Epistaxis: A retrospective review of hospitalized patients

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.

Impact of COVID-19 lockdown on hospital admissions for epistaxis in Germany

BACKGROUND

Reports of a decrease in hospital admissions during the coronavirus disease 2019 (COVID-19) lockdown period have raised concerns about delayed or missed diagnoses and treatments for non-COVID-19-related illnesses.

AIM

To investigate the impact of the COVID-19 pandemic-induced lockdown and its end on hospital admissions of patients with epistaxis in Germany.

METHODS

A retrospective analysis based on the national database of the Hospital Remuneration System was used to compare hospital admissions during defined time periods between 2019 and 2022 with the lockdown period as the reference period. This was done on a weekly basis before, during, and after the lockdown. An Interrupted Time Series was used as the analysis method.

RESULTS

In our analysis, we included 26183 patients. The implementation of the lockdown led to a substantial reduction in the overall occurrence of epistaxis among patients (P < 0.05). This effect was most pronounced in the age group of 0-39 years, where the decrease was highly significant (P < 0.001). However, there was no change observed in patients aged 80 years and older (not significant). With the end of the lockdown period, the overall number of patients, especially in the youngest age group, increased abruptly and significantly (P < 0.01).

CONCLUSION

During the lockdown period, there was a decrease in hospital admissions for younger patients with epistaxis, possibly due to the fear of COVID-19 exposure. We also conclude that the severity of epistaxis was not underestimated in the elderly during the pandemic.

Knowledge, Attitude, and Practice of First Aid for Epistaxis Among the General Population in the Jazan Region of Saudi Arabia

Background Epistaxis, or nosebleeds, is a widespread medical condition that can be effectively managed with appropriate first aid. Understanding the general public's knowledge and practices about this is crucial. Objectives This study sought to evaluate the awareness and practice regarding first aid for epistaxis within the general population of the Jazan region in Saudi Arabia. Methods A cross-sectional survey was administered from April through June 2023, using a questionnaire that covered sociodemographic factors, knowledge of epistaxis, first aid practices for epistaxis, and any previous training received. Statistical analysis was performed using SPSS (IBM Corp., Armonk, NY), with chi-square tests to evaluate the variables' associations. Results The questionnaire was completed by 622 participants, predominantly females, Saudis, and individuals from the age group of 18 to 25 years. It was found that 60% of the participants had experienced epistaxis, but only 52% had received prior first aid training. Although the majority (91.8%) accurately defined epistaxis, a mere 40.8% correctly identified all the steps for first aid management of epistaxis. There was a notable insufficiency in understanding the causes, risk factors, and appropriate first aid steps. Participants' knowledge was evenly split, with approximately half exhibiting low knowledge (49.70%) and the remainder showing high knowledge (50.30%). Certain sociodemographic factors such as older age (p=0.028), Saudi nationality (p=0.045), and higher education (p=0.001) were linked with more experiences of epistaxis. Conversely, younger age (p=0.002), female gender (p=0.036), single status (p=0.001), prior experience with epistaxis (p=0.001), and higher overall knowledge (p=0.001) were associated with a higher likelihood of having received first aid training. Conclusions The study reveals significant gaps in the knowledge and practices of first aid for epistaxis among the general population in the Jazan region. Public awareness campaigns and educational programs are urgently needed, particularly for specific groups. Enhancing first aid knowledge could help alleviate the impacts of epistaxis. Further research is required to develop effective educational interventions.

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.

The Level of School Teachers' Knowledge About First-Aid Management and Control of Epistaxis in Qassim Region, Saudi Arabia

BACKGROUND

 Epistaxis is an acute episode of nasal bleeding commonly caused in children by traumatic injuries in a school setting. It is one of the common ear, nose, and throat emergencies, which should be managed with first-aid measures. To the best of our knowledge, no studies have been conducted among school teachers in the Qassim region of Saudi Arabia regarding this information. This study thus aimed to assess levels of knowledge about first-aid management and control of epistaxis among school teachers in the Qassim region, Saudi Arabia.

MATERIALS AND METHODS

 A cross-sectional study using a validated online questionnaire was distributed via social media platforms. Information was collected regarding sociodemographic characteristics, and eight items assessed participants' knowledge about epistaxis and its management. Univariate, bivariate, and multivariable analyses were conducted to assess the factors associated with good levels of knowledge.

RESULTS

 The study had a total of 1,152 participants, of which 69.7% were female. The mean of knowledge was 3.29 (SD=1.39, range: 0-7). Only 19.4% of participants had a good level of knowledge. In multivariate analysis, females and those who had received information on first aid to stop nose-bleeds were significantly associated with good knowledge levels (adjusted odds ratio {AOR}: 1.72, 95% CI: 1.18-2.51, p=0.005; and AOR: 3.38, 95% CI: 2.47-4.64, p<0.001, respectively).

CONCLUSION

 Less than one-quarter of participants had good knowledge levels. Health education sessions for teachers are highly recommended and should specifically target male teachers.

[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.

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck

OBJECTIVES

Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain.

METHODS

We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization.

RESULTS

Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24 h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%.

CONCLUSIONS

CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Clinical Practice Guideline: Nosebleed (Epistaxis)

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Geographic Variation in Epistaxis Interventions Among Medicare Beneficiaries

OBJECTIVES

To quantify the utilization of epistaxis procedures in the elderly population and assess whether the geographic variability of these procedures is associated with hypertension and direct oral anticoagulant (DOAC) use.

METHODS

A cross-sectional study was performed on publicly available Medicare procedure and beneficiary data from 2013 to 2016 for all epistaxis procedures categorized by Common Procedural Terminology (CPT). Epistaxis procedures were analyzed by state, complexity, and provider type. Pearson's correlation coefficient was calculated.

RESULTS

Over 4 years, 2 19 827 epistaxis procedures were performed on Medicare patients, 44.3% of which were categorized as simple (control of nasal hemorrhage: anterior simple or posterior primary). Otolaryngologists performed 92.6% of all epistaxis procedures. The frequency of epistaxis procedures performed by state ranged from 0.99 procedures per 10 000 Medicare beneficiaries (PP10K) in Hawaii to 25.7 PP10K in New Jersey. The percentage of epistaxis interventions categorized as complex (anterior complex, posterior subsequent, with nasal endoscopy, or open procedures) in each state varied from 0% in North Dakota to 72.6% in Hawaii. Epistaxis procedure utilization was weakly correlated with the prevalence of hypertension (R² = 0.08, P = .04) and higher percentage of DOAC among all anticoagulants prescribed (R² = 0.08, P = .04) in a state's Medicare population. Utilization of complex epistaxis interventions was not correlated with the prevalence of hypertension or DOAC use.

CONCLUSIONS

Otolaryngologists perform the vast majority of epistaxis procedures in the Medicare population. However, practice patterns vary across the United States. Hypertension and DOAC use are weakly associated with the utilization of epistaxis interventions.

Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

OBJECTIVE

Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

PURPOSE

The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

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.)

Endoscopically guided chitosan nasal packing for intractable epistaxis

BACKGROUND

The purpose of this study was to evaluate the effectiveness and safety of endoscopically guided chitosan packing in controlling intractable epistaxis. A prospective case series was performed.

METHODS

This is a prospective clinical study conducted in a tertiary rhinology fellowship training hospital between January 2009 and November 2009. The study population consisted of patients with intractable epistaxis that failed to respond to traditional anterior-posterior nasal packing using either a 10-cm Pope PVA Merocel or a Rapid-Rhino. The bleeding site was identified using a nasal endoscope and controlled using a pack made of a ChitoFlex chitosan dressing wrapped around a polyvinyl acetal nasal sponge.

RESULTS

The intent-to-treat population consisted of 20 severe epistaxis subjects (8 men and 12 women) who continued to bleed despite traditional anterior-posterior nasal packing. The mean age was 67 years (±19 years). Sixteen subjects were on antiplatelets and/or anticoagulants. Eleven subjects (55%) presented with anterior epistaxis, and 7 subjects (35%) presented with posterior epistaxis. Chitosan nasal packing was performed on an outpatient basis and resulted in effective and immediate hemostasis in 19/20 subjects (95%). One subject had persistent bleeding after the first packing attempt and was successfully repacked within 30 minutes. Time to complete cessation of bleeding was 3.6 ± 2.2 minutes in the 19 subjects; the pack was removed after 48 hours, without any evidence of rebleeding or any serious side effects.

CONCLUSION

Endoscopically guided chitosan packing is a safe, effective, and well-tolerated outpatient treatment for the management of intractable epistaxis.

The Efficacy of Ankaferd Blood Stopper in Heparin-Induced Hemostatic Abnormality in a Rat Epistaxis Model

Objective. To assess the in vivo hemostatic effect of Ankaferd Blood Stopper (ABS).

Study Design. An experimental study of an animal anterior epistaxis model.

Setting. A tertiary care university hospital.

Subjects and Methods. Wistar rats were randomized into 4 groups of 7 each: group 1, control, no pretreatment, irrigated with saline; group 2, no pretreatment, irrigated with ABS; group 3, control, heparin pretreatment, irrigated with saline; and group 4, heparin pretreatment, irrigated with ABS. In all groups, a standardized rat epistaxis model was obtained by cutting the anterior nasal septal mucosa. To control bleeding, compressive dressings were placed after instilling 1 mL of either ABS or saline to the bleeding area. The hemostasis time and amount of nasal bleeding were measured in all groups to compare the treatments without and with ABS.

Results. Without heparin pretreatment, ABS shortened the hemostasis time by 1.57 minutes ( P = .003) and reduced the amount of the bleeding by 0.35 g ( P = .006). With heparin pretreatment, ABS shortened the hemostasis time by 2.86 minutes and reduced the amount of the bleeding by 0.49 g (both P = .002).

Conclusion. ABS irrigation was more effective than saline irrigation for treating anterior epistaxis hemostasis in animals using a compressive dressing with or without heparin pretreatment.

Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis

OBJECTIVES

The precise identification of the bleeding point is important to the efficient management of epistaxis. Our hypothesis was that the septum was the commonest bleeding site.

STUDY DESIGN AND SETTING

This was a prospective clinical study of 50 consecutive adult idiopathic posterior epistaxis patients carried out in a busy teaching hospital.

METHODS

The nasal cavity was inspected with endoscopy to identify the site of bleeding before any intervention. The location of bleeding sites was recorded on a proforma.

RESULTS

Of bleeding sites posterior to the piriform fossa, 94 percent were identifiable, with 70 percent arising from the septum.

CONCLUSIONS AND SIGNIFICANCE

This is the largest prospective study of the bleeding site in adult patients with posterior epistaxis and the only one with a well-defined population. The vast majority of posterior bleeding sites can be identified by endoscopy without general anesthesia. The septum should be examined closely in cases of idiopathic bleeding.

Management Pitfalls in the use of Embolization for the Treatment of Severe Epistaxis

Angiographic embolization for the treatment of severe recurrent epistaxis was added to the traditional treatment options—nasal packing, cauterization, and surgical vessel ligation—in 1974. Since then, clinical experience has shown that this procedure is safe and effective. When epistaxis cannot he controlled with cautery, nasal packing is the most common next step. As such, it is often performed by emergency physicians and other clinicians who are not otolaryngologists. We report two cases in which intranasal neoplasms were obscured as a result of a significant distortion of the normal anatomy. This distortion was secondary to emergency-room treatment of severe epistaxis by repeated nasal packing followed by angiographic embolization. Pre-embolization angiographic studies and subsequent postembolization endoscopic evaluations did not reveal the presence of the occult neoplasms because of the presence of inflammation and edema after treatment. Clinicians should be aware that nasal packing and embolization can obscure the underlying source of epistaxis, and follow-up radiologic studies and endoscopic evaluations are essential to avoid delays in diagnosis.