica y pacientes controles.
Método: estudio observacional analítico retrospectivo de pacientes ingresados en el servicio de Otorrinolaringología de un hospital de tercer nivel, entre enero de 2010 y diciembre de 2016. Se han recogido características epidemiológicas, clínicas y terapéuticas de los pacientes a través de su historia clínica electrónica y se ha realizado análisis estadístico comparativo entre los pacientes con terapia antitrombótica y pacientes controles.
Resultados: 85 pacientes analizados (74,1% varones) con una edad media al diagnóstico de 66,7 años. El 49,4% realizaban terapia antitrombótica. En todos los pacientes se realizó taponamiento anterior y en 16 pacientes, posterior. 37 pacientes precisaron cirugía endoscópica nasal. La embolización se realizó en cuatro pacientes. En el estudio estadístico comparativo no se han encontrado diferencias estadísticamente significativas entre ambos grupos en ninguna de las variables analizadas.
Discusión y conclusiones: las indicaciones actuales de terapia antitrombótica son muy amplias y por ello es frecuente atender epistaxis en este tipo de pacientes. Aunque no está claramente demostrado que la terapia antitrombótica por sí sola se asocie con sangrados más graves, creemos que es fundamental realizar un manejo multidisciplinar de estos pacientes con el fin de conseguir un adecuado control del sangrado sin necesidad de recurrir a intervenciones más agresivas.
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Shorter hospital stays in epistaxis patients with atrial fibrillation when taking rivaroxaban or apixaban versus phenprocoumon. J Thromb Thrombolysis 2019; 47:384-391. [PMID: 30729376 DOI: 10.1007/s11239-019-01824-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patients taking oral anticoagulants (OACs) currently represent one-third of all patients treated for epistaxis and an upward trend is expected. New direct oral anticoagulants (DOACs) have been on the market for approximately 10 years. DOACs are favoured over Vitamin K-Antagonists (VKAs) in the current guidelines. There are barely studies that investigate the impact of DOACs on patients with epistaxis. A retrospective study was performed analysing all patients who had stationary treatment for epistaxis from 01.01.2011 to 01.01.2018 in a tertiary care centre. In a total of 466 patients, 46.1% were on OACs. The main indication was atrial fibrillation (AF, 67.4%).The number of DOACs taken surpassed that of the VKAs during the past 2 years. The length of hospital stay was significantly longer in the phenprocoumon group (3 ± 0.2 days) in comparison to both the rivaroxaban (2.3 ± 0.1) and the apixaban (2.2 ± 0.1) groups (p = 0.005). Posterior epistaxis occurred more frequently in the phenprocoumon group (10.8%) than in the rivaroxaban (0%) and apixaban (0%) groups (p = 0.03). A correlation between CHA2DS2-VASc score (risk score for apoplexy in patients with AF, p = 0.01), HAS-BLED score (score for assessment of major bleeding in patients taking anticoagulants with AF, p = 0.006), and length of hospital stay (p = 0.002) with recurrence of epistaxis was found. Shorter hospital stays and exclusively anterior bleeding was noted in AF patients taking rivaroxaban and apixaban, whereas AF patients taking phenprocoumon stayed in hospital longer and had more posterior bleeding.
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Müller M, Schlittler F, Schaller B, Nagler M, Exadaktylos AK, Sauter TC. Characteristics, treatment and outcome of bleeding after tooth extraction in patients on DOAC and phenprocoumon compared to non-anticoagulated patients-a retrospective study of emergency department consultations. Clin Oral Investig 2018; 23:2273-2278. [PMID: 30291493 DOI: 10.1007/s00784-018-2676-7] [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] [Received: 08/03/2017] [Accepted: 10/01/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Bleeding after tooth extraction range from minor bleeding to life-threating haemorrhagic shock and are among the leading complications in patients under oral anticoagulation with direct oral anticoagulants (DOACs) or phenprocoumon. Little is known about how anticoagulation in patients under DOAC or phenprocoumon alters the characteristics, treatment or outcome of bleeding events, in comparison to non-anticoagulated patients. METHODS Patients admitted to a tertiary ED in Bern, Switzerland, from June 1st 2012 to 31st May 2016 with bleeding related to tooth extraction under DOAC, phenprocoumon or without anticoagulation, were compared. RESULTS Out of 161,458 emergency consultations, 64 patients with bleeding from tooth extraction were included in our study. In anticoagulation groups, we found significantly more delayed bleeding events than in patients without anticoagulation (9 (81.3%) DOAC, 19 (86.4%) phenprocoumon, 8 (30.8%) no anticoagulation, p < 0.001). Anticoagulated patients had to stay longer in the ED than non-anticoagulated patients, with no significant difference between DOAC or phenprocoumon (hours: 4.8 (3.2-7.6 IQR) DOAC, 3.0 (2.0-5.5 IQR) phenprocoumon, p = 0.133; 2.7 (1.6-4.6) no anticoagulation; p = 0.039). More patients with anticoagulation therapy needed surgery than patients without anticoagulant therapy (11 (68.8%) DOAC, 12 (54.6%) VKA, p = 0.506; 7(26.9%) no anticoagulation; p = 0.020). CONCLUSIONS Delayed bleeding occur more often in anticoagulated patients with both DOAC and phenprocoumon compared to patients without anticoagulation. Bleeding events in anticoagulated patients with DOAC and phenprocoumon equally need longer ED treatment and more frequent surgical intervention. CLINICAL RELEVANCE Caution with delayed bleeding in anticoagulated patients with DOACs and phenprocoumon is necessary and treatment of bleeding is resource-demanding.
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Affiliation(s)
- Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Schlittler
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benoit Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Beck* R, Sorge* M, Schneider A, Dietz A. Current Approaches to Epistaxis Treatment in Primary and Secondary Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:12-22. [PMID: 29345234 PMCID: PMC5778404 DOI: 10.3238/arztebl.2018.0012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 05/15/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment. METHODS This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience. RESULTS There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk. CONCLUSION The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.
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Affiliation(s)
- Rafael Beck*
- * Both authors contributed equally to this paper
- Department of Otolaryngology, University of Leipzig
| | - Martin Sorge*
- * Both authors contributed equally to this paper
- Department of Otolaryngology, University of Leipzig
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