Epistaxis in adults: a clinical review

Epistaxis in people with hereditary haemorrhagic telangiectasia: surgical management and psychological impact

From the emergency management of acute epistaxis to the surgical procedures for chronic epistaxis, this article covers the options available to control the archetypal symptom of hereditary haemorrhagic telangiectasia while exploring the psychological effect such a disease has on the patient.

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.

The long-term fate of epistaxis patients with exposure to antithrombotic medication

The goal of this study was to evaluate independent risk factors for long-term epistaxis recurrences and their severity. Individual retrospective cohort study-2b level of evidence. The medical information of 603 emergency epistaxis patients was acquired during a former study. This cohort has been contacted 6 years later by conventional mail and asked to answer a specific paper questionnaire. The following parameters were evaluated: recurrent epistaxis episodes, need for a surgical intervention to stop the recurrent bleeding, patient's history for hypertension and diabetes, intake of hemostasis impairing medication now and in the past. One hundred and six (106) patients were included in the study (35.8 % response rate). The mean observation period was 76.58 months. Almost half of the patients (41.5 % = 44/106) reported at least one recurrent epistaxis episode. Patients with exposure to VKA (vitamin K antagonists) showed significantly more frequently a recurrent epistaxis episode. The binary logistic regression confirmed the intake of VKA as an independent and significant risk factor with an odds ratio of 11.6. Every single patient who had to undergo a surgical intervention to stop a recurrent bleeding stated ASA (Acetylsalicylic Acid) intake. We provide evidence that the intake of a vitamin K antagonist is an independent long-term risk factor for recurrent epistaxis episodes. The intake of ASA is a risk factor for the severity of recurrent epistaxis with the increased need for a surgical intervention not only in a short- but also in a long-term perspective.

LEVEL OF EVIDENCE

This prognostic investigation, designed as a combined prospective and retrospective cohort study, reaches level 2b level of evidence as it includes retrospective aspects.

The utility of FloSeal haemostatic agent in the management of epistaxis

Background:

FloSeal, a locally applied haemostatic agent, has been shown to be effective in a variety of clinical situations. This study investigated its potential benefits in the management of epistaxis.

Methods:

The outcomes of a series of patients with epistaxis presenting to one ENT unit, over a two-month period, were compared. Patients were either treated with FloSeal or traditional epistaxis management techniques. Success of FloSeal was classed as complete haemostasis after its application, without the need for further interventions and no readmission with epistaxis within 7 days.

Results:

Our study comprised 101 adults, with a mean age of 70 years (range, 22–98 years). The overall success rate for FloSeal was 14 per cent (5 out of 36 cases). It was successful in 66 per cent of anterior epistaxis cases (2 out of 3) and in only 9 per cent of posterior epistaxis cases (3 out of 33). There was a significantly higher failure rate of FloSeal compared with nasal packing in posterior epistaxis (p < 0.001).

Conclusion:

Our findings suggest that FloSeal has a limited role in the management of epistaxis.

Risk factors for recurrent spontaneous epistaxis

OBJECTIVE

To identify risk factors associated with spontaneous recurrent epistaxis.

PATIENTS AND METHODS

This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence.

RESULTS

Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event.

CONCLUSION

Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.

Skull base oncocytoma presenting as epistaxis: an unusual presentation of a rare tumour successfully managed with active surveillance

Oncocytomas are rare tumours, usually occurring in the salivary glands, but may very occasionally occur in other sites. The authors present a skull base oncocytoma as a rare cause of spontaneous epistaxis. Following diagnosis through imaging and intranasal biopsy, the patient opted for annual surveillance instead of active treatment and made a full recovery nonetheless. Skull base oncocytoma is a rare tumour that may result in otherwise common symptomatology. While excision is the mainstay of management, active surveillance may be a viable alternative for select patients.

Epistaxis: some aspects of laterality in 326 patients

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Evaluation of stat orders in a teaching hospital: a chart review

BACKGROUND

Physicians frequently prescribe 'stat' orders that need to be actioned immediately or within a limited time frame. This process can be time consuming and expensive. Stat medications are reserved for the highest priority orders and life-threatening situations that need to be dealt with immediately or within a limited time frame.

OBJECTIVES

The goals of this study were to evaluate whether stat medications in a teaching hospital were ordered appropriately and to assess the rationale for the stat order.

METHODS

The study was carried out between July and August 2009 in Masih Daneshvari Hospital. All newly admitted patients' charts were reviewed and the records of all inpatients who received at least one stat order were included in the study. Detailed analyses were undertaken to examine the stat use of agents and the rationale for their prescription. Several different guidelines were used to evaluate the rationale for the prescriptions.

RESULTS

Charts for 175 patients were reviewed. Of these, 109 (62.3%) patients received a total of 220 stat orders. The mean number of stat orders on each chart of patients who received stat orders was 2.0. Stat orders were divided into two categories: 146 (66.4%) that were administered only once and 74 (33.6%) that were reordered. The internal medicine ward accounted for the most stat medications (35%). The major reasons for stat medication orders were: prophylaxis or management of emesis (22.3%), control of dyspnoea (15.9%), preoperative medications (8.2%) and treatment of exacerbations of chronic obstructive pulmonary disease (7.2%). Hydrocortisone (14.1%), dexamethasone (11.3%), granisetron (9.5%), ceftriaxone (8.6%) and morphine (6.8%) accounted for the most common stat orders. Analysis showed that 133 of the total 220 stat orders (60.5%) were prescribed appropriately; the rationale for 19 orders (8.6%) could not be evaluated.

CONCLUSION

This study showed that most stat orders at Masih Daneshvari Hospital during the study period were prescribed appropriately. Further investigations are recommended to evaluate the outcomes of unnecessary stat orders with respect to adverse drug events.

Preliminary experience with epsilon aminocaproic acid for treatment of intractable upper tract hematuria in children with hematological disorders

PURPOSE

Gross, intractable hematuria is rare in children. Although the role of epsilon aminocaproic acid in the management of refractory hematuria is well established in the adult population, few data exist about its use in children for this indication. We present our initial experience with epsilon aminocaproic acid for the treatment of intractable hematuria after more conservative measures failed, and propose an algorithm for administration of epsilon aminocaproic acid in children.

MATERIALS AND METHODS

We reviewed the charts of all patients treated with epsilon aminocaproic acid for intractable gross hematuria at our institution during a period of 36 months. All patients underwent hematological evaluation and any underlying bleeding dyscrasias were addressed. All patients also underwent renal and bladder ultrasound, retrograde pyelogram and ureteroscopy. Demographic information, medical and surgical histories, and epsilon aminocaproic acid dosing and outcomes were recorded.

RESULTS

Three boys and 1 girl 11 to 17 years old were treated with epsilon aminocaproic acid. Three patients had sickle trait (1 with nutcracker phenomenon) and 1 had hemophilia A. Three patients required packed red blood cell transfusions to maintain hematocrit. Three renal angiograms were performed, all of which were nondiagnostic. Duration of hematuria ranged from 1 to 52 weeks before administration of epsilon aminocaproic acid. Endoscopic evaluation demonstrated hematuria localized to 1 ureteral orifice in all 4 patients. All patients received 100 mg/kg epsilon aminocaproic acid orally every 6 hours, which uniformly led to cessation of hematuria.

CONCLUSIONS

Epsilon aminocaproic acid is useful for the management of gross refractory hematuria when more conservative measures fail. Because of its potential side effects, it should be used cautiously.