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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.
OBJECTIVE: To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis. STUDY DESIGN: A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997-2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded. SETTING: A tertiary referral centre in south-west London serving a population in excess of 2.8 million. METHOD: A retrospective analysis of all patients presenting or admitted to St George's Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearson's correlation coefficient was performed. RESULTS: 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series. CONCLUSION: To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.
STUDY OBJECTIVE: We sought to evaluate whether patients with epistaxis in the emergency department have a higher arterial blood pressure compared with patients with other medical emergencies and to study the association of elevated blood pressure during epistaxis with sustained arterial hypertension. METHODS: In a prospective, cross-sectional, prevalence study we compared arterial blood pressure on admission in the ED in 213 consecutive patients treated for epistaxis with that of 213 sex- and age-matched control subjects. In 33 of those patients with elevated blood pressure during epistaxis, we evaluated the prevalence of sustained arterial hypertension. Main outcome measures were arterial blood pressure during epistaxis and evidence of sustained arterial hypertension, as determined by 24-hour ambulatory blood pressure measurement. RESULTS: Patients with epistaxis had significantly higher blood pressure values compared with those of control patients (systolic blood pressure 161+/-30 versus 144+/-22 mm Hg, P<.001; diastolic blood pressure 84+/-19 versus 75+/-15 mm Hg, P <.001). Of 33 (30%) of 108 patients with elevated blood pressure during epistaxis who were further evaluated, 26 (79%) patients were classified as having sustained arterial hypertension. Nine (27%) patients with sustained arterial hypertension were unaware of a history of hypertension. Patients with sustained arterial hypertension had significantly more episodes of epistaxis compared with patients with elevated blood pressure during epistaxis and no sustained arterial hypertension (mean 5 versus 1; P=.004). CONCLUSION: Patients with epistaxis have a higher blood pressure compared with that of control patients. Twenty-six (79%) of 33 patients with elevated blood pressure during epistaxis had sustained arterial hypertension. Nine (27%) of these patients were unaware of a history of hypertension. Continued management of patients with epistaxis and high blood pressure should include confirmation or exclusion of sustained arterial hypertension by 24-hour ambulatory blood pressure recording.
OBJECTIVE: To report a case of a patient who experienced serious, intractable epistaxis warranting emergency department (ED) visits and hospital admission after initiation of topiramate therapy. CASE SUMMARY: A 61-year-old woman with significant cardiovascular disease was started on topiramate 25 mg daily for lower extremity neuropathy. After 7 days of treatment, she began to experience severe, intractable epistaxis that lasted 8 days, warranting an ED visit. The epistaxis resolved 1 week after topiramate discontinuation. Topiramate was restarted 3 months later, and the patient again developed intractable epistaxis. After 2 days of epistaxis, she returned to the ED with significant anginal pain and was admitted to the hospital, where she received 2 units of packed red blood cells. One week after stopping topiramate, the epistaxis stopped. At the time of writing, she had exhibited no epistaxis for 6 months. According to the Naranjo probability scale, topiramate was the probable cause of epistaxis. DISCUSSION: Topiramate is a neuromodulatory compound approved for management of migraines, as well as partial and generalized tonic-clonic seizures. Over the past decade, its use has expanded to include many other neuropathic conditions. Currently, epistaxis has been reported in only 1-4% of patients receiving topiramate in clinical trials; however, these data were derived from a young study population. Like topiramate, calcium-channel blockers (CCBs) modulate voltage-gated L type calcium ion channels. These specific channels are located on vascular smooth muscle and non-contractile tissues such as platelets. Due to their possible antiplatelet effects, CCBs have been associated with an increased risk of hemorrhage, epistaxis, and prolonged bleeding time. The same may hold true for topiramate. CONCLUSIONS: Topiramate, particularly in combination with antiplatelet medications, may be associated with severe, intractable epistaxis. Intractable epistaxis should be added to the list of potentially serious adverse reactions that are monitored when topiramate is administered.
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.
OBJECTIVES: To find if the presence of epistaxis after nasal trauma can be used to predict post-traumatic external nasal deformity or a symptomatic deviated nasal septum. METHODS: Retrospective analysis of all patients seen in the fractured nose clinic by the first author between 17 October 2003 and 27 February 2004. Presence of epistaxis, newly developed external nasal deformity, and the presence of a deviated nasal septum with new symptoms of nasal obstruction were noted. RESULTS: A total of 139 patients were included in the study. Epistaxis following injury was noted in 106 (76%). Newly developed external nasal deformity was noted in 71 (51%), and 33 (24%) had a deviated nasal septum with new symptoms of nasal obstruction. Of the 106 patients with post-trauma epistaxis, 50 (67%) had newly developed external nasal deformity and of the 33 patients without post-traumatic epistaxis, 11 (33%) had nasal deformity (p<0.05). Post-trauma epistaxis was not associated with the presence of a newly symptomatic deviated septum (25% in patients with epistaxis after injury versus 18% if there was no epistaxis). CONCLUSIONS: Presence of epistaxis after nasal trauma is associated with a statistically significant increase in external nasal deformity. However, one third of patients without epistaxis following nasal trauma also had external nasal deformity and hence all patients with a swollen nose after injury, irrespective of post-trauma epistaxis, still need to be referred to the fractured nose clinic.
Recurrent epistaxis is a common pediatric problem with uncertain etiology in most cases. We observed frequent complaints, or history of epistaxis in children with migraine. The aim of this study was to determine whether there is an association between epistaxis and migraine in children. A detailed questionnaire was used to conduct a study of 45 consecutive patients, ages 6-11 years, with migraine, diagnosed according to the 1997 proposed pediatric revisions to the International Headache Society criteria; the patients were evaluated in our Pediatric Neurology Clinic. Control subjects consisted of 64 children without recurrent headaches, matched as a group for age and sex, and drawn as a convenient sample from two general pediatric practices and an elementary school. Sixteen (36%) of 45 patients with migraine had epistaxis as compared with 7 (11%) of 64 control subjects (odds ratio = 4.5; 95% confidence interval 1.6-12.1; P = 0.002). Epistaxis began an average of 3 years before migraine with similar characteristics to idiopathic epistaxis in habitual nose-bleeders, such as onset in early childhood, high incidence in sleep, and family history of epistaxis. This study demonstrates a significant association between migraine and recurrent epistaxis in children. Recurrent epistaxis increased the odds of migraine more than fourfold. Moreover, these data raise the question of whether epistaxis may represent a precursor to childhood migraine. The two disorders may share a common pathogenesis, and a prospective, longitudinal study is required to define further the relationship between them.
INTRODUCTION: Epistaxis is the most common symptom of a complex, genetically determined vasculopathy, which is known under the notion hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber-syndrome). This study was initiated to gain more knowledge about the natural history of epistaxis in a German HHT-population. PATIENTS AND METHODS: Data of 49 HHT patients were ascertained by interviewing these patients with a standardized disease specific questionnaire. Patients' files were retrospectively reviewed for data concerning age, gender, past medical history, laboratory parameters, number of hospital admissions for epistaxis, conservative and operative types of therapy, treatment results and follow-up. MAIN RESULT: Epistaxis was the first and most prominent symptom in 93% of the patients and could be triggered most frequently by stress. Half of the patients had experienced first episodes of epistaxis in childhood, but usually epistaxis did not become troublesome before the age of 35 years. The effects of hormonal changes or therapies with systemic hormones were inconclusive with regard to impact on epistaxis. Patients with septal perforations had to be admitted for inpatient epistaxis treatment more frequently than patients with an intact nasal septum. An overall reduction of frequency and intensity of epistaxis could be achieved in 89% of the patients through the daily use of nasal lubricants and a minimum of two treatment sessions with the Nd:YAG laser. However in none of the cases the treatment results were permanent. More than 50% of the patients, who had been screened for visceral arteriovenous malformations, were positive for pathologic vascular lesions. PRINCIPAL CONCLUSION: The natural history of epistaxis in German HHT patients is similar to previously described entities from other parts of the world. First clinical signs of HHT may be present at an earlier age than previously thought.
STUDY OBJECTIVE: The epidemiology of emergency department (ED) visits for epistaxis is unknown. We use national data to fill this gap and test hypotheses that epistaxis visits are more common with increasing age and in winter. METHODS: We identify ED visit with epistaxis from 10 years of the National Hospital Ambulatory Medical Care Survey. We calculate visit rates by age and other demographic characteristics and assess mode of arrival and disposition. Results are presented with 95% confidence intervals (CIs). RESULTS: From 1992 to 2001, epistaxis occurred at 4,503,000 ED visits, or 0.46% (95% CI 0.41% to 0.51%) of all visits. Per 1,000 population, 1.7 (95% CI 1.5 to 1.9) ED visits for epistaxis occurred annually. The age-related frequency was bimodal, with peaks among those younger than 10 years (4.0 per 1,000 visits) and aged 70 to 79 years (12.0 per 1,000 visits). Most cases (83%; 95% CI 80% to 86%) were atraumatic. Traumatic cases were younger than atraumatic cases (mean age 31 versus 49 years). From December to February, atraumatic epistaxis occurred in 0.50% (95% CI 0.40% to 0.60%) of all visits versus 0.34% (95% CI 0.30% to 0.39%) during nonwinter months. Fifteen percent (95% CI 12% to 18%) of cases arrived by ambulance, and 6% (95% CI 5% to 7%) of patients were hospitalized. CONCLUSION: Epistaxis accounts for about 1 in 200 ED visits in the United States. Although there is an early age peak (age >10 years), the frequency increases from age 20 years onward, with the highest rates in the elderly. Epistaxis visits are more common in the winter. Future efforts to decrease epistaxis visits might focus on education of the elderly and parents of young children about nasal mucosa care and basic approaches to home management.
OBJECTIVE: We investigated whether an apoptosis of nasal microvessels contributes to probable mechanism of the onset of epistaxis. STUDY DESIGN AND SETTING: Nasal septal mucosa of Little's areas taken from patients without (n = 19) and with (n = 26) epistaxis were examined. Active caspase-3 in the mucosa was detected according to the methods of immunohistochemistry and Western blotting. On Western blot analysis of the homogenates of the mucosa, we also sought probable signaling factors after caspase-3 activation. RESULTS: Marked activation of caspase-3 was detected in the capillaries and its neighboring muscle cells of Little's area from patients with epistaxis, and the activation was due to enhanced expression of procaspase-3 protein and progressive cleavage of the precursor. As a result of Western blotting of signaling factors, enhanced expressions of caspase-9 and Bax protein in the homogenates of Little's area in epistaxis group were found compared with those in control group. Increased levels of cytochrome c released into a cytosol were also detected in the capillaries in epistaxis group. CONCLUSION: In the present study, caspase-3 activation was found in the capillaries of Little's area from patients with epistaxis, suggesting that an apoptosis of capillaries may contribute to a mechanism of the onset of epistaxis. Moreover, alterations of some apoptotic factors such as caspase-9, Bax, and cytochrome c in the tissues demonstrated participation of mitochondrial disturbance in one of the apoptotic mechanisms. SIGNIFICANCE: Further explorations of the pathobiologic mechanism of capillary apoptosis can lead not only to an identification of risk factors in the onset of epistaxis but also to the development of medical therapy of epistaxis.
To investigate the hypothesized relationship between various daily atmospheric pollutant concentrations and hospital epistaxis presentation. A retrospective analysis of all presentations of non-traumatic epistaxis to our institution was performed, and the results were cross-referenced with London air quality data supplied by the National Air Quality Data Archive at the National Environmental Technology Centre (NETCEN) at the multi-centre tertiary referral ENT Department. An analysis of epistaxis presentation to St George's Hospital during the 5-year period January 1997-2002 was made from the patient administration system and accident and emergency records. The study includes 1373 emergency patients after traumatic and iatrogenic epistaxis were excluded. Factors measured were atmospheric ozone (O(3)), carbon monoxide (CO), sulphur dioxide (SO(2)), nitrogen dioxide (NO(2)) and particulate matter less than 10 mum in diameter (PM(10)). Hospital epistaxis presentation and atmospheric pollutant concentration were documented for each day of the 5-year period, weekly change in both parameters was recorded and statistical analysis was performed. The statistical methods used are linear correlation using Pearson's coefficient. Increased hospital epistaxis presentation was strongly associated with increased concentration of airborne particulate matter (r = 0.289, P < 0.001; significant if P < 0.05) and less strongly associated with increased concentrations of atmospheric O(3) (r = 0.150, P = 0.019; significant if P < 0.05). There was no association between epistaxis attendance and atmospheric concentrations of CO, NO(2) and SO(2) in this study. The concentrations of local airborne particulate matter and atmospheric O(3) in the days preceding hospital attendance for epistaxis are relevant when considering the associations of the episode. This further increases understanding of the pathophysiology of spontaneous epistaxis.
Epistaxis is the second most common cause of spontaneous bleeding. Of the two categories of epistaxis, mundane and severe, the mundane, usually anterior epistaxis, is the more common. It has been reported that 60% of individuals report at least one episode of epistaxis during their lifetime. Eighty percent of epistaxis occurs in Kiesselbach's plexus, a vascular network in the anterior portion of the nasal septum. We have designed a nasal tampon to control this common variety of epistaxis which is a fast, efficient, and cost-effective method of anterior epistaxis control. The material used in the manufacture of the device (MerocelTM) has been used for over 5 years by the author, both in treatment of severe epistaxis and as a postoperative nasal packing. The design presented here has been used for anterior epistaxis for 18 months without untoward sequelae and with universal success.
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.
BACKGROUND: Epistaxis is a common disease. That is usually self-limited and controlled by extemal compression. However, posterior epistaxis is occasionally complicated and needs hospitalization. The aim of this study is to analyze the etiology of epistaxis that requires hospitalization, and present the results of the treatments. METHODS: From June 1997 to May 1999, 44 patients admitted under diagnosis of epistaxis were retrospectively investigated. Among these patients, 7 were admitted twice for epistaxis. The demographics, administrative history, post-history and associated diseases, treatment and complications were analyzed. Noninterventional treatment comprised of nasal packing and local electrocauterization; interventional treatment included surgery and embolization. RESULTS: The mean age of the patients enrolled was 53.4 years. Men outnumbered women in a rate of 3:1. The mean length for hospital stays was 8.1 days for noninterventionally-treated patients, 11.8 days for interventionally-treated patients. Emergency room visit prior to admission was noted in 68.6% of the patients. Hypertension, nasopharyngeal carcinoma (NPC) after radiotherapy, a history of nasal operations and smoking were four major associated diseases. The failure rate to control the epistaxis was 26.7% for noninterventional treatments and 16.7% for interventional treatments. The complication rate was 2% for the entire study, and the mortality rate was 7.8%. All the mortal patients were post-irradiation NPC patients with internal carotid artery bleeding. CONCLUSIONS: Most epistaxis patients can be managed in a noninterventional manner. Interventional treatment is only warranted in those whose epistaxis persists after adequate noninterventional treatment. For internal carotid artery epistaxis in NPC patients, embolization should be performed as soon as possible.
OBJECTIVES: Epistaxis is a common ENT complaint. Although casual observation suggested that it is more common in Caucasian, compared with Asian people, a literature search failed to find any studies investigating ethnicity and epistaxis. The aim of this study was to identify any differences in emergency admission rates for epistaxis between Asian and Caucasian people. DESIGN: Retrospective observational study using hospital computerised data (HISS). SETTING: Large University Hospital accepting ENT emergencies. PARTICIPANTS: All Asian and Caucasian patients admitted under ENT care as an emergency (1 January 2000 to 30 November 2005), split into two groups: one composed of epistaxis patients, the other of all other ENT emergency admissions. MAIN OUTCOMES MEASURES: The proportions of Asian and Caucasian patients among the two patient groups, either epistaxis admissions or other ENT emergency admissions. RESULTS: The proportions of Asian and Caucasian patients in the group admitted with emergency epistaxis were 7.1% (100/1410) and 92.9% (1310/1410) respectively. However, the proportions of Asian and Caucasian patients in the group composed of any other ENT emergency were 13.2% (729/5515) and 86.8% (4786/5515), respectively (chi-squared P < 0.01). CONCLUSIONS: Caucasian people form an unexpectedly large, and Asians a smaller proportion of emergency epistaxis admissions. The possibility of an ethnic risk factor for epistaxis warrants further investigation.