Influence of meteorological variables on the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate (Lorca, Spain)

BACKGROUND AND OBJECTIVES

Epistaxis is a common emergency for otorhinolaryngologists. Although the aetiological factors have been widely studied, they remain subject to debate. The role of meteorological variables has been discussed in recent years, but results have been inconsistent. Given a lack of prior data, the aim of our study was to identify the meteorological variables that influence the frequency of visits and hospital admission for epistaxis in a city with a cold semi-arid climate in Spain.

METHODS

Case-control study.

CASES

patients who attended the accident and emergency department of a secondary level hospital for epistaxis over a 9-year period (2011-2019). Controls were established by simple random sampling among emergency rooms visits in general (patients who attended the same centre over the same period of time). Sociodemographic, clinical and meteorological variables were all taken into account.

RESULTS

2749 patients in the epistaxis group and 2764 in the control group. There were significant differences in the epistaxis group, with a higher proportion of male (62.85%) and older patients. Univariate and multivariate analysis revealed that the daily minimum temperature and maximum wind speed were factors significantly associated with the onset of epistaxis. In addition, logistic regression analysis showed that decreases in minimum temperature and increases in maximum wind speed were associated with an increase in epistaxis (p < 0.01). No association was found between hospital admission and the weather conditions.

CONCLUSION

Our findings suggest that low minimum temperatures and high wind speeds are associated with the number of visits to hospital accident and emergency departments for epistaxis, but not with hospital admission.

Environmental Risk Factors for Pediatric Epistaxis vary by Climate Zone

INTRODUCTION AND OBJECTIVE

Prior studies have provided variable results regarding environmental risk factors for epistaxis. These studies were conducted in varying climate zones, which may explain discrepancies in results. The objective of this study is to investigate correlations between season, temperature, and humidity on frequency of pediatric epistaxis across climate zones.

METHODS

Children seen in the outpatient setting for epistaxis were identified from the 2007-2010 IBM MarketScan database. Climate zones were assigned according to International Energy Conservation Code (IECC) classification, where temperature zones in the United States and territories were assigned on an ordinal scale from 1 (tropical) to 8 (subarctic), and humidity zones were categorized as moist, dry, or marine. The control population was a sample of all well-child visits matched by age and county.

RESULTS

We identified 184,846 unique children seen for epistaxis and 1,897,012 matched controls. Moderate temperature zones were associated with lower odds of epistaxis compared with the hottest and coldest zones. Humidity was associated inversely with epistaxis rates in moderate temperature zones but was not a significant predictor of epistaxis in climates with extreme heat. Additionally, summer was associated with lower odds of epistaxis compared to winter. Interestingly, however, there were significantly higher rates of cautery procedures during summer months, driven largely by increased procedures performed in clinic, as opposed to the operating room or emergency room.

CONCLUSIONS

Environmental risk factors for epistaxis vary by climate zone. The model presented reconciles prior reports and may allow for more personalized clinical management based on regional climate.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1450-1456, 2024.

Exploring effects of atmospheric conditions in hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder characterized by recurrent epistaxis, telangiectasias, and visceral arteriovenous malformations. Individuals with HHT often identify low humidity and temperature as detrimental to epistaxis severity. We set out to assess the relationship between humidity and temperature on epistaxis severity in patients with HHT.

METHODS

Retrospective cross-sectional study at an academic hospital with an HHT center between July 1, 2014 and January 1, 2022. The primary outcome of this study was ESS. Pearson correlation analyses and multiple linear regression analyses were performed to test the association between weather variables and epistaxis severity scre (ESS). Results were reported as coefficient and 95% confidence interval (CI).

RESULTS

Four hundred twenty-nine patients were included in the analysis. Through a Pearson correlation analysis, neither humidity (regression coefficient = -0.01; 95% CI, -0.006 to 0.003; p = 0.50), daily low temperature (regression coefficient = 0.01; 95% CI, -0.011 to 0.016; p = 0.72), or daily high temperature (regression coefficient = 0.01; 95% CI, -0.004 to 0.013; p = 0.32) were significantly correlated with ESS. In a multiple linear regression analysis, adjusting for both daily low temperature and humidity, medications taken, demographics, and genotype, neither daily low temperature (regression coefficient = -0.02; 95% CI, -0.04 to 0.01; p = 0.14) nor humidity (regression coefficient = 0.01; 95% CI, -0.01 to 0.01; p = 0.64) were significantly associated with ESS.

CONCLUSION

We have shown in a large clinical sample that neither humidity nor temperature were strongly correlated with HHT patient epistaxis severity.

Use of tranexamic acid-soaked NasoPore® in the emergency department, to reduce epistaxis admissions

OBJECTIVES

The aim of this study was to assess the efficacy of a new emergency department (ED) intervention for the management of non-traumatic, anterior epistaxis in adult patients, aiming to reduce epistaxis admissions.

DESIGN

A new epistaxis pathway was introduced for use by ED practitioners. This was disseminated in ED through an educational campaign by the ear, nose and throat team. A tranexamic acid (500 mg/5 mL)-soaked NasoPore® packing step was introduced for epistaxis which did not terminate following 10 min of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation periods were defined, and all adults attending ED with non-traumatic, anterior epistaxis were included. Pre- and post-implementation epistaxis treatment interventions, admission rates and re-attendance rates were recorded by retrospective audit and compared.

RESULTS

In the post-implementation group, epistaxis admissions were 51.7% (p < .05) lower than in the pre-implementation group, as a proportion of the total number attending ED with epistaxis during these periods.

CONCLUSIONS

The significant reduction in epistaxis admissions demonstrates that this ED intervention is beneficial for patient outcomes.

Rhinologic outcome of endoscopic transnasal-transsphenoidal pituitary surgery: an institutional series, systematic review, and meta-analysis

PURPOSE

We aimed to summarize the available data on the objective rhinologic outcome after endoscopic transnasal-transsphenoidal (ETT) surgery.

METHODS

Retrospective study on a consecutive cohort of treatment-naïve patients undergoing ETT pituitary gland surgery. Additionally, a systematic review and meta-analysis with focus on the rhinologic outcome, including postoperative smell function was performed.

RESULTS

The institutional series incorporated 168 patients. A concomitant endoscopic septoplasty was performed in 29/168 patients (17.3%). A nasoseptal flap was used for reconstruction of large skull-base defects or high-flow CSF leaks in 4/168 (2.4%) patients. Early postoperative rhinologic complications (< 4 weeks) included epistaxis (3%), acute rhinosinusitis (1.2%) and late postoperative complications (≥ 8 weeks) comprised prolonged crusting (15.6%), symptomatic synechiae (11.9%) and septal perforation (0.6%). Postoperative smell function was not impaired (Fisher's exact test, p = 1.0). The systematic review included 19 studies on 1533 patients with a median postoperative epistaxis rate of 1.4% (IQR 1.0-2.2), a postoperative acute rhinosinusitis rate of 2.3% (IQR 2.1-3.0), a postoperative synechiae rate of 7.5% (IQR 1.8-19.1) and a postoperative septal perforation rate of 2.2% (IQR 0.5-5.4). Seven studies including a total of 206 patients reported adequate outcome measures for smell function before and after ETT surgery. Only 2/7 studies reported an impairment of smell function postoperatively, especially in patients with nasoseptal flap harvesting.

CONCLUSION

Early and late postoperative rhinologic complication rates after ETT surgery for pituitary lesions seem to be low. A thorough evaluation of smell function, in particular in patients at risk for nasoseptal flap harvesting, may be an important factor in optimal postoperative care.

Clinical Characteristics and Risk Factors for Allergic Rhinitis in Children with Epistaxis

Background

Epistaxis is frequently observed in children with allergic rhinitis. However, few studies have addressed the clinical characteristics and risk factors for allergic rhinitis in children with epistaxis. This study aimed to describe the factors associated with allergic rhinitis in children with epistaxis.

Methods

In total, we recruited 80 children (aged 3-14 years) who presented with epistaxis at a tertiary hospital between January 2014 and January 2022. The follow-up duration was at least 3 months, and we performed a multivariate logistic regression analysis to identify the risk factors for allergic rhinitis.

Results

Among the 80 children examined, 57 (71.25%) had allergic rhinitis. Epistaxis mainly occurred in autumn in children with allergic rhinitis; in contrast, it mostly occurred in summer in children without it (P = 0.029). Mites are common allergens for allergic rhinitis in children with epistaxis; the univariate analysis revealed significant differences between allergic-rhinitis group and nonallergic-rhinitis group in the number of allergens (P  <  0.001) and total IgE (P  <  0.001). The difference in severity of nasal symptoms between the two groups was statistically significant and included nasal obstruction (P  <  0.001), rhinorrhea (P  <  0.001), sneezing (P  <  0.001), and nasal itching (P  <  0.001). After adjusting for potential confounders, the severity of rhinorrhea symptoms was found to be associated with an increased risk of allergic rhinitis in children with epistaxis (odds ratio: 3.86; 95% confidence interval: 1.61-9.26; P = 0.003).

Conclusions

Observing the onset season, number of allergens, total IgE, and nasal symptoms in cases of epistaxis could suggest the presence of associated allergic rhinitis and reduce the number of missed diagnoses; antiallergic drugs could help control epistaxis in these cases.

Environmental factors differentially affect epistaxis among preschool and school-aged children

Introduction

Environmental factors are closely associated with pediatric epistaxis. Whether this association differs according to age has not been previously reported. Therefore, we tried to evaluate the differences in associations between environmental factors and epistaxis in children of different ages.

Methods

A total of 20,234 patients with epistaxis who visited the hospital between January 1, 2002, and December 31, 2015, were enrolled in this study. The patients were divided into two groups according to their ages: preschool-aged (<6 years) and school-aged children (6-18 years). Daily, monthly, and yearly data on environmental factors were collected. We performed a stepwise logistic regression to identify the potential environmental risk factors for epistaxis in each age group.

Results

The mean number of epistaxis cases per month in both groups was highest in September. The cases were lowest in February in preschool-aged children and in November in school-aged children. Temperature, humidity, maximum wind speed, and sunshine duration were associated with epistaxis in preschool-aged children. Average wind speed, particulate matter (>10 μm diameter), temperature, humidity, sunshine duration, and sulfur dioxide concentration were associated with epistaxis in school-aged children.

Conclusion

This study indicates that the differences in environmental risk factors for epistaxis are associated with the patient's age.

Knowledge and awareness of aetiological and risk factors as determinants of health-seeking pattern of parents of children with epistaxis in a tertiary health institution: A 7-year prospective study

Aim

This prospective study aimed to assess the knowledge and awareness of aetiological and risk factors as determinants of the health-seeking pattern of parents of children with epistaxis in a tertiary health institution.

Materials and Methods

This was a 7-year cross-sectional prospective study where copies of the questionnaire were distributed to consenting parents whose children presented to our institution with epistaxis between January 2015 and December 2021. A total of 570 parents were enrolled in the study in the research time period.

Results

Out of 570 patients, majority (39%) were aged between 11 and 15 years, followed by 35% aged between 6 and 10 years, 17% aged between 1 and 5 years and 11% aged between 16 and 18 years. Three hundred and eighty (66.67%) were male and 190 (33.33%) were female. Two hundred and ninety-five (51.75%) patients had primary education, followed by 189 (33.16%) patients with secondary education and 86 (15.09%) patients with preschool education. Three hundred and seventy-three (65.44%) patients had anterior bleeding and 107 (18.77%) patients had posterior bleeding while 90 (15.79%) patients had both anterior and posterior bleeding. The majority of the parents, 399 (70%), were aware about the epistaxis while 171 (30%) parents were unaware about the epistaxis.

Conclusion

A significant number of parents are unaware of the epistaxis and also unaware of the various aetiological and risk factors of the epistaxis and these issues need a more nuanced analysis in light of Africa's rich cultural diversity.

Impact of SARS-CoV-2 infection in patients with hereditary hemorrhagic telangiectasia: epidemiological and clinical data from the comprehensive Italian retrospective multicenter study

Rare Disease patients manifested high concern regarding the possible increased risk of severe outcomes and worsening of disease-specific clinical manifestation due to the impact of COVID-19. Our aim was to assess the prevalence, outcomes, and impact of COVID-19 in patients with a rare disease such as Hereditary Hemorrhagic Telangiectasia (HHT) in Italian population. A nationwide, multicentric, cross-sectional observational study was conducted on patients with HHT from five Italian HHT centers by online survey. The association between COVID-19-related signs and symptoms and nosebleeds worsening, the impact of personal protective equipment on nosebleeds pattern, and the relationship between the presence of visceral AVMs and severe outcomes were analyzed. Out of 605 total survey responses and eligible for analysis, 107 cases of COVID-19 were reported. A mild-course COVID-19 disease, not requiring hospitalization, was observed in 90.7% of patients, while the remaining eight cases needed hospitalization, two of them requiring intensive-care access. No fatal outcome was recorded and 79.3% of patients reported a complete recovery. No difference in infection risk and outcome between HHT patients and general population was evidenced. No significative interference of COVID-19 on HHT-related bleeding was found. The majority of patients received COVID-19 vaccination, with relevant impact on symptoms and need for hospitalization in case of infection. COVID-19 in HHT patients had an infection profile similar to the general population. COVID-19 course and outcome were independent from any specific HHT-related clinical features. Moreover, COVID-19 and anti-SARS-CoV-2 measures did not seem to affect significantly HHT-related bleeding profile.

Comparison of the Nasal Cavity Guidance Methods' Effects during Nasotracheal Intubation Using a Preformed Nasotracheal Tube: A Prospective Randomized Controlled Trial

Nasotracheal intubation is mainly performed to provide a safe airway during maxillofacial surgeries. Several guiding devices are suggested to facilitate nasotracheal intubation and reduce complications. We attempted to compare intubation conditions during nasotracheal intubation using a nasogastric tube and a suction catheter, which are readily available in operating rooms. In this study, 114 patients undergoing maxillofacial surgery were randomly divided into the nasogastric tube guidance group (NG group) and the suction catheter guidance group (SC group). The primary outcome was the total intubation time. Moreover, the incidence and degree of epistaxis, the position of the tube in the nasal cavity after intubation, and the number of manipulations during intubation in the nasal cavity were investigated. The insertion time from the nostril to the oral cavity and the total intubation time were significantly shorter in the SC group than in the NG group (p < 0.001). The incidence of epistaxis was lower at 35.1% in the NG group and 43.9% in the SC group than the previously reported 60-80%, but there was no statistical difference between the two groups. The use of a suction catheter aid during nasotracheal intubation can be used effectively because it shortens the intubation time and does not increase complications.

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.

[Epidemiology and modern methods of treatment of non-traumatic nosebleeds]

Data on the detection incidence of nosebleeds (NBs) of non-traumatic origin in the population show considerable variability in statistical indicators, and NBs treatment and consequences depend on the localization of hemorrhage source, the volume of blood loss, patient's general condition, the presence and nature of comorbid pathology and a number of other factors. There are some differences in the choice of NBs treatment options, evaluation of their clinical and economic efficiency, which indicates the need to analyze and systematize the results of such studies.

OBJECTIVE

To analyze data on prevalence and current treatment approaches of non-traumatic nosebleeds.

MATERIAL AND METHODS

The search for publications (articles and related abstracts) on the subject of the study, presented in the PubMed database, has been conducted. The choice of material was made according to the following key words: non-traumatic nosebleeds, causes, incidence, methods of stopping nosebleeds.

RESULTS

The literature data show a significant prevalence of NBs in the population, their potential hazard to the life of patient and the importance of clinical and demographic characteristics of persons for determining treatment tactics in each case. In practical terms, primary and secondary NBs should be distinguished. In case of primary NB, the use of coagulation and nasal packing is recommended after determining the place of bleeding. In secondary NB it is necessary to establish its cause in order to assess risk factors and apply appropriate topical or systemic drug therapy. The so-called difficult (difficult-to-treat) NBs deserve special attention. As a rule, these cases involve bleeding from the posterior parts of nose. The analysis of publications shows a high (90%) efficacy of surgical interventions, used as first-line treatment. Effectiveness of embolization in such cases was 75% and of anterior/posterior nasal packing was 62%.

CONCLUSION

The literature data show a significant prevalence of nosebleeds in the population and their potential hazard to the life of patient. The existing differences in the assessments of treatment options for this pathology, their clinical and economic efficiency are the basis for further research, in particular, to clarify the causes of nosebleeds' occurrence and recurrence, the impact of treatment methods on quality of patients' life.

Clinical analysis of delayed epistaxis following endoscopic sinus surgery

OBJECTIVE

To investigate the clinical characteristics and treatment methods associated with delayed epistaxis following endoscopic sinus surgery.

METHODS

The clinical data of 46 patients with delayed epistaxis following endoscopic sinus surgery were retrospectively analyzed. To explore the clinical features, pathogenesis, and treatment plan for delayed epistaxis, the postoperative bleeding time, bleeding inducements, systemic complications, surgical approach, the hemorrhage locations and responsible vessels, and treatment methods were analyzed.

RESULTS

The average bleeding time was 16.34 ± 9.05 days after the operation, and 76.6% of the cases occurred 6-20 days after the operation. Sphenopalatal artery hemorrhage accounted for 69.6% (32/46), the most common of which was a posterior nasal septal artery hemorrhage (17/32). A total of 45 patients received endoscopic low-temperature plasma hemostasis following ineffective nasal packing, and no rebleeding in the ipsilateral nasal cavity was observed during the postoperative follow-up for 3 to 6 months.

CONCLUSIONS

The peak of hemorrhaging in delayed epistaxis following endoscopic sinus surgery occurred at 6-20 days post-operatively. Bleeding of the posterior nasal septal artery from the sphenopalatine artery was the most common. Surgical methods were closely related to delayed postoperative hemorrhage. Treatment with low temperature plasma hemostasis under nasal endoscope was found to be effective.

Epistaxis in the Sars-CoV-2 Era

Introduction Epistaxis was the third most common unscheduled ENT surgical intervention in Ireland in 2019. Otorhinolaryngologists are exposed to a high viral reservoir of Sars-CoV-2, as they are dealing with pathology in the upper respiratory tract. Risk analysis is required to minimise nosocomial transmission. Methods A prospective audit of epistaxis management in the outpatients at a tertiary hospital was undertaken pre pandemic. A retrospective review of patients records during the Sars-CoV-2 pandemic. Comparative analysis was utilised to assess outcomes. Results Pre Sars-CoV-2 analysis revealed 14 patients (70%) were manged with rigid endoscopy compared to one (5%) interpandemic. Cauterization treated 20 patients (100%) pre pandemic and four patients (20%) interpandemic. Nasal packing modality differed in that 13 patients (65%) were treated with Nasopore pre pandemic and 14 (70%) with Rapid Rhino interpandemic. This exhibited a paradigm shift in that 18 (90%) patients were managed conservatively with nasal packing interpandemic. Conclusion A paradigm shift in the management of Epistaxis during the pandemic has led to treatment which is less invasive, has less morbidity for the patient, requires less hospital admissions and lessens nosocomial transmission of the Sars-CoV-2. Further study is required given the advent of vaccines and development of various strains Sars-CoV-2.

For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis

BACKGROUND

Nasotracheal intubation is usually required in patients undergoing oromaxillofacial, otolaryngological or plastic surgery to prevent the airway encroaching into the operating field. Epistaxis is the most common complication, but which nostril is associated with a lower incidence and severity of epistaxis is still unclear.

OBJECTIVE

When both nostrils are patent, to determine the preferred nostril for nasotracheal intubation under general anaesthesia.

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs). The primary outcome was the incidence of epistaxis and the secondary outcomes included the incidence of severe epistaxis, the time required to pass the tube through the nasal passage and total intubation time.

DATA SOURCES

PubMed, Embase and the Cochrane Register of Controlled Trials were searched from database inception to 1 March 2020.

ELIGIBILITY CRITERIA

The only studies included were RCTs comparing epistaxis related to nasotracheal intubation via right or left nostril, in adult surgery patients undergoing general anaesthesia.

RESULTS

Ten RCTs with 1658 patients were included. Compared with the left nostril, intubation via the right nostril was associated with a significantly lower incidence of epistaxis: risk ratio (RR) and 95% confidence intervals (CI) were 0.78 (0.62 to 0.99), P = 0.04: a lower incidence of severe epistaxis (five studies, n=923), RR 0.40 (0.22 to 0.75), P = 0.004: and a shorter intubation time (three studies, n=345), mean difference -7.28 (-14.40 to -0.16) seconds, P = 0.05. In two studies (n=310), no significant difference between the right and left nostril was observed in the time to pass the tube through the nasal passages, mean difference -0.59 (-1.95 to 0.77) s, P = 0.40.

CONCLUSION

On the basis of the current available evidence, when both nostrils are patent, the right nostril is more appropriate for nasotracheal intubation, with a lower incidence and severity of epistaxis and faster intubation time.

TRIAL REGISTRATION

The study protocol has been registered in PROSPERO (CRD42020169949).

Are laboratory evaluations required in every case admitted to the pediatric emergency department with epistaxis?

BACKGROUND

Epistaxis is a mostly self-limiting condition common among children and is rarely severe. In this study, it was aimed to evaluate the incidence, demographic characteristics, causes of bleeding and treatment methods of patients who presented to the pediatric emergency department (PED) with epistaxis, and to determine in which cases a laboratory test should be used.

METHOD

Admitted to Gazi University Faculty of Medicine, PED which provides trauma care and is a tertiary hospital, from 1 January 2019 to 31 December 2019, 452 patients aged 0-18 years who presented with epistaxis for any reason or secondary to systemic disease were analysed retrospectively.

RESULTS

The annual incidence was found at 1.23%. The median age was 5.25 years, 258 of the cases (57.1%) were male. It was found that the cases most frequently applied to the hospital in the autumn months (37.6%). Sixty of the patients (13.3%) had a chronic disease and 54 (11.9%) had a history of drug use. Bleeding time was less than 5 minutes in 75.2% and 84.4% of the bleeding was unilateral. Nasal bleeding is local in 73.4%; 4.7% of them developed because of systemic reasons. The most common cause of epistaxis; while they were trauma at the first 10 years of age, they were idiopathic causes after the age of 10 years. In 434 (96%) of the patients, epistaxis spontaneously stopped and there was no need for additional treatment.

CONCLUSION

As a result of this study, it was concluded that laboratory tests should be performed in cases with chronic disease history, bilateral bleeding, active bleeding and nontraumatic epistaxis. The situation that causes epistaxis in the childhood age group should be determined with a good history and physical examination, laboratory tests should not be used in every patient.

Prevalence of bleeding symptoms among young adults in Saudi Arabia, a national survey

Prevalence of bleeding disorders vary due to several factors including geographical location. Mild bleeding disorders can lead to iron deficiency, morbidity, and in severe cases mortality. Quantification of haemorrhagic symptoms is a key component in management of bleeding disorders and a challenging task for clinicians.An abridged version of MCMDM-1vWD questionnaire with validated Arabic translation was used to quantify bleeding disorders in adult students (n = 1138) in 4 different regions of Kingdom of Saudi Arabia. Statistical analysis was performed to indicate gender disparity and prevalence.74.5% of respondents answered at least 1 question with affirmation, with 32.3% affected in Riyadh showing the highest prevalence and 14.03% affected in Dammam showing the least prevalence (P-value < .001). Gender-wise, higher prevalence of bleeding disorders in females 54.9% than in males 45.1% was observed (P-value .01). Epistaxis prevalence was significantly higher in males 30.7% vs 23.2% in females (P-value .0004), while cutaneous symptoms were reported significantly more by female participants 29.7% vs 12.3% in males (P-value < .001). Menorrhagia was reported by 28% of females, with heavy bleeding experienced by 57.6% female participants for <7 days while in 42.4% of females for >7 days.The current study signifies the ethnic distribution and gender disparity of mild bleeding disorders, and highlights the need for national surveillance system in order to improve management of patients with bleeding disorders.

Prevalence of bleeding symptoms among young adults in Saudi Arabia, a national survey

ABSTRACT

Prevalence of bleeding disorders vary due to several factors including geographical location. Mild bleeding disorders can lead to iron deficiency, morbidity, and in severe cases mortality. Quantification of haemorrhagic symptoms is a key component in management of bleeding disorders and a challenging task for clinicians.An abridged version of MCMDM-1vWD questionnaire with validated Arabic translation was used to quantify bleeding disorders in adult students (n = 1138) in 4 different regions of Kingdom of Saudi Arabia. Statistical analysis was performed to indicate gender disparity and prevalence.74.5% of respondents answered at least 1 question with affirmation, with 32.3% affected in Riyadh showing the highest prevalence and 14.03% affected in Dammam showing the least prevalence (P-value < .001). Gender-wise, higher prevalence of bleeding disorders in females 54.9% than in males 45.1% was observed (P-value .01). Epistaxis prevalence was significantly higher in males 30.7% vs 23.2% in females (P-value .0004), while cutaneous symptoms were reported significantly more by female participants 29.7% vs 12.3% in males (P-value < .001). Menorrhagia was reported by 28% of females, with heavy bleeding experienced by 57.6% female participants for <7 days while in 42.4% of females for >7 days.The current study signifies the ethnic distribution and gender disparity of mild bleeding disorders, and highlights the need for national surveillance system in order to improve management of patients with bleeding disorders.

A case series and review of the mononostril endoscopic transnasal transsphenoidal approach: Safe and effective in a low resource setting

BACKGROUND

A transnasal transsphenoidal (TNTS) approach can be performed through a binostril or mononostril technique. The binostril technique is generally preferred, however the mononostril may be an underutilized approach with significant benefits.

METHODS

All (n = 521) pituitary adenoma transsphenoidal surgeries performed from March 2008 until July 2017 at a university hospital in Indonesia were isolated. The majority (n = 512) were performed through a mononostril approach with no nasal speculum by a single experienced neurosurgeon. A PubMed literature review researching the differences in indications, techniques, and outcomes for both approaches supplements the case series. The mononostril surgical technique is described in detail.

RESULTS

The average mononostril operating time was 105 min. The most prevalent surgical complications were CSF leak (4.1 %), diabetes insipidus (3.7 %) and cacosmia (2.1 %). Visual field deficits noted in 85 %, 89 % improved. Length of stay was less than 2 days for 90 %, with 13 ICU admissions (average one day). Recurrence rate was 8.2 % at follow up (1-10 years).

CONCLUSIONS

Based on a literature review, binostril TNTS surgeries have longer operative time and a higher risk of epistaxis. According to our experience, post-operative patient comfort and satisfaction are higher with the monostril approach. Furthermore, this technique is easier to teach, ENT assistance unnecessary, and thus especially advantageous in low resource settings. Our CSF leak and tumor recurrence rates were lower than reported binostril rates in the literature. The mononostril technique is both safe and effective and should be strongly considered for an appropriately pre-selected subset of pituitary adenomas.

Epistaxis as a marker for severe acute respiratory syndrome coronavirus-2 status - a prospective study

OBJECTIVE

To evaluate the prevalence of severe acute respiratory syndrome coronavirus-2 infection in patients presenting with epistaxis to a tertiary otolaryngology unit.

METHODS

A prospective study was conducted of 40 consecutive patients presenting with epistaxis referred to our tertiary otolaryngology unit. A group of 40 age-matched controls were also included. All patients underwent real-time reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus-2. Symptoms of fever, cough and anosmia were noted in the study group.

RESULTS

The mean age was 66.5 ± 22.4 years in the study group. There were 22 males (55 per cent) and 18 females (45 per cent). The mean age in the control group was 66.3 ± 22.4 years (p = 0.935). There were six positive cases for severe acute respiratory syndrome coronavirus-2 (15 per cent) in the epistaxis group and one case (2.5 per cent) in the control group. The difference was statistically significant (p = 0.05).

CONCLUSION

Epistaxis may represent a presenting symptom of severe acute respiratory syndrome coronavirus-2 infection. This may serve as a useful additional criterion for screening patients.

Frontal sinus "mega-trephination" in a tertiary rhinology practice

BACKGROUND

Frontal sinus trephination is traditionally performed through a small cutaneous incision and osteotomy, allowing irrigation of the frontal sinus. Utilizing the trephination osteotomy for endoscopic visualization and surgical manipulation requires a larger opening. This "mega-trephination" is thought to carry an increased risk of cosmetic deformity given the increased bony removal at the anterior table. The purpose of our study was to clarify the risks of frontal sinus mega-trephination and examine how this technique is incorporated into a modern, tertiary care rhinology practice.

METHODS

Patients were identified through billing records and confirmed by retrospective chart review. All patients underwent frontal sinus mega-trephination, which is defined as an osteotomy large enough for insertion of a 4-mm endoscope and an operative instrument simultaneously. All patients had at least 2 years of follow-up. The primary outcome was complication rate, including cosmetic deformity.

RESULTS

Sixty-four patients underwent frontal sinus mega-trephination from 2006 to 2016. The most common surgical indications were chronic sinusitis (34%), mucocele (19%), osteoma (17%), acute sinusitis (11%), and inverting papilloma (9%). Ten patients (16%) underwent mega-trephination alone, whereas the others had mega-trephination with endoscopic sinus surgery. Twenty-one patients (33%) had minor complications. The most common complications were self-limited paresthesia (11%), infection (8%), and epistaxis (3%). No patient complained of permanent cosmetic deformity or required revision surgery for cosmesis.

CONCLUSION

Frontal sinus mega-trephination is a useful tool to augment the rhinologist's armamentarium in complex frontal sinus anatomy and pathology. This procedure is well tolerated, safe, and not associated with long-term cosmetic deformity.

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.

Clinical features of nasal and sinonasal inverted papilloma associated with malignancy

OBJECTIVE

Nasal and sinonasal inverted papilloma (IP) are rare benign tumors and have the potential to exhibit malignancy in approximately 10% of cases. This study aimed to analyze the clinical features of IP associated with malignancy. Furthermore, we reviewed our therapeutic strategy and the clinical course of malignant IP.

METHODS

Overall, 70 patients with IP at our institution were retrospectively analyzed from April 2006 to December 2015; of these, six (9%) had associated malignancy. Data was collected on sex, age, presenting symptoms (nasal bleeding, rhinorrhea, facial or cheek pain, and nasal obstruction), bone destruction, and extent of disease on CT and MRI. Categorical data of patients with and without malignancy were compared using the chi-square test. A p value of <0.05 was considered statistically significant. Our therapeutic strategy for IP with malignancy, particularly the surgical procedure, i.e., the external incision or the endoscopic nasal approach, varied based on when the carcinoma was detected. In addition, we considered postoperative radiation therapy depending on histological examination.

RESULTS

Nasal bleeding (p<0.001), pain (p=0.040), bone destruction (p<0.001), and extent of disease (p=0.026) on CT and MRI findings were significantly associated with malignancy. Carcinoma was diagnosed preoperatively in two (33%) and postoperatively in four patients (67%). We operated five patients (one case was not treated because of end-stage pancreatic cancer). Two patients underwent endoscopic sinus surgery (ESS) alone, two ESS plus Denker's method, and one ESS plus anterior craniotomy. Three patients underwent surgery only, and two patients received postoperative radiotherapy. The median follow-up period was 69.3 months. One patient died of the disease and the remaining patients are alive without recurrence.

CONCLUSION

For IP patients exhibiting these clinical findings preoperatively, we should suspect complication with malignancy and plan a treatment. Even if postoperative histology does not confirm malignancy, we should ensure careful observation because of metachronous malignant transformation or the possibility to overlook small malignant lesions. Our result suggests that our strategy for malignant IP could be a reasonable option.

Manifestation of granulomatosis with polyangiitis in head and neck

OBJECTIVES

Granulomatosis with polyangiitis is a rare autoimmune disease of the group of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Involvement of the ear, nose and throat (ENT)-region is only described in a few case series and case reports. The objective of this study is to systematically characterise the ENT-involvement in a large series of GPA patients.

METHODS

GPA patients examined in the Department of Otorhinolayngology of the Christian-Albrechts-University of Kiel between 1990 and 2012 were included. Diagnosis was based on histological, serological and clinical parameters. GPA patients were examined in a standardised way based on the Ear Nose and Throat Activity Score (ENTAS) or its precursor. Medical history, ENT examination, diagnostic findings (ear, nose) and cranial radiology were documented cumulatively.

RESULTS

A total of 230 GPA patients were included in this study. Over 95% of them showed ENT-involvement. 59% of the patients showed nasal obstructions, 57% a loss of smell. A hearing loss was diagnosed in 23% of the patients, 50% involvement in MR or CT scans and 15% showed laryngeal involvement.

CONCLUSIONS

The data of the largest monocentric study presented here demonstrate a frequent ENT-involvement in GPA patients. Rhinological and ontological manifestations are most common.

Incidence of epistaxis after endoscopic pituitary surgery: Proposed treatment algorithm

Endoscopic transsphenoidal surgery for pituitary tumors is an increasingly common practice. Little has been reported on the incidence and treatment of postoperative epistaxis in this population. The aim of this study was to analyze the incidence of postoperative epistaxis and formulate a treatment algorithm based on our experience. We performed a case series with chart review. A total of 434 consecutive patients who had endoscopic transsphenoidal pituitary surgery were identified between April 2006 and November 2013. The incidence, clinical management, and outcomes were recorded. Based on the data, a treatment algorithm was constructed. Fifty-two percent of patients treated were female (mean age: 51.4 years). Tumor types included pituitary adenomas (73.3%), Rathke cleft cysts (19.6%), and other pathologies (6.7%). Eighteen patients reported an epistaxis event within 6 weeks of surgery (4.1%). Treatment included office cauterization in 7 (1.6%) patients, a return to the operating room for 5 (1.2%), nasal packing in 3 (0.7%), embolization in 2 (0.5%), and use of intranasal hemostatic agents in 1 (0.2%). Epistaxis after endoscopic pituitary surgery is concerning for rapid blood loss and risk of intracranial complications. Fortunately, in the absence of new cranial nerve palsy, most bleeding can be controlled with conservative measures such as topical cautery, hemostatic agents, and nasal packing. An algorithm is presented to help guide physician decision making in this clinical scenario.

An Epistaxis Emergency Associated with Multiple Pollutants in Elementary Students

Emergencies of epistaxis in students caused by environmental pollution have rarely been reported to date. This study aimed to explore the cause of an emergency of epistaxis in elementary students by using a field epidemiological investigation. Twenty-two epistaxis cases from a single school with differences in gender, age, and classroom, were diagnosed within a period of 7 days. The air concentration of chromic acid mist (Cr6+) in the electroplating factory area, new campus, and residential area exceeded the limit of uncontrolled emissions. The emission of HCL and H2SO4 was also observed. Formaldehyde levels in the classrooms exceeded the limits of indoor air quality. Abnormal nasal mucosa was significantly more frequent in the case group (93.3%) and control group 1 (of the same school) (66.7%) than in control group 2 (from a mountainous area with no industrial zone) (34.8%; P < 0.05 and P < 0.01, respectively). On the basis of the pre-existing local nasal mucosal lesions, excessive chromic acid mist in the school's surrounding areas and formaldehyde in the classrooms were considered to have acutely irritated the nasal mucosa, causing epistaxis. Several lessons regarding factory site selection, eradication of chemical emissions, and indoor air quality in newly decorated classrooms, should be learned from this emergency.

Is blood type really a risk factor for epistaxis?

Is blood type really a riskfactorfor epistaxis?

OBJECTIVES

To determine the association between ABO blood type and epistaxis.

METHODS

This retrospective study involved 359 patients with idiopathic epistaxis. Patients with risk factors for bleeding, including anticoagulant use, thrombocytopenia, hypertension, liver diseases, elevated bleeding time, low coagulation factor levels, or any benign/malignant tumor, were excluded from the study. Thus, only patients with idiopathic epistaxis were included in this study. For the control group, blood-type information was retrieved from the database of the Turkish Red Crescent, the largest blood bank in Turkey.

RESULTS

The distributions of blood types A, B, AB, and 0 were compared between the epistaxis and control groups. The distribution of blood types A and AB did not significantly differ between the epistaxis and control groups (P>0.05). Blood type B occurred significantly less frequently (P<0.05) and blood type 0 occurred significantly more frequently (P<0.001) in the epistaxis group than in the control group.

CONCLUSIONS

Our study indicates that in the Turkish population, the 0 blood type is over-represented in patients with idiopathic epistaxis versus the general population. We conclude that blood type 0 is a risk factor for idiopathic epistaxis in the Turkish population.

[Risk Factors for Re-bleeding after the Treatment of Epistaxis]

Epistaxis is the most frequent, but readily treatable rhinological emergency. However, epistaxis can be difficult to control and can require hospitalization. First-line treatments sometimes fail and episodes of epistaxis recur. The present study assesses factors involved in being hospitalized for epistaxis or re-bleeding after treatment. 　This retrospective study enrolled 923 patients (male, n=628 [57.3%]; female, n=468 [42.7%]; mean age, 58.3 [range, 1-98] years) who were treated for 1,096 episodes of epistaxis at Okayama Saiseikai General Hospital between January 2006 and December 2013. Among the 1,096 episodes, 66 (6.0%) required hospitalization and 135 (12.3%) recurred. Patients with bleeding points other than the nasal septum, who were treated with gauze packing, who had a history of hypertension or other heart diseases, who were receiving anticoagulant therapy and who were treated by a family doctor before the initial visit, tended to require treatment with hospitalization. Bleeding points other than the nasal septum, a medical history of hypertension, and treatment with gauze packing were significant risk factors for re-bleeding. In conclusion, these factors should be considered before treating and admitting epistaxis patients to hospital.

Why do geriatric patients visit otorhinolaryngology?

The number and proportion of people more than 65 years old in the population are increasing with the rise in life expectancy. This study was designed to investigate the otolarygologic needs and visits of geriatric patients. We conducted a retrospective study that included all patients ≥65 years of age who visited the otolaryngology department between 8 a.m. and 4 p.m. during 1 year. Age, gender, main complaint, and clinical diagnosis were noted on a chart and analyzed. In 2012, a total of 19,875 patients attended the otolaryngology department between 8 a.m. and 4 p.m., of whom 418 (2.1%) were aged ≥65 years. The most common complaints were ear and hearing disorders (24.2%), epistaxis(15.3%), balance disorders (15.1%), pharyngotonsillar pathologies (14.8%), and head and facial trauma (9.6%). This study shows that the changing patient population will change the type and frequencies of pathologies seen in general otolaryngology practices. Geriatric patients need a targeted approach to their diseases because they have special issues unique to their population.

Inpatient management of epistaxis: Outcomes and cost

OBJECTIVE: Evaluate treatments for epistaxis.

STUDY DESIGN AND SETTING: Retrospective review of Nationwide Inpatient Sample (1998-2000).

RESULTS: A total of 9778 admissions with admitting diagnosis “epistaxis” were identified. Among admissions involving 1 treatment, 454 (9.6%) received arterial ligation, 94 (2.0%) embolization, and 4188 (88.4%) nasal packing. There were no differences in length of stay, transfusions, complications, or deaths between groups (all P >0.05). Mean total hospital charges were $6,282 for the packing group, $12,805 for the ligation group, and $17,517 for the embolization group; differences between ligation and packing groups, and embolization and packing groups demonstrated significance ( P >0.05).

CONCLUSIONS: Nasal packing is used commonly for epistaxis that requires inpatient management. Although embolization and arterial ligation are associated with higher hospital charges, complications, transfusion rates, and lengths of stay are similar. Further studies are needed to quantify other outcome measures, such as recurrence rates and patient quality of life.

SIGNIFICANCE: Nasal packing is associated with lower hospital charges and similar complication rates as arterial ligation or embolization. (Otolaryngol Head Neck Surg 2005;132:707-12.)

Change in and long-term investigation of neuro-otologic disorders in disaster-stricken Fukushima prefecture: retrospective cohort study before and after the Great East Japan Earthquake

On March 11, 2011, Japan's northeast Pacific coast was hit by a gigantic earthquake and subsequent tsunami. Soma City in Fukushima Prefecture is situated approximately 44 km north of Fukushima Daiichi Nuclear Power Plant. Soma General Hospital is the only hospital in Soma City that provides full-time otolaryngological medical care. We investigated the changes in new patients from one year before to three years after the disaster. We investigated 18,167 new patients treated at our department during the four years from April 1, 2010 to March 31, 2014. Of the new patients, we categorized the diagnoses into Meniere's disease, acute low-tone sensorineural hearing loss, vertigo, sudden deafness, tinnitus, and facial palsy as neuro-otologic symptoms. We also investigated the changes in the numbers of patients whom we examined at that time concerning other otolaryngological disorders, including epistaxis, infectious diseases of the laryngopharynx, and allergic rhinitis. The total number of new patients did not change remarkably on a year-to-year basis. Conversely, cases of vertigo, Meniere's disease, and acute low-tone sensorineural hearing loss increased in number immediately after the disaster, reaching a plateau in the second year and slightly decreasing in the third year. Specifically, 4.8% of patients suffering from these neuro-otologic diseases had complications from depression and other mental diseases. With regard to new patients in our department, there was no apparent increase in the number of patients suffering from diseases other than neuro-otologic diseases, including epistaxis, and allergic rhinitis. Patients suffering from vertigo and/or dizziness increased during the first few years after the disaster. These results are attributed to the continuing stress and tension of the inhabitants. This investigation of those living in the disaster area highlights the need for long-term support.

Idiopathic epistaxis and meteorological factors: case-control study

OBJECTIVE

The aim of this study was to determine the relationship between the occurrence of idiopathic epistaxis and daily values of air pressure, temperature, and humidity. We also investigated whether biometeorological forecasts should be addressed to persons with a history of nosebleed diathesis.

METHODS

We analyzed consecutive idiopathic epistaxis events over a 3-year period. Patients were included if they had been in the municipality of Mostar, Bosnia and Herzegovina at least 24 hours before the epistaxis occurrence. The monthly variation in epistaxis events was determined. Epistaxis days (Days "0", 0 = day with epistaxis occurrence) and selected nonepistaxis days (Days "-1", -1 = each first single day without epistaxis prior to Day 0) were compared according to daily values of mean, minimum, and maximum temperature; diurnal temperature range; minimum and maximum atmospheric pressure; diurnal pressure range; and mean relative humidity.

RESULTS

The greatest and smallest percentage of epistaxis events occurred in the months of March and August, respectively. There were no significant differences between Days 0 and Days -1 with respect to the examined meteorological factors.

CONCLUSION

In this region with a Mediterranean climate, we found a seasonal variation with an incidence peak during the spring transition months, but we did not identify any meteorological trigger factors for epistaxis. Thus, there is no need for biometeorological forecasts to be addressed to persons with a history of nosebleed diathesis.

Idiopathic thrombocytopenic purpura in children: a 10 years experience at tertiary care hospital

OBJECTIVE

To evaluate presenting features, treatment modalities and response to therapy in children with idiopathic thrombocytopenic purpura.

METHODS

The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised clinical data, presenting demographics, clinical spectrum, management and outcome of children admitted with idiopathic thrombocytopenic purpura from 2001 to 2010. SPSS 20 was used for statistical analysis.

RESULTS

Records of 95 children between 0-15 years in the period 2001 to 2010 were reviewed. The overall mean age at the time of presentation was 6.1±3.8 years. There were 45(47.3%) male and 50(52.7%) female cases. A total of 34(35.8%) patients had history of preceding illness. Regarding clinical presentations, bruises 81(85.3%), petechial rash 75(79%), epistaxis 23(24%) were common. Median platelet count at the time of presentation was 5,000 (Inter-quartile range: 4000-13,000). Spontaneous recovery was seen in 7(7.4%) children. Overall, 24(25.2%) patients received intravenous immunoglobulin G and only 19(20%) showed complete response. Besides, a total of 32(33.7%) patients did not respond and only 5(5.3%) developed chronic ailment.

CONCLUSION

Bruises, petechial rash and epistaxis were the common presentations. Overall prognosis was good.

Epistaxis and its Management in a Tertiary Health Facility in Nigeria:A need for thorough Evaluation

BACKGROUND

Epistaxis is one of the most common acute otorhinolaryngologic emergency disorders

OBJECTIVE

To review the aetiological profile, management and outcome of epistaxis in a resource challenged environment in Nigeria Methods: A retrospective review of patients that were managed for epistaxis over a five year period

RESULTS

A total of 88 patients with an incidence of 18/1000 consisting of 53 males M:F ratio 1.5:1. The age ranged from 2- 68 years and age group 0-10 years was the most affected 29 (33%). Majority 73.9% presented during hot, dry season. Larger proportion (60.2%) was due to Idiopathic cause followed by trauma (11.4%). Over 47% has systemic illnesses that were incidentally discovered. Anterior nasal packing was the most common treatment modality in 46 (52.3%) patients. Thirty three (37.5%) patients were admitted either due to severe anaemia necessitating blood transfusion or due to underline medical condition. Eight (9.1%) patients had blood transfusion.

CONCLUSION

Epistaxis is a common otorhinolaryngologic emergency among the children and the young adult in Africa with highest prevalence during the dry season. A deliberate effort to find the cause of epistaxis is hereby advocated as poverty and ignorance usually prevent most of our patients with underlying medical condition to present until they are in critical emergency situation.

Hemorrhage-adjusted iron requirements, hematinics and hepcidin define hereditary hemorrhagic telangiectasia as a model of hemorrhagic iron deficiency

Background

Iron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT).

Methodology/Principal Findings

The hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin² explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped.

Conclusions/significance

HAIR values, providing an indication of individuals’ iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses.

Effect of temperature and humidity on epistaxis in Hazara division

BACKGROUND

Epistaxis is one of the commonest ENT emergencies and is experienced by up to 60% of people in their lifetime, with 6% requiring medical attention. The objective of the study was to determine the frequency of primary epistaxis and its relationship with temperature and relative humidity.

METHODS

This cross sectional study included 460 patients with epistaxis attending the ENT Department of Ayub Medical College, Abbottabad. Daily temperature and humidity record was obtained from the department of Hydrology and Meteorology of Hazara Division. The results of four hundred and sixty patients were analyzed for the effect of temperature and humidity on the frequency of epistaxis. Data was analysed using SPSS-11. Pearson's r was calculated to determine correlation between different variables.

RESULTS

A total of 460 patients were included, out of which 206 (44.8%) had primary epistaxis. The frequency of primary epistaxis was seen to be higher during the cold period from October to March. Statistical analysis showed good negative correlation between temperature and primary epistaxis (r = -0.948) while average correlation with humidity (r = -0.445).

CONCLUSION

The relationship between temperature and primary epistaxis was good while that with relative humidity was average.

Is epistaxis associated with arterial hypertension? A systematic review of the literature

Both epistaxis and hypertension are frequent problems in the adult population. The relationship between the level of arterial pressure and incidence of epistaxis in a patient with hypertension is a question that appears frequently in the clinical practice. A systematic review of the literature regarding the relation of arterial hypertension with epistaxis was performed through MEDLINE and EMBASE. All studies, whether examining the correlation of arterial pressure at presentation of a patient with nasal bleeding or the repercussion of episodes of epistaxis in hypertensive patients, were included in this review. Studies were evaluated independently by two reviewers according to a standard evaluation form. Overall, nine studies fulfilled our inclusion criteria. Five of them were single-group (patient) studies, while the remaining four included a control group. In eight studies, the patient group included patients with epistaxis, while one focused on hypertensive patients. Six out of nine studies agree that arterial pressure is higher at the time of epistaxis, as compared to the control group or to the general population. Seven out of nine studies conclude that there is cross-correlation between arterial pressure and the actual incident of epistaxis. The presence of high arterial blood pressure during the actual episode of nasal bleeding cannot establish a causative relationship with epistaxis, because of confounding stress and possible white coat phenomenon, but may lead to initial diagnosis of an already installed arterial hypertension.

Epistaxis in children under the age of two: possible marker of abuse/neglect? A retrospective study in North-Eastern Piedmont hospitals

AIM

Epistaxis is an extremely common event at all ages; however, under two years of age epistaxis is a very rare event and recent studies carried out in Great Britain concern this event as related to possible non-accidental trauma. To date, no other studies carried out in Italy are available on this topic.

METHODS

A file review of all cases of epistaxis occurred in children under the age of 2 who were admitted into the ED in our area over a period of two years was carried out.

RESULTS

We have collected data concerning 10 cases of epistaxis occurred in children under 2 years of age with an incidence of 10.4 cases per 10000 accessions to the ED of children under the age of 2. Four of the cases had attendances for head injury or facial trauma.

CONCLUSION

The results obtained are higher than the results of the British studies adopting the same methodology, but comparable to their surveillance data on the general population. Through the analysis of the collected data, two correlated assumptions have been made: a possible relationship between epistaxis and neglect, and a relation between epistaxis and domestic accidents.

Clinical profile of idiopathic epistaxis in a hospital

INTRODUCTION

Epistaxis is a common otolaryngological emergency but most of the cases are idiopathic. This study was done to assess clinical profile in patients with idiopathic epistaxis.

METHODS

Patients presenting in ENT outpatient department or emergency with epistaxis and no definite cause were selected. Patients demographic data, present and past history was recorded. All patients underwent anterior rhinoscopy and rigid nasal endoscopy.

RESULTS

There were 142 patients with epistaxis without definite cause. Age ranged from 11 to 84 years with mean 32.8 years. Approximately two-third were male. Bleeding from right side was seen in 64 (45.0%) patients. Past history of bleeding was given by 79 (55.6%) patients and out of them 60 (75.9) % had bleeding from same side. Presentation was mostly in months of January to March. Bleeding point was seen in 65 patients. Most of them (37/65) was in Little's area. Deviated nasal septum was seen in 102 patients. More than half of patients with unilateral bleeding were having bleeding from convex side of deviation. Blood pressure was found to be equal or more than 140/90 mm Hg in 55 (38.7%) patients at the time of presentation. Antihypertensive was required in less than half of these patients.

CONCLUSION

Idiopathic epistaxis is common in male, in winter season and in right side and from nasal septum. Hypertension may be found at presentation but most of them don't need antihypertensive.

[The significance of bleeding disorders in patients with epistaxis]

BACKGROUND

Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction.

METHOD

A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis.

RESULTS

A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both.

CONCLUSION

The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.

The effects of Vaseline gauze strip, Merocel, and Nasopore on the formation of synechiae and excessive granulation tissue in the middle meatus and the incidence of major postoperative bleeding after endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) has become the widely accepted procedure for the treatment of medically refractory chronic rhinosinusitis and nasal polyps. Nasal packing is usually placed after ESS to prevent synechia formation and postoperative bleeding and to support wound healing. The aim of this study was to evaluate the effects of three different nasal packing materials [Vaseline gauze strip, Merocel (Metronic Xomed, Jacksonville, FL, USA), and Nasopore (Polyganics, Rozenburglaan, Groningen, The Netherlands)] on the formation of synechiae and excessive granulation tissue in the middle meatus and incidence of major postoperative bleeding in patients who had undergone ESS.

METHODS

A total of 626 patients (1,018 sides) who had undergone ESS were studied retrospectively. Each patient chose one of the three different nasal packing materials according to his or her own preference. The outcome variable was the formation of synechiae and excessive granulation tissue in the middle meatus, which was identified from the medical records of endoscopic evaluations performed 3-4 weeks and 10-12 weeks after surgery. Major postoperative bleeding within 2 weeks after the operation was also documented for analysis. Finally, multiple logistic regression models were used to confirm the results of this study.

RESULTS

We did not observe significant intergroup differences in the effect on the formation of synechiae in the middle meatus. Nasopore packing showed a trend toward causing the formation of excessive granulation tissue during the early stages of wound healing (p=0.004). Patients who had received packing with Nasopore had a greater chance of undergoing readmission or additional packing because of major nasal bleeding within the first 2 weeks after the operation (p=0.03). Multivariable logistic regression models showed that Nasopore was a significant factor for the formation of excessive granulation tissue at 3-4 weeks after the operation (p=0.022) and for major postoperative nasal bleeding within the first 2 weeks after the operation (p=0.023).

CONCLUSION

Among patients who had undergone ESS for rhinosinusitis with or without polyps, the incidence of synechiae and excessive granulation tissue in the middle meatus and major postoperative bleeding in the patients who received Vaseline gauze packing was equivalent to the incidence of these complications in the patients who received Merocel. Nasopore was not superior to the other two nonabsorbable packing materials.

[Epistaxis: diagnosis and therapy]

Epistaxis or nosebleed is one of the most frequent emergencies in otorhinolaryngology. It is clearly an important condition--not only to the ear-nose-throat (ENT)-specialist but also to any general practitioner. This review looks at the aetiology, associated clinical considerations and evolution of its management. Intractable epistaxis requires a broad armamentarium of different diagnostic and therapeutic options.

Analysis of risk factors associated with recurrence of nasopharyngeal angiofibroma

OBJECTIVE

Surgical outcomes and prognostic factors were analyzed to determine what factors increase the probability of juvenile nasopharyngeal angiofibroma (JNA) recurrence.

METHODS

Ninety-seven males with JNA were diagnosed and underwent surgery at Fudan University Affiliated Eye, Ear, Nose and Throat Hospital from 1997 to 2006. Clinical data were extracted from medical records and were used in the statistical analysis.

RESULTS

The total recurrence rate of JNA was 39.2% after the initial surgery. A patient whose tumour staging was higher was more likely to have a recurrence than a patient whose tumour staging was lower (p = .0031). The recurrence rates in two groups (age >or= 18 years group and < 18 years group) were 26.8% and 48.2%, respectively (p = .03). The recurrence rates with tumour size < 4 cm and >or= 4 cm were 21.7% and 54.9%, respectively (p = .0008).

CONCLUSION

The significant predictors of recurrence in our study were age at diagnosis, tumour size, and Radkowski classification.

Risk factors for epistaxis on British racecourses: evidence for locomotory impact-induced trauma contributing to the aetiology of exercise-induced pulmonary haemorrhage

REASONS FOR PERFORMING STUDY

The proposed biological mechanisms for exercise-induced pulmonary haemorrhage (EIPH) are many and varied. Better knowledge of risk factors should lead to achievable measures to reduce the incidence.

OBJECTIVES

To identify risk factors associated with epistaxis following racing in UK Thoroughbreds, to gain possible insights into the pathogenesis of the condition and to investigate the association between epistaxis and race finishing position.

METHODS

The association of epistaxis occurring on UK racecourses between 1996 and 1998 with a wide range of race-, horse- and start-level variables was examined in multivariable mixed effect logistic regression analyses. Four multivariable analyses were conducted, one for all race types considered collectively and one each for flat, hurdle and steeplechase race types considered separately.

RESULTS

Risk of epistaxis was significantly increased for hurdle and steeplechase race types compared to both flat and National Hunt flat races. In 3 of the 4 final models, there was a significant biological trend for increasing risk of epistaxis with increasing ground hardness ('going') and accumulated years spent racing. However, in flat races epistaxis was such a rare outcome (0.33 cases per 1000 starts) that this subset analysis had insufficient power to measure the detectable effect of 'going' as statistically significant. Horses with epistaxis were significantly more likely to have a poorer finishing position than those without blood at the nostrils.

CONCLUSIONS

Findings were consistent with the theory that locomotory impact-induced trauma contributes to exercise-induced epistaxis. Further validation of this hypothesis through application of similar methods to endoscopically visible EIPH and through biomechanical studies is warranted.

POTENTIAL RELEVANCE

Knowledge of significant risk factors should allow formulation of practical measures, such as track watering, to reduce the risks of EIPH and epistaxis in racehorses.

Epistaxis in a low level hydrogen fluoride exposed industrial staff

OBJECTIVES

To assess the effect of exposure to hydrogen fluoride (HF) on the airway mucosa in an industrial setting.

METHODS

A cross-sectional study encompassing 33 industrial workers in a flame soldering plant and 44 assembly workers unexposed to HF was performed by means of a questionnaire on symptoms and diagnosis regarding upper and lower airways as well as through conduct of a clinical examination of the exposed group. Air concentrations of HF that were monitored in winter amounted to 1.0 mg/m(3) and in summer time to 0.15 mg/m(3).

RESULTS

A threefold risk for epistaxis (RR = 3.6, 95% confidence interval 1.1-11.0) was observed in the exposed group. Time from the start of exposure to HF until debut of a nose bleeding period varied from 1 month to 6 years. Mean induction (latency) time was 42 months. Mean duration of symptoms was 26 months, range 3-72 months, indicating that the exposure level in summer time was sufficient to maintain the propensity of almost daily nose bleeding.

CONCLUSION

HF is an irritating vapor, even at relatively low air concentrations. We recommend an 8 hr TLV lower than 1.0 mg/m(3).

Relationship between epistaxis and hypertension: a study of patients seen in the emergency units of two tertiary health institutions in Nigeria

BACKGROUND

Both epistaxis and hypertension are common in the general population.

OBJECTIVE

This study aimed at determining the prevalence of hypertension among epistaxics, and the relationship between epistaxis and hypertension.

METHODS

Retrospective analysis of 62 adults comprising 31 each of males and females with a mean age of 41.4 +/- 16.6 years (range: 18-90 years) that presented in the emergency units of two tertiary health institutions seen over 11 years was done. Main outcome measure was the prevalence of hypertension amongst epistaxics. Seventy-six age and sex-matched patients with bleeding from sites other than the nostrils with no record of epistaxis were selected by simple random sampling as controls.

RESULTS

Peak prevalence of epistaxis occurred during the months of January and March. Compared to the controls, the epistaxics had significantly higher blood pressures: (146.1 +/- 40.7 mmHg versus 123.2 +/- 16.3 mmHg systolic, P=0.001), and (91.3 +/- 24.8 mmHg versus 78.2 +/- 12.8 mmHg diastolic, P=0.001), and higher proportions of patients with previous history of hypertension (32.3% versus 7.9%; p<0.001) and family history of hypertension (12.9% versus 2.6%; p<0.02). The proportion of subjects with blood pressure elevation at presentation that remained sustained was significantly higher among the epistaxics than the nonepistaxics (87.5% versus 47.6%, chi2=8.1, P=0.005). The epistaxics had significantly higher prevalence of hypertension than the non-epistaxics (45.2% versus 13.2%, chi2=17.5, p=0.001). Univariate analysis demonstrated association between epistaxis and hypertension (OR=5.4, 95% CI=2.4-12.5, P=0.001), and between epistaxis and age (OR=0.9, 95% CI=1.3-12.5, P=0.02). On multivariate analysis using logistic regression the association between epistaxis and hypertension persisted, after adjusting for age, sex, season and causes of epistaxis (OR=5.6, 95% CI=1.7-15.6, P=0.01).

CONCLUSIONS

Our findings support an association between epistaxis and hypertension in the study population.