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PubMed2001

Treatment of intractable epistaxis using arterial embolization.

Arterial embolization has become the procedure of choice for managing intractable epistaxis in certain centres in North America and Europe, with arterial ligation reserved for those patients in which it fails. In Ireland, the role of this relatively new technique is poorly defined. The aim of this retrospective study was to investigate the outcome of all patients who underwent arterial embolization for intractable epistaxis in Dublin since it was introduced in 1998. Embolization resulted in complete and immediate resolution of epistaxis in 10 out of 12 patients (82%). Two patients required carotid ligation because of persistent epistaxis. One other patient had a further minor epistaxis 2 days following embolization, which was treated successfully with cautery. No major complications occurred in any of the patients. This study suggests that arterial embolization is an effective and safe method of managing patients with intractable epistaxis.

Adult↗
PubMed2002

Active epistaxis at ED presentation is associated with arterial hypertension.

Epistaxis and hypertension are frequent in the general population, but an association is still controversial. Aim of this retrospective cohort study was to test if active epistaxis at emergency department (ED) presentation is associated with hypertension. Patients with active epistaxis at ED presentation (n = 271; 73%) were compared with controls without active bleeding (n = 101; 27%). By multivariate logistic regression modeling we found that active epistaxis was independently associated with history of hypertension (odds ratio 2.8 [95% CI 1.4 to 5.6; P =.004] adjusted for age, gender, rhinitis, diffuse bleeding, and malignant diseases). Patients with active epistaxis had higher blood pressure at presentation compared with controls (systolic blood pressure 165 v 153 mmHg, P <.001, diastolic blood pressure 85 v 77 mmHg, P <.001). Active epistaxis at ED presentation is associated with arterial hypertension.

Blood Pressure↗
PubMed2003

Absence of association between hypertension and epistaxis: a population-based study.

The association between epistaxis and hypertension is still disputed. In a cross-sectional study, we evaluated this association in a sample of 1174 individuals older than 18 years, representative of inhabitants of Porto Alegre, RS, Brazil. Epistaxis was defined as any episode of non-traumatic nosebleeding after 18 years of age. Hypertension was defined as the mean of two blood pressure readings > or = 160/95 mmHg or the use of antihypertensive drugs. The prevalence of epistaxis and hypertension were 14.7% (95% confidence interval, CI 12.7-16.7) and 24.1% (95% CI 21.7-26.6), respectively. History of epistaxis in the adulthood (risk ratio = 1.24, 95% CI 0.83-1.85), and in the previous 6 months (risk ratio 0.79, 95% CI 0.40-1.56; p = 0.510) were not associated with hypertension after controlling for gender, age, race, history of allergic rhinitis or nasal abnormalities, alcohol abuse, smoking and years of study. History of epistaxis was positively associated with history of allergic rhinitis and inversely associated with years at school. In conclusion, we demonstrated that hypertension is not associated with history of epistaxis in the adulthood in free-living individuals.

Adult↗
PubMed1996

Recurrent epistaxis and nasal septal deviation in young adults.

Epistaxis is common in young adults but the aetiology is unknown in many cases. To investigate the possibility that septal deviations are associated with epistaxis, 54 servicemen with recurrent epistaxis were compared with 46 controls. The epistaxis group were significantly more likely to have a history of nasal trauma (P = 0.008) and radiologically-proven nasal fracture (P = 0.002); on clinical examination, they were more likely to have a deviated septum (P < 0.00001), maxillary spur (P = 0.00004) and nasal obstruction (P = 0.011); they were also more likely to have radiological evidence of a deviated septum (P = 0.020). Those patients able to locate their epistaxis to one side tended to do so to the side of their septal deviation. This study supports the hypothesis that septal deviation is associated with epistaxis.

Adolescent↗
PubMed1991

Idiopathic intractable epistaxis: endovascular therapy.

Thirty patients with intractable idiopathic epistaxis were treated with endovascular therapy. Embolization of the internal maxillary artery controlled the epistaxis in 87% of the patients, and the success rate was increased to 97% after supplemental embolization of the facial artery. The only complication observed was transient postembolization hemiparesis, which occurred in one of the 30 patients. Intractable idiopathic epistaxis is defined as epistaxis of unknown cause that is refractory to nasal packing. Such epistaxis is commonly treated with surgical intervention, including ligation of the terminal segments of the internal maxillary artery and the ethmoid arteries. An alternative approach is performance of endovascular therapy. In our opinion, embolization is a safe and effective procedure when it is carried out by appropriately trained personnel. In most patients, its performance requires use of only neuroleptanalgesia; surgery can be avoided, and the duration of hospitalization is significantly shortened. We recommend that embolization be adopted as the primary modality for the treatment of idiopathic intractable epistaxis.

Catheterization↗
PubMed2001

Use of aspirin, epistaxis, and untreated hypertension as risk factors for primary intracerebral hemorrhage in middle-aged and elderly people.

BACKGROUND AND PURPOSE: The incidence of primary intracerebral hemorrhage (ICH) increases exponentially with age, but the risk factors are not well known. We investigated lifestyle factors, previous diseases, and medications as risk factors for ICH in middle-aged and elderly people. METHODS: We compared 98 consecutive patients with primary ICH between 36 and 90 years of age with 206 community-based control subjects matched for age and sex. Odds ratios (ORs) and 95% confidence intervals (CIs) after adjustment for possible confounding variables were calculated by logistic regression. RESULTS: The independent risk factors for ICH were untreated hypertension (OR, 6.95; 95% CI, 3.06 to 15.8), previous ischemic stroke (OR, 3.83; 95% CI, 1.70 to 8.63), epilepsy (OR, 13.8; 95% CI, 2.49 to 76.6), recent strenuous physical exertion (OR, 3.97; 95% CI, 1.95 to 8.10), and a history of epistaxis (OR, 2.92; 95% CI, 1.28 to 6.62). In men, treated hypertension (OR, 2.67; 95% CI, 1.03 to 6.93) was also a significant risk factor. Patients with a history of epistaxis who had used nonsteroidal anti-inflammatory drugs, especially aspirin in high doses, had an increased risk for ICH (adjusted OR of epistaxis, 2.75; 95% CI, 1.11 to 6.81; adjusted OR of aspirin use, 14.7; 95% CI, 2.03 to 106). In addition, there was a significant (P:<0.01) positive interaction between the history of epistaxis and the use of aspirin on the risk for ICH. CONCLUSIONS: Epistaxis is a risk factor for ICH in middle-aged and elderly people, both independently and combined with the use of aspirin. Other independent risk factors are untreated hypertension, previous ischemic stroke, epilepsy, and recent strenuous physical exertion. Epistaxis may be a warning sign of an increased risk for ICH in subjects using aspirin.

Adult↗
PubMed2002

Risk factors for epistaxis during nasotracheal intubation.

We performed a study to confirm which risk factors are significantly associated with epistaxis during nasotracheal intubation. One hundred patients who underwent nasotracheal intubation were included. Risk factors for epistaxis were analysed using the multiple logistic regression analysis with stepwise variable selection method. Epistaxis was most likely to occur if transit of the tube through the nasal passage was difficult (P=0.0001, odds ratio 625, 95% confidence interval 3.14-14.26). On the other hand, age and gender, obesity, smoking, tube size, repeated attempts of intubation, and intubation performed with the aid of Magillforceps were not significantly related with risk of epistaxis. The presence of nasal anatomical abnormalities also did not correlate significantly with epistaxis. Strategies to ensure smooth transit of the tube through the nasal passageways are essential to reduce the incidence of epistaxis.

Adult↗
PubMed1994

A "bubble-tip" (Airguide) tracheal tube system: its effects on incidence of epistaxis and ease of tube advancement in the subglottic region during nasotracheal intubation.

Epistaxis and tubal obstruction in the subglottic region are difficulties encountered during nasotracheal intubation. Trauma to the nasal airway must be avoided, especially in patients receiving anticoagulant therapy. In addition, smooth passage of the tracheal tube through the larynx is desired. The tip of an Airguide tracheal tube system has a soft, round, glossy balloon head which should be less traumatic to the nasal mucosa than other more commonly used tubes. We, therefore, determined whether the Airguide reduces the incidence of epistaxis and increases smooth passage of the tracheal tube in the subglottic region during nasotracheal intubation. Sixty-six patients were divided into two groups, Airguide (n = 39) and Standard (n = 27). Each group was divided into two subgroups, topical epinephrine application as a mucosal decongestant and non-epinephrine. The incidences of epistaxis and smooth passage were compared between the two groups. The Airguide group had a significantly lower incidence of epistaxis (9/39 vs 13/26; P < 0.05; bleeding was not checked in one patient in the Standard group) and provided a significantly smoother passage in the subglottic region than the Standard group (tube impingement in the subglottic region, 0/39 vs 11/27; P < 0.01). There was no significant difference in the incidence of epistaxis between the subgroups with and without topical application of epinephrine. The Airguide helps to minimize epistaxis and increases navigability in the subglottic region during nasotracheal intubation.

Epistaxis↗
PubMed2003

Epistaxis related to exercise-induced pulmonary haemorrhage in south African Thoroughbreds.

This study investigated if environmental factors had an effect on the incidence of epistaxis related to exercise-induced pulmonary haemorrhage (EIPH) among racehorses in southern Africa. Data covering the period 1986-2001 and involving 778 532 race runs were analysed. This included the following information: date of race, age, sex, name of breeder, trainer, distance, jockey, state of going, weight carried, racing centre and altitude. Veterinarians employed by the Jockey Club suspended officially entered horses that presented with epistaxis (frank bleeding from the nostrils) after racing. On-course endoscopy is not performed as a standard practice at any southern African racetrack. Epistaxis was identified in 1287 horses (0.165%). More horses presented with EIPH-related epistaxis (a) at sea level, (b) from May to October, (c) when older (> 3 years), (d) after 1995, (e) on Fridays and Sundays, and (f) more in geldings than in mares or entire males. No association could be established between epistaxis and breeder, trainer, distance run, jockey, state of going and weight carried. It is concluded that the frequency of EIPH-related epistaxis is associated with altitude, winter and spring, sex and age. It is suggested that racing at lower altitudes may increase the probability of exercise-induced pulmonary haemorrhage.

Age Factors↗
PubMed1999

Epistaxis: study of aetiology, site and side of bleeding.

The present study comprises 300 cases of epistaxis. The analysis of these cases revealed a higher incidence in young males. Unilateral bleeding was seen in almost 60% each of indoor and outdoor cases. Litte's area was the most common site responsible for epistaxis in 28.8% of the indoor and 26.2% of the outdoor patients. Hypertension was the most common systemic cause among indoor patients (62.2%) and sickle cell disorder among the outdoor patients (37.5%). Atrophic rhinitis with myiasis was the local cause of epistaxis in maximum (27%) of the indoor patients and traumatic epistaxis was the commonest cause (33%) among outdoor patients-fingernail trauma in 75.9% of them. Idiopathic epistaxis contributed for 16.5% indoor and 26.1% of outdoor cases. Intractable epistaxis was seen in one case following accidental facial trauma.

Adolescent↗
PubMed2001

[Treatment of recurrent epistaxis with endoscopic electrocoagulation of the sphenopalatine artery].

INTRODUCTION: Treatment of posterior epistaxis with an intranasal balloon catheter (double balloon--Epistat) or posterior balloon (Foley catheter) as a posterior packing combined with a gauze plug as the anterior packing is often very troublesome for the patient. In the western world, the introduction of endoscopic electrocoagulation or ligation of the sphenopalatine artery has proved to be effective in the treatment of persistent posterior epistaxis, and it reduces morbidity. We have therefore introduced the same treatment modality. MATERIAL AND METHODS: We have used this technique so far on six patients with persistent posterior epistaxis. They were admitted to the ENT Department, H:S Rigshospitalet, Copenhagen, during the period 1.4.2000-15.11.2000. RESULTS: The treatment terminated the epistaxis in all cases. One patient had anterior epistaxis postoperatively, and this was treated with ligation of the arterior ethmoidal artery. The time spent in hospital after the operation was 1-2 days. CONCLUSION: This method is recommended for the treatment of persistent posterior epistaxis, when functional endoscopic techniques are mastered. Early treatment reduces morbidity and cuts down the stay in hospital.

Adult↗
PubMedDate not supplied

Epistaxis management: what's new and what's noteworthy.

In many ways, the treatment of epistaxis is not new. Nasal packing was used in the 4th century BC. Our modern-day management of epistaxis is a little more sophisticated, with the advent of new products, rigid endoscopes, improved surgical techniques, and arterial embolization. Research plays a critical role in shaping our epistaxis practice management. Epistaxis is recognized as one of the most common ear, nose, and throat (ENT) problems; it affects persons of all ages. Proper first aid steps can be effective. Only 10% of individuals with nasal bleeding seek medical attention. Health care providers in all primary care settings encounter patients experiencing epistaxis and need to be knowledgeable in emergency epistaxis management. The evaluation will be key to successful identification of the site of bleeding and to identify possible underlying cause(s) that will guide treatment options.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMedDate not supplied

[Haemostatic ointment efficacy in the treatment and prevention of epistaxis: a multi-centric study in 100 patients].

OBJECTIVE: To evaluate the protective effects of an haemostatic ointment, at rhinosinusal mucosa level, on the development of bleeding in patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days. PATIENTS AND METHODS: 100 patients affected by epistaxis or with a positive clinical history for epistaxis in previous 7 days. Patients underwent 15 days of treatment with an haemostatic ointment 2 times/day. RESULTS: The haemostatic ointment significantly reduced the percentage of patients affected by epistaxis and the number and severity of bleeding episodes (p < 0.001). 51% of patients experienced nasal obstruction during treatment, which persisted at the end of therapy only in 11% of them (p < 0.001). Nasal burning, nasal itching and rinorrhea involved less than 40% of patients in the first days of treatment and no more than 10% at the end of therapy (p < 0.001). CONCLUSIONS: The use of the haemostatic ointment in the treatment and in the prevention of not severe epistaxis acquire, in our opinion, a strong rationale.

Adult↗
PubMed2005

Persistent epistaxis: what is the best practice?

Epistaxis is the commonest otolaryngological emergency, which is often managed by a nasal pack. A significant number of cases fail to respond to nasal packing and various surgical measures are available to control the nosebleed in these cases. However evidence is sparse regarding the best available surgical option for the management of persistent epistaxis. We designed a retrospective cohort study comparing endoscopic ligation of sphenopalatine artery (ELSA) and all other surgical options (non-ELSA) in the management of persistent epistaxis. All consecutive cases of persistent epistaxis between 1997-2004 (Feb) requiring operative intervention were included in the study and divided in two groups according to the surgical intervention. Postoperative epistaxis was excluded. Non-ELSA group consisted of various procedures including nasal cautery and packing, submucous resection, anterior ethmoid artery ligation, external carotid artery ligation, internal maxillary artery ligation. Both groups were matched for age, sex, risk factors, other medical conditions and medications. The main outcome measures evaluated were immediate success in arresting the bleeding and the mean hospital stay. Recurrence and patient acceptability of the procedure were the secondary variables investigated. We found that ELSA proved to be the best practice to manage persistent epistaxis on all measures of immediate success rate, shorter hospital stay, recurrence rate, and patient satisfaction.

Adult↗
PubMedDate not supplied

[Intracranial post-traumatic aneurysm of the internal carotid artery as cause of epistaxis: considerations on 2 cases].

Aneurysm of the internal carotid artery is rarely mentioned as a cause of epistaxis. This condition is quite rare but it is important to consider aneurysms in the etiology of epistaxis because of their high mortality rate and since they require management quite different from that of epistaxis of other origins. After arteriosclerosis the most frequent cause of an aneurysm of the internal carotid artery is a closed or penetrating craniofacial trauma injuring the artery. This leads to subsequent aneurysmal dilation of the cavernous and petrous portions of the artery itself. Aneurysms of the cavernous portion of the artery are more frequent. In this location the aneurysm has a close anatomical relationship with the sphenoid sinus as well as the nasal fossae. In the present paper two cases of traumatic intracavernous carotid aneurysms presenting epistaxis are described. In the first case, reported 25 years ago, the diagnosis was made on an autoptic table in young man who died after two severe episodes of massive nasal hemorrhage. The second case involved a 17-year-old man with a severe epistaxis reported one month after a close craniofacial trauma. An intracranial carotid pathology was suspected because of the recurrence of nose-bleeding and the history of reduced visual activity. Therefore angiography was performed which revealed a small aneurysm of the intracavernous segment of the left internal carotid artery. Subsequently, an endovascular balloon embolization of the aneurysm was successful, preserving the parent artery. The importance of considering aneurysms in the differential diagnosis of massive epistaxis is emphasized.

Accidents, Traffic↗
PubMed1996

[Epistaxis in Rendu-Weber-Osler disease. The role of brachytherapy].

Rendu-Weber-Osler disease is a rare autosomic disorder. Its most common symptom is epistaxis with transitory periods of remission and of ingravescent exacerbation compromising normal daily activities and forcing the patient to give up his normal life-style for prolonged periods of time. Often it proves difficult to control the recurrent epistaxis and the treatments available today are not always totally satisfactory. The authors present the results obtained using endonasal brachytherapy in 8 patients (13 treatments) epistaxis stemming from previously diagnosed Rendu-Weber-Osler disease. Brachytherapy employs thin plastic tubes, positioned in the nostril with the heaviest epistaxis. These tubes are then filled with Iridum192. The total dose, prescribed against the reference isodose, strictly adjacent to the nasal fossae mucosa, was 30 Gy over a period ranging from two to four days (average 2.5 days). Four patients required a second treatment to the controlateral nostril as the symptoms returned after a period ranging from 36 to 60 months (average 47.1 months). Only one patient required a second treatment in the same nostril 9 years later. The episodes of epistaxis were scored by symptom severity on a scale from 0 to 5. Of the 13 treatments administered (mono and bilateral treatments), 12 can be considered satisfactory as the epistaxis was reduced from the initial pre-treatment score of 4-5 to 2 or less (5 were reduced to 0, 3 to 1 and 4 to 2). In only 1 case was the score 3. Remission of symptoms lasted for a period ranging from 11 to 108 months with an average of 51.6 months. No complications arose from the use of brachytherapy. Only one patient required embolization 3 years after the endonasal brachytherapy treatment.

Adult↗
PubMed1998

[Recurrent epistaxis in children as an indicator of hemostatic disorders].

OBJECTIVE: To distinguish which nosebleeds in children hide an underlying coagulation disorder, characteristics of recurrent epistaxis were evaluated correlating the severity with a battery of specific tests on primary and secondary hemostasis. PATIENTS AND METHODS: Epistaxis of fifty-eight children were classified as mild or severe according to frequency, duration, amount of blood lost, proportion of life that nosebleeds have been recurrent and uni- or bilateral bleeding. Epidemiological characteristics were evaluated, as well as hemostatic tests including: platelet count, mean platelet volume, plasmatic fibrinogen level, prothrombine time, activated partial thromboplastin time, thrombin time, bleeding time, von Willebrand factor antigen and ristocetin cofactor, factor VIII coagulant, and platelet aggregation to different agents. The effect of drugs or the presence of tumors was discarded. RESULTS: In the group of children with mild epistaxis (n = 39) there were three cases with laboratory abnormalities (10.3%). In severe epistaxis (n = 19) abnormalities were found in eleven cases (57.9%) and specific entities were detected in six of them (three children with von Willebrand's disease, one Bernard-Soulier syndrome, one autoimmune thrombocytopenic purpura and one Rendü-Osler-Weber disease). Epistaxis labeled as mild needed less cauterizations and packings, were more related to seasonal prevalence and self-handling, and poorly influenced iron metabolism. CONCLUSIONS: The five qualities pointed out on recurrent epistaxis in children allow the identification of who must be thoroughly studied by means of specific tests to rule out any kind of hemostatic disorder.

Adolescent↗
PubMed1995

Therapeutic embolization in the treatment of intractable epistaxis.

OBJECTIVE: To determine the effectiveness of therapeutic embolization in the treatment of intractable epistaxis. DESIGN: Cohort. SETTING: Tertiary care hospital. PATIENTS: Consecutive referred sample of 57 patients with intractable epistaxis. INTERVENTION: Percutaneous transfemoral catheterization and angiography of the internal maxillary arteries. Embolization of the most distal branches with 0.1- to 0.9- cm3 medium-sized polyvinyl alcohol particles on the suspected side of bleeding. OUTCOME: Outcome was successful if no further interventional treatment was required for epistaxis. RESULTS: Anatomical abnormalities precluded embolization in three patients. Three of the remaining 54 patients required supplementry embolization. Including these three patients, 52 (96%) of 54 patients had successful control epistaxis. The major neurologic complication rate was 6% (three of 54 patients), with no permanent deficits. CONCLUSIONS: Therapeutic embolization is an effective and safe technique and should be considered as the primary treatment modality in severe epistaxis.

Adolescent↗