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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.
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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
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Cardiovascular risk and severity factors in patients admitted to hospital for spontaneous epistaxis. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:119-122. [DOI: 10.1016/j.anorl.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Monga J, Pathania V. THE EFFECTIVENESS OF NASAL ENDOSCOPIC CAUTERIZATION AS FIRST LINE MANAGEMENT FOR EPISTAXIS- A PROSPECTIVE STUDY. ACTA ACUST UNITED AC 2017. [DOI: 10.18410/jebmh/2017/697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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.
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MALCOMSON KG. The Surgical Management of Massive Epistaxis. The Journal of Laryngology & Otology 2007; 77:299-314. [PMID: 13932461 DOI: 10.1017/s0022215100060679] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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EVANS J. The ætiology and Treatment of Epistaxis: Based on a Review of 200 Cases. The Journal of Laryngology & Otology 2007; 76:185-91. [PMID: 13890981 DOI: 10.1017/s0022215100059193] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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.
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Affiliation(s)
- Flávio D Fuchs
- Division of Cardiology, Hospital de Clínicas Porto Alegre, Porto Alegre, RS, Brazil.
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Vaiman M, Eviatar E, Segal S. Effectiveness of second-generation fibrin glue in endonasal operations. Otolaryngol Head Neck Surg 2002; 126:388-91. [PMID: 11997778 DOI: 10.1067/mhn.2002.123345] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We evaluated the efficacy and safety of the Quixil fibrin sealant after its application to endonasal operative sites. A total of 153 patients underwent nasal surgery. The rate of hemorrhagic complications was compared in the group with nasal packing and in the group in whom fibrin glue was used to stop postoperative bleeding. Our results indicate that the application of Quixil fibrin glue to the operative sites in various endonasal operations provides effective hemostasis and sealing. This fibrin glue is a more effective hemostatic agent than foam nasal packing and provides no complications, as can occur with packing. Patients with hypertension have no greater risk for postoperative bleeding if Quixil is used.
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Affiliation(s)
- Michael Vaiman
- Department of Otolaryngology, Assaf Harofeh Medical Center, Israel.
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Lubianca-Neto JF, Sant'anna GD, Mauri M, Arrarte JL, Brinckmann CA. Evaluation of Time of Nasal Packing After Nasal Surgery: A Randomized Trial. Otolaryngol Head Neck Surg 2000; 122:899-901. [PMID: 10828806 DOI: 10.1016/s0194-59980070021-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A randomized, prospective trial was carried out to compare the rate of hemorrhagic complications after removal of nasal packing left for 24 and 48 hours. A total of 104 patients underwent nasal surgery and were randomly assigned to 1 of 2 groups: group 1, 24 hours of nasal packing; group 2, 48 hours of nasal packing. No statistical difference was observed between the groups in terms of occurrence of hemorrhagic complications. Hypertension was the only prognostic factor for postoperative bleeding. The routine use of 48-hour postoperative nasal packing after nasal surgery is not justified because of the low incidence of bleeding and the potential associated morbidity. At the end of the procedure, surgeons should evaluate the risk of postoperative bleeding (ie, presence of hypertension) and decide whether 24-hour nasal packing is enough.
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Affiliation(s)
- J F Lubianca-Neto
- Department of Ophthalmology and Otorhinolaryngology, Fundação Faculdade Federal Ciências Médicas of Porto Alegre, Brazil
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Lubianca Neto JF, Fuchs FD, Facco SR, Gus M, Fasolo L, Mafessoni R, Gleissner AL. Is epistaxis evidence of end-organ damage in patients with hypertension? Laryngoscope 1999; 109:1111-5. [PMID: 10401851 DOI: 10.1097/00005537-199907000-00019] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS To study the association between history of mild to severe epistaxis with different stages of hypertension and with other evidence of target organ damage in a sample of patients attending an outpatient hypertension clinic, controlling for potential confounding factors. STUDY DESIGN A survey of adult patients with hypertension. METHODS A consecutive sample of 323 adults with hypertension was studied. The main outcome measures were history of adult epistaxis, high blood pressure, duration of hypertension, nasal abnormalities, and fundoscopic and electrocardiogram abnormalities. RESULTS Ninety-four patients (29.1% of the whole sample) reported at least one episode of nosebleed after 18 years of age. Of these, 59 (62.8%) needed medical assistance to control at least one of the episodes. The history of epistaxis was not associated with blood pressure classified according to the World Health Organization/International Society of Hypertension paradigm or classified as severe or not severe. There was a trend of an association between history of epistaxis and duration of hypertension. The history of severe epistaxis (epistaxis that needed medical assistance) was not associated with blood pressure classified as severe or not severe and with duration of hypertension. More patients with left ventricular hypertrophy had a positive history of adult epistaxis. There was no association between history of epistaxis or history of severe epistaxis and fundoscopic abnormalities. Among the abnormalities detected at rhinoscopy, only the presence of enlarged septal vessels was associated with history of epistaxis. The presence of enlarged septal vessels was strongly and independently associated with history of epistaxis in the logistic regression model. Duration of hypertension and left ventricular hypertrophy showed a trend for an association with the history of epistaxis in the adult life. CONCLUSIONS A definite association between blood pressure and history of adult epistaxis in hypertensive patients was not found. The evidence for an association of duration of hypertension and left ventricular hypertrophy with epistaxis suggests that epistaxis might be a consequence of long-lasting hypertension. The association between the presence of enlarged vessels at rhinoscopy with history of epistaxis in hypertensive patients is a novel observation that needs to be addressed in future observations.
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Affiliation(s)
- J F Lubianca Neto
- Department of Ophthalmo-Otorhinolaryngology, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Brazil
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Abstract
Epistaxis is a common clinical problem. The widespread availability of endoscopic equipment is shifting management philosophy toward targeting the bleeding point. This shift may have a significant impact on decreasing length of stay and blood transfusion rates. Advances in interventional radiology have also reduced the risk of embolization. Patient education, especially teaching first-aid measures to patients at high risk for nosebleeds, also encourages more effective use of health care resources.
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Affiliation(s)
- L K Tan
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, USA
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Lubianca-Neto JF, Bredemeier M, Carvalhal EF, Arruda CA, Estrella E, Pletsch A, Gus M, Lu L, Fuchs FD. A study of the association between epistaxis and the severity of hypertension. AMERICAN JOURNAL OF RHINOLOGY 1998; 12:269-72. [PMID: 9740920 DOI: 10.2500/105065898781389985] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hypertension (HTN) has frequently been cited as a general risk factor for epistaxis. However, studies dealing with this association have yielded equivocal results. In this study, a sample of 121 hypertensives (blood pressure > or = 140/90 mmHg) was selected to evaluate the association between the severity of HTN and a previous history of epistaxis. Patients with an average blood pressure > or = 160/100 mmHg were classified as suffering from a more severe form of HTN and were compared with those with a less severe form of the disease (160/100 mm Hg < or = blood pressure > or = 140/90 mm Hg). The frequency of epistaxis did not differ among patients categorized by the severity of HTN. Users of aspirin were found to be twice as likely to have a history of epistaxis. In addition, there was a statistical tendency for an association between a history of epistaxis and the duration of hypertension. We conclude that the severity of HTN and a history of epistaxis were not associated in a cohort of hypertensive patients. The identification of other risk factors for epistaxis, including the duration of HTN, deserves further study.
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Affiliation(s)
- J F Lubianca-Neto
- Department of Ophthalmo-Otorhinolaryngology of Fundacão, Faculdade Federal de Ciêncas Médicas de Porto Alegre (FFFCMPA), Brazil
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Abstract
STUDY OBJECTIVE To describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis. DESIGN Retrospective chart review. SETTING University-affiliated community teaching hospital. PARTICIPANTS We studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded. RESULTS Posterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as "severe" (OR, 2.53; 95% CI, .88 to 7.39; chi 2 = 2.84, 1 df, P = .92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; chi 2 = 3.66, 1 df, P = .056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon). CONCLUSION Although posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission.
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Affiliation(s)
- R A Viducich
- Department of Emergency Medicine, Akron City Hospital, Ohio, USA
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Abstract
A case of accelerated hypertension associated with severe oral hemorrhage is described. The evidence in this case suggests that a hypertensive crisis may have been caused by a failure to take medication as prescribed, or may have occurred as a sequel to severe postoperative hemorrhage. The reopening of the surgical site was probably caused by masticatory trauma, and the hemorrhage exacerbated by localized fibrinolytic activity.
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Ibrashi F, Sabri N, Eldawi M, Belal A. Effect of atherosclerosis and hypertension on arterial epistaxis. J Laryngol Otol 1978; 92:877-81. [PMID: 712220 DOI: 10.1017/s0022215100086254] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Eye fundus examination in twenty cases of hypertensive nose bleeding was carried out to evaluate the effect of hypertension and atherosclerosis on epistaxis. Arteriolar attenuation, atherosclerosis and venous congestion were detected in most of the cases. None showed haemorrhages or exudates. Hypertension and atherosclerosis seem to maintain and increase the severity of epistaxis, once it has been initiated by other factors.
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Abstract
The status of nose bleeding as a symptom of high blood pressure has been studied in patients admitted because of epistaxis. Twenty-six patients with a factor predisposing to nasal bleeding had age- and sex-adjusted systolic and diastolic scores similar to those of the general population. One hundred and sixty-eight patients with no such factor formed a different population with significantly higher age- and sex-adjusted systolic and diastolic scores. It is concluded that epistaxis is a true symptom of hypertension.
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Barlow DH, Beevers DG, Hawthorne VM, Watt HD, Young GA. Blood pressure measurement at screening and in general practice. Heart 1977; 39:7-12. [PMID: 831740 PMCID: PMC483186 DOI: 10.1136/hrt.39.1.7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
As part of an epidemiological study of hypertension, an analysis was made of the general practitioner records of all attenders at a screening survey. A blood pressure recording, made before screening, was found in 37-9 per cent of cases. The pressures obtained correlated well with those obtained by the screening unit, though the practitioners' readings tended to be lower. Further cases of hypertension were found, not diagnosed by the screening unit; the estimate made of the prevalence of hypertension at the survey could be corrected by inclusion of these cases. Chest pain, headaches, lightheadedness, and dizziness were common reasons for blood pressure measurement in general practice, but these symptoms were not associated with a rise in the blood pressure; symptoms were not helpful in the diagnosis of hypertension. Some form of screening programme is necessary to detect cases of hypertension. This could be carried out by general practitioners.
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Abstract
If arterial ligation is contemplated and the site of bleeding has not been identified it is reasonable to ligate the external carotid or maxillary artery, on the basis that this vessel supplies the major part of the nose. If bleeding persists in spite of ligation, this does not mean that the wrong vessel has been tied off but that arterial anastomoses are allowing blood to seep from the ethmoidal to the sphenopalatine area of the nose. If the anterior ethmoidal artery is to be ligated it is worth remembering that in 14-3 per cent of cases the anterior ethmoidal artery is absent unilaterally and in 2-4 per cent of cases absent bilaterally (Shaheen, 1967). The presence of a foramen with a periosteal cuff going through it does not necessarily mean that there is an artery present (Fig. 23). Finally, the blood vessel changes which occur and which are responisble for the persistence of nose bleeds in the elderly are a collagenous change in the muscle coat of medium and small arteries and calcification (not atheroma) in the larger feeding vessels.
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Petruson B. Epistaxis. A clinical study with special reference to fibrinolysis. ACTA OTO-LARYNGOLOGICA. SUPPLEMENTUM 1974; 317:1-73. [PMID: 4528551 DOI: 10.3109/00016487409129566] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Symptoms in hypertension. BRITISH MEDICAL JOURNAL 1973; 1:433-4. [PMID: 4689825 PMCID: PMC1588484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Weiss NS. Relation of high blood pressure to headache, epistaxis, and selected other symptoms. The United States Health Examination Survey of Adults. N Engl J Med 1972; 287:631-3. [PMID: 5076458 DOI: 10.1056/nejm197209282871303] [Citation(s) in RCA: 90] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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