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Introduction: Epistaxis in children is a very common reason for consultation in ENT and pediatric emergencies. Most of these epistaxis are benign, but it is their recurrence that motivates anxious parents, to consult. Allergic rhinitis is a common pathology among children in Tunisia, it seemed interesting to us to study the association between allergic rhinitis and epistaxis., Aim: Identify the clinical features and the risk factors for epistaxis in children with allergic rhinitis., Methods: Retrospective descriptive cohort study over a period of 4 years, including children, who consulted for epistaxis at the ENT and CCF department of FSI Hospital, La Marsa Tunis. All cases were divided into 2 groups: ERA+ Group: epistaxis with allergic rhinitis versus ERA- Group: epistaxis without allergic rhinitis., Results: 79 children were included, including 21 (26.6%) meeting the diagnostic criteria for allergic rhinitis. A female predominance was noted in the ERA+ group. In the ERA+ group, epistaxis mainly occurred in summer and autumn (38% and 28%) while it predominated in winter and summer in the ERA- group. Rhinorrhea and nasal pruritus were factors significantly associated with epistaxis in children with allergic rhinitis., Conclusion: the ENT doctor must think about allergic rhinitis in case of Repetitive epistaxis in a child, and look for suggestive symptoms, particularly rhinorrhea and nasal prurit.

Background: A growing body of literature explores environmental risk factors for pediatric epistaxis, yielding variable results. We aim to clarify these associations through a systematic review and meta-analysis., Methods: PubMed, Scopus, Cochrane Central Register of Control Trials, Web of Science, Medline, Google Scholars, and Embase were systematically searched up to April 2024. Eligible articles were reviewed, and the quality was assessed. A systematic review and meta-analysis was conducted to clarify correlations between the incidence of epistaxis and multiple environmental factors according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines., Results: A total of 8 studies, comprising 55,176 participants, met the inclusion criteria. The incidence of epistaxis peaked during the summer months (Proportion = 12.73 %, CI: 9.629 %-16.201 %). Significant risk factors included environmental variables elevated in the summer, including higher monthly mean temperatures, increased sunlight exposure, elevated O3 levels, and lower atmospheric pressure. In contrast, factors like mean monthly humidity, wind speed, SO2, CO, NO2, and PM-10 levels were not associated with an increased risk of epistaxis., Conclusions: This meta-analysis underscores the significant impact of multiple environmental factors, particularly those more pronounced during the summer months, on the incidence of pediatric epistaxis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: Epistaxis is a common condition that affects about 60% of the population in their lifetime, with 6% needing medical attention. Little is known about the epidemiology and risk factors of epistaxis outside the health care system. This study aimed to investigate the prevalence and risk factors of epistaxis in a rural Danish population using data from the Lolland-Falster Health Study (LOFUS)., Methods: We conducted a cross-sectional survey based on data from LOFUS, a household-based, prospective cohort study in the rural provincial area of Lolland-Falster, Denmark. We enrolled 10,065 participants (≥ 50 years) and collected data on demographics, comorbidities, medication, lifestyle factors, and laboratory parameters. Logistic regressions were used to test for correlations between epistaxis and different risk factors., Results: In total 5.3% of the participants had experienced epistaxis within the past 30 days, and 7.9% had sought medical attention for epistaxis at some point in their lives. We identified several factors that were significantly correlated with increased odds of epistaxis, such as male gender, age group 50-59 years, high BMI (> 25), allergy, diabetes, hypertension, atherosclerosis, angina, and anticoagulant treatment. Excellent or good self-reported health was correlated to significantly lower odds of epistaxis., Conclusion: This study provides a comprehensive overview of the prevalence and risk factors of epistaxis outside the health care system. Our study suggests that preventive measures targeting these risk factors may reduce the incidence and severity of epistaxis in this population., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Epistaxis is the most common otorhinolaryngological emergency and historically there have been an important debate whether there is a cause-effect relationship with high blood pressure., Aim: This retrospective study explored whether hypertension is a significant risk factor for epistaxis in Emergency Department (ED) patients and examined associations between blood pressure levels and epistaxis episodes., Materials and Methods: Two groups were studied: Group A (patients with epistaxis) and Group B (control). Patient characteristics, comorbidities, and medication use were recorded. Blood pressure measurements were taken upon ED arrival and after specialist evaluation. Statistical analyses included descriptive statistics, T-test, χ2 test, and logistic regression., Results: Group A, enrolled from April 2014 to February 2015, included 102 patients, mean age 67, male-female ratio 2:1. Blood pressure on arrival was over 140/90 mmHg in 73%, decreasing to 26% after 30 minutes. Group B, enrolled from May 2023 to August 2023, included 126 patients, mean age 59, male-female ratio 2:1. Blood pressure on arrival was over 140/90 mmHg in 60%, decreasing to 23% after 30 minutes. Both groups showed reduced blood pressure post-evaluation. Logistic regression identified anticoagulant and/or antiplatelet therapy as the main independent risk factor for epistaxis. Age, sex, blood pressure levels, and hypertension did not significantly influence epistaxis occurrence., Conclusion: No significant correlation between hypertension and epistaxis was found. Anticoagulant and/or antiplatelet therapy was the primary independent risk factor, highlighting the importance of considering medication history in evaluating epistaxis., (© 2024. The Author(s).)

Purpose: This study aims to investigate the bleeding sites and their relationship with clinical characteristics in hospitalized epistaxis patients., Methods: We retrospectively reviewed the data of 646 hospitalized epistaxis patients., Results: The bleeding sites were identified in 395 (61.1%) patients and unidentified in 251 (38.9%). We found that age > 50 years (P = 0.030) and the history of cardiovascular diseases (P = 0.027) were more frequent in patients with unidentified bleeding sites. Among patients with identified sites, inferior meatus (n = 130, 32.9%) was the most common site, followed by the septal surface of the olfactory region (n = 102, 25.8%), nasal septum (n = 80, 20.3%), middle meatus (n = 60, 15.2%), and others (n = 23, 5.8%). After dividing patients into five groups by the area of the bleeding sites, we found significant differences in age (P = 0.026), history of hypertension (P = 0.001), cardiovascular diseases (P = 0.032), and nasal packing (P = 0.011). The logistic regression also revealed that these four factors were predictors for different bleeding sites., Conclusion: The bleeding sites can be identified in most epistaxis patients. Age > 50 years and the history of cardiovascular diseases are more frequent in patients with unidentified bleeding sites. In our patients, the most common bleeding site is inferior meatus, followed by the septal surface of the olfactory region, nasal septum, and middle meatus. Age, histories of hypertension, cardiovascular diseases, and nasal packing are factors associated with the bleeding risks of different bleeding sites. According to the different clinical characteristics of patients, the order of the nasal endoscopic examination should be adjusted to develop their treatment plans., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: This study aimed to determine which comorbidities were associated with intractable epistaxis requiring electrocauterization or embolization, and to identify the location where intractable epistaxis frequently occurred., Methods: The patients were divided into two groups: patients with epistaxis successfully controlled in outpatient department (OPD) and those with intractable epistaxis in OPD which was controlled by surgical exploration or arterial embolization (OP/EM). Evaluations of the bleeding locations, related vessels, and patient's comorbidities were conducted., Results: A total of 41 patients from the OP/EM group and 725 patients from the OPD group were enrolled. The following comorbidities showed elevated risks of the intractable epistaxis (p< 0.05) in multivariate analysis; hypertension (OR 1.089, 95% CI 1.049 - 1.132), dyslipidemia (1.132, 1.041 - 1.232), liver cirrhosis (1.272, 1.152 - 1.406), chronic obstructive pulmonary disease (1.234, 1.078 - 1.412) and asthma (1.205, 1.053 - 1.379). Inferior and middle turbinate were equally the most common location of the intractable bleeding., Conclusion: In patients with epistaxis requiring hemostatic treatments, comorbidities such as hypertension, dyslipidemia, liver diseases, COPD, and asthma were associated with intractable epistaxis. The main bleeding sites of intractable epistaxis were the middle and inferior turbinate., Competing Interests: Declaration of competing interest All of authors declare that they have no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Background: Delayed epistaxis after endoscopic transnasal pituitary tumor resection (ETPTR) is a critical complication, tending to cause aspiration or hemorrhagic shock. This study assessed clinical characteristics, risk factors, and provide treatment and prevention advice of this complication., Methods: This was a retrospective monocentric analysis of 862 patients who underwent ETPTR. Statistical analyses of clinical data revealed the incidence, sources and onset time of delayed epistaxis. Univariate analysis and binary logistic regression were used to identify risk factors., Results: The incidence of delayed epistaxis was 2.78% (24/862), with an average onset time of 20.71 ± 7.39 days. The bleeding sources were: posterior nasal septal artery branch of sphenopalatine artery (12/24), multiple inflammatory mucosae (8/24), sphenopalatine artery trunk (3/24) and sphenoid sinus bone (1/24). Univariate analysis and binary logistic regression analysis confirmed that hypertension, nasal septum deviation, chronic rhinosinusitis and growth hormone pituitary tumor subtype were independent risk factors for delayed epistaxis. Sex, age, history of diabetes, tumor size, tumor invasion and operation time were not associated with delayed epistaxis. All patients with delayed epistaxis were successfully managed through endoscopic transnasal hemostasis without recurrence., Conclusions: Delayed epistaxis after ETPTR tends to have specific onset periods and risk factors. Prevention of these characteristics may reduce the occurrence of delayed epistaxis. Endoscopic transnasal hemostasis is recommended as the preferred treatment for delayed epistaxis., (© 2024. The Author(s).)

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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

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., (© 2023 ARS-AAOA, LLC.)

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., (© 2023 John Wiley & Sons Ltd.)

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., (© 2023. The Author(s).)

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., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2023 Jing Qing et al.)

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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ahn and Min.)

Purpose: The Curaçao criteria are well-established diagnostic criteria for hereditary hemorrhagic telangiectasia (HHT), but they lack details regarding a predictive presentation of epistaxis and telangiectasias. This study collects and compares data in HHT and population cohorts to inform the application of these criteria., Methods: In-person interviews regarding epistaxis and targeted examination for telangiectases in a general population cohort (n = 204) and an HHT cohort (n = 432) were conducted., Results: Frequency of epistaxis, rather than intensity or duration, was the best discriminator of HHT. A cutoff of ≥4 nosebleeds per year alone yielded a diagnostic sensitivity of 97%, and specificity of 84%. The mean number of telangiectases at the sites investigated was 0.4 in the general population cohort and 26.5 in the HHT cohort. The most distinctive sites for telangiectases in HHT were lips and palmar fingers, whereas telangiectases of the face and dorsum of the hand were comparable in both cohorts., Conclusion: We propose that the Curaçao criteria be modified to include the following cutoffs: (1) epistaxis frequency of ≥4 nosebleeds per year and (2) telangiectasia count of at least 2 in characteristic locations (palmar aspect of fingers, lips, and oral cavity), and that cutaneous telangiectases at other sites not be considered relevant for diagnostic purposes., Competing Interests: Conflict of Interest The authors declare no conflicts of interest., (Published by Elsevier Inc.)

Objective: There is anecdotal evidence SARS-CoV-2 (COVID) RT-PCR screening nasal swabs confer an elevated epistaxis risk. We aimed to assess the association between epistaxis and exposure to a COVID nasal swab., Study Design: A matched pairs design was used., Setting: The study was performed in a single, integrated health care system., Methods: All patients who received a single COVID nasal swab at our institution between April 2020 and March 2021 were included. McNemar's test was used to compare rates of epistaxis between the 7 days following the index COVID swab (hazard period), and the 7 days preceding the index COVID swab (control period). Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis., Results: A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis during the hazard period (95% confidence interval [1.73, 2.12]). Older age, Asian/Pacific Islander (PI) (compared to white), male sex, hypertension, prior facial trauma, and warfarin or direct-acting oral anticoagulant use were also associated with significantly increased odds of epistaxis (p ≦ 0.01)., Conclusion: COVID nasal swabs are associated with increased odds of epistaxis. Physicians should counsel patients, particularly those at the highest risk, including a history of prior facial trauma, anticoagulants/antiplatelets, or hypertension., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

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., Competing Interests: None

Introduction: Data describing safety and tolerability of anticoagulation and antiplatelet therapy in hereditary hemorrhagic telangiectasia (HHT), the second-most-common inherited bleeding disorder, is limited., Methods: We performed a scoping review, searching MEDLINE and EMBASE from inception to March 2023 for eligible studies reporting detailed clinical data describing antithrombotic use in HHT. Data extracted included study design, patient population, and characteristics and outcomes of antithrombotic therapy., Results: Of 625 unique manuscripts identified through database search, 77 were included: 64 case reports/case series describing 65 patients and 13 cohort studies. Data were extracted on a total of 466 patients with HHT, covering 587 episodes of antithrombotic therapy. The most common reasons for antithrombotic therapy were venous thromboembolism (VTE) (44.6 %), atrial arrhythmias (17.8 %) and stroke (10.5 %). anticoagulation was used in in 356 episodes (61.9 %), antiplatelet therapy in 140 episodes (24.3 %), and both together in 50 episodes (8.7 %). Complications of therapy included worsened HHT-associated bleeding (primarily epistaxis and gastrointestinal bleeding) in 198 antithrombotic treatment episodes (38.9 %) and premature antithrombotic therapy discontinuation in 142 episodes (28.9 %). Bleeding-directed therapy (local ablative therapy and systemic therapies) were employed to address worsening bleeding in 14.6 % of episodes. No specific complications of therapy were reported in 322 total antithrombotic events (58.4 %). Rates of bleeding (8.3 % to 80 %), therapy discontinuation (14.3 % to 57.1 %), and other complications ranged considerably from study to study., Conclusion: Current publications vary widely on the outcomes and tolerability of antithrombotics in HHT, but confirm the clinical challenge of adequate antithrombotic therapy in this population. More formal studies are needed to better guide optimal antithrombotic use in HHT., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Universal Disclosures (none relevant to the content of the manuscript): Zhang: No disclosures. Virk: No disclosures. Rodriguez-Lopez: No disclosures. Al-Samkari: Universal disclosures include consultancy (Agios, Dova, Rigel, Argenx, Sobi, Novartis, Moderna) and research funding to institution (Agios, Dova, Amgen, Novartis, Vaderis)., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

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., (© 2023. The Author(s).)

Objectives: To describe management, and to assess factors associated with antithrombotic prescription thereafter in patients who had epistaxis referred to emergency department (ED)., Design: Prospective cohort study. From EDs, clinical, biological and hospital data were collected. The clinical database was linked to the French Health Insurance Database where we retrieved antithrombotic drug deliveries in a 3-month period before and after referral., Setting: Multicentric population-based cohort study within five well-defined areas., Participants: We considered 306 patients referred for epistaxis with a stable oral antithrombotic regimen before referral., Main Outcome Measures: We considered management, hospital outcome and case fatality. Antithrombotic prescription in a 3-month follow-up period was categorised into three classes: no change, class change, or discontinuation. During follow-up, hospitalisation for epistaxis or ischaemic events was searched., Results: Among 306 adult individuals (mean age: 76 years), 166 took oral anticoagulant and 140 an antiplatelet drug. Blood transfusion was needed in 13.7% of patients and anterior packing alone in 61%. Half of the patients were hospitalised; 301 were discharged alive. Considering antithrombotic prescription thereafter we observed no change in 219 patients (72.8%), class changes in 47 patients (15.6%) and discontinuation in 35 patients (11.6%). We identified four independent predictors for antithrombotic prescription: hospitalisation (vs. returning home, p = .05), age (p = .03), haemoglobin level (p = .03) and oral anticoagulant (vs. antiplatelet agent, p < .001). During the 3 months following discharge, 2 thrombotic and 15 bleeding events were identified., Conclusions: Epistaxis referred to emergency department had an impact on subsequent antithrombotic prescription., Clinical Trial Registration: Clinical Trials.gov identifier: NCT02886533., (© 2023 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd.)

Background: Climate change has been associated with an increase in extreme weather conditions. The aim of this study was to identify environmental factors and the effect of extreme weather events (95th percentile) on the risk for epistaxis-related emergency room visits (EV)., Methods: A total of 2179 epistaxis-related EVs were identified between 2015 and 2018. A distributed lag non-linear model was fitted to investigate the relationship between extreme weather conditions and the total number of epistaxis-related EVs per day. Cumulative relative risk (cRR) is defined as the cumulated daily risk of EV for epistaxis within a stated period after an extreme weather condition compared to the risk of EV at the median value of that weather condition., Results: At a mean daily temperature of 27°C (P95), cRR for epistaxis-related EV was 2.00. At a relative humidity of 39% (P5), cRR was highest on day 3 at 1.59, while extremely high humidity (92%, P99) led to a decreased cRR of 0.7 on day 1. Intense precipitation of 24mm (P99) reduced the cRR on day 3 to 0.38. For prolonged extreme conditions over three days, extremely low wind speed, as well as both high and low atmospheric pressure events, diminished cRR., Conclusions: Extreme temperatures, relative humidity, and precipitation, as well as extended periods of extreme wind speeds and atmospheric pressure, significantly impact cRR for epistaxis-related EVs.

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.

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., (© 2022 Royal Australasian College of Surgeons.)

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.

Background: Although recent studies have identified an association between race and adverse outcomes in head and neck surgeries, there are limited data examining the impact of racial disparities on adult inpatient outcomes following epistaxis management procedures., Objective: To analyze the association between race and adverse outcomes in hospitalized patients undergoing epistaxis treatment., Methods: This retrospective cohort analysis utilized the 2003 to 2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify cases with a primary diagnosis of epistaxis that underwent a procedure for epistaxis control. Cases with missing data were excluded. Higher total charges and prolonged length of stay (LOS) were indicated by values greater than the 75th percentile. Demographics, hospital characteristics, Elixhauser comorbidity score, and complications were compared among race cohorts using univariate chi-square analysis and one-way analysis of variance (ANOVA). The independent effect of race on adverse outcomes was analyzed using multivariate binary logistic regression while adjusting for the aforementioned variables., Results: Of the 83 356 cases of epistaxis included, 80.3% were White, 12.5% Black, and 7.2% Hispanic. Black patients had increased odds of urinary/renal complications (odds ratio [OR] 2.148, 95% confidence interval [CI] 1.797-2.569, P  < .001) compared to White patients. Additionally, Black patients experienced higher odds of prolonged LOS (OR 1.227, 95% CI 1.101-1.367, P  < .001) and higher total charges (OR 1.257, 95% CI 1.109-1.426, P  < .001) compared to White patients. Similarly, Hispanic patients were more likely to experience urinary/renal complications (OR 1.605, 95% CI 1.244-2.071, P < .001), higher total charges (OR 1.519, 95% CI 1.302-1.772, P  < .001), and prolonged LOS (OR 1.157, 95% CI 1.007-1.331, P  = .040) compared to White patients., Conclusion: Race is an important factor associated with an increased incidence of complications in hospitalized patients treated for epistaxis.

The differential effect of meteorological factors and air pollutants on pediatric epistaxis in younger and older children has not been evaluated. We evaluated the distribution of pediatric epistaxis cases between younger (0-5 years) and older children (6-18 years). Subsequently, we assessed and compared the effects of meteorological variables and the concentration of particulate matter measuring ≤ 10 μm in diameter (PM10) on hospital epistaxis presentation in younger and older children. This retrospective study included pediatric patients (n = 326) who presented with spontaneous epistaxis between January 2015 and August 2019. Meteorological conditions and PM10 concentration were the exposure variables, and data were obtained from Korea Meteorological Administration 75. The presence and cumulative number of epistaxis presentations per day were considered outcome variables. Air temperature, wind speed, sunshine duration, and PM10 concentration in younger children, and sunshine duration and air pressure in older children, significantly correlated with the presence of and cumulative number of epistaxis presentations per day. The PM10 concentration was not a significant factor in older children. Thus, meteorological factors and PM10 concentration may differentially affect epistaxis in younger (0-5-year-olds) and older (6-18-year-olds) children. Risk factors for pediatric epistaxis should be considered according to age., (© 2022. The Author(s).)

Background: There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed., Methods: A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0-2657 days)., Results: Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0-8 times)., Conclusion: Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

Objective: Several studies have demonstrated that environmental factors, such as meteorological factors and air pollutants, are closely associated with epistaxis. However, age-specific associations between environmental factors and epistaxis have not yet been evaluated. This study aimed to evaluate the associations between individual meteorological factors and air pollutants and epistaxis, by age., Study Design: A retrospective cohort study., Setting: Records of patients covered by the Korean National Health Insurance Service who visited our hospital for epistaxis between January 1, 2002, and December 31, 2015, were retrospectively reviewed., Methods: The 46,628 enrolled patients were divided into four age groups: age group 0 (<18 years, N = 19,580); age group 1 (18-40 years, N = 10,978); age group 2 (41-70 years, N = 13,395); and age group 3 (>70 years, N = 2,675). Cases of epistaxis and data on environmental factors were analyzed according to the day, month, and year. Stepwise logistic regression was performed to identify the environmental risk factors for epistaxis in each age group., Results: Age group 0 had the highest number of patients with epistaxis, whereas age group 3 had the lowest. Relative humidity, temperature, concentrations of particulate matter (PM10) and sulfur dioxide, sunshine duration, and wind speed were significantly associated with the occurrence of epistaxis in the study population. However, analysis according to age group showed that the meteorological factors and air pollutants associated with epistaxis were different in each age group., Conclusion: We suggest that the environmental risk factors for epistaxis should be differentially analyzed according to age., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ahn and Min.)

Background: Although epistaxis is one of the most common side effects of oral anticoagulation, it is unclear whether epistaxis rates vary between different oral anticoagulants (OAC)., Objective: To compare rates of clinically relevant epistaxis between OAC., Methods: Epistaxis event rates were compared between new users of apixaban, dabigatran, rivaroxaban, and warfarin in a nationwide population-based cohort study over a 5-year study period, 2014-2019. Data was collected from the Icelandic Medicine Registry and the five major hospitals in Iceland. Inverse probability weighting (IPW) was used to yield balanced baseline characteristics, and epistaxis rates were compared using Kaplan-Meier survival estimates and Cox regression., Results: During the study period, 2098 patients received apixaban, 474 dabigatran, 3106 rivaroxaban, and 1403 warfarin. In total, 93 patients presented with clinically relevant epistaxis, including 11 (12%) major epistaxis events and one fatal epistaxis episode. Furthermore, seven patients (9%) with non-major epistaxis later presented with major bleeding during the follow-up period. Warfarin use was associated with higher rates of epistaxis compared to apixaban (2.2 events per 100-person years (events/100-py) vs. 0.6 events/100-py, hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.08-8.59, p < 0.001), rivaroxaban (2.2 events/100-py vs. 1.0 events/100-py, HR 2.26, 95% CI 1.28-4.01, p = 0.005), and dabigatran (2.2 events/100-py vs. no events, HR n/a, p < 0.001)., Conclusion: Warfarin treatment was associated with higher rates of clinically relevant epistaxis compared to direct oral anticoagulants., (© 2022 The Association for the Publication of the Journal of Internal Medicine.)

Background: Epistaxis after endoscopic endonasal skull base surgeries does not typically occur as an accidental circumstance but often results from multiple factors. We aimed to assess the possible risk factors associated with postoperative epistaxis., Methods: Patients who underwent endoscopic endonasal skull base surgery at Huashan hospital from August 2018 to November 2019 were enrolled in the study. Postoperative epistaxis was defined as severe, persistent, or recurrent arterial nosebleed, which required therapeutic intervention. Patients were divided into the epistaxis and no epistaxis groups. The incidence, clinical characteristics, management, and intraoperative findings were recorded., Results: A total of 762 patients were included in the study. 20 (2.6%) patients experienced postoperative epistaxis, which happened in a delayed fashion between 6 and 30 postoperative days. Multivariate logistic regression analysis showed that arterial hypertension (OR=3.394, 95%CI: 1.094-10.531, P = 0.034) and preoperative systolic blood pressure (SBP) (OR=1.035, 95%CI: 1.002-1.068) were identified as predictors for postoperative epistaxis. The bleeding sites were identified at the left posterior septal artery (PSA) in 10 (62.5%) cases, the right PSA in 4 (25%) cases, the left palatovaginal artery in 1 (6.25%) case, and the right inferior turbinate branch of the posterior lateral nasal artery in 1 (6.25%) case, respectively. Direct bipolar cauterization was used to stop the bleeding. After definitive treatment, no patients had recurrent epistaxis., Conclusions: Arterial hypertension and preoperative SBP were associated with postoperative epistaxis after endoscopic endonasal skull base surgery, and the left PSA contributed to the dominant site of bleeding during surgical re-exploration., (Copyright © 2022. Published by Elsevier B.V.)

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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors do not declare any conflict of interest.

Introduction: Von Willebrand disease (VWD) is the most common inherited bleeding disorder. The bleeding phenotype is variable, and some individuals have persistent symptoms post-diagnosis., Aim: To characterize bleeding patterns in patients with VWD before and after diagnosis., Methods: De-identified claims data for commercially insured patients in the IQVIA PharMetrics® Plus US database (Jan-2006 to Jun-2015) were extracted. Eligible patients had ≥2 claims for VWD (ICD-9 code 286.4), and continuous health-plan enrolment for ≥2 years before and after diagnosis. Bleeding event, treatment and treating-physician type were analysed for 18 months before and 7-24 months after diagnosis, according to pre-diagnosis bleeding phenotype (claims from one vs multiple bleed sites) and post-diagnosis bleeding status (resolved [no post-diagnosis bleed claims] vs continued [≥1 claim])., Results: Data for 3756 eligible patients (72.6% female; 71.0% aged ≥18 years at diagnosis) were analysed. Overall, 642 (17.1%) and 805 (21.4%) patients had single- and multiple-site bleed claims pre-diagnosis, respectively, and 1263 (33.6%) patients (38.5% of women, 20.8% of men) continued to bleed post-diagnosis. Multiple-site bleeding was associated with pre-diagnosis heavy menstrual bleeding (HMB), oral contraceptive (OC) use and nasal cauterization. Continued bleeding post-diagnosis was associated with pre-diagnosis gastrointestinal bleeding, HMB and epistaxis; pre-diagnosis use of OCs, aminocaproic acid and nasal cauterization; and younger age at diagnosis. Few patients consulted a haematologist for bleed management., Conclusion: Many patients with VWD have persistent bleeding from multiple sites and continue to bleed post-diagnosis. Our findings suggest a need to optimize management to reduce the symptomatic burden of VWD following diagnosis., (© 2021 The Authors. Haemophilia published by John Wiley & Sons Ltd.)

Background: Epistaxis is the main complaint in patients with Hereditary haemorrhagic telangiectasia (HHT). Even though the role of epistaxis in affecting the quality of life (QoL) is well-known, little is known about epidemiological and clinical factors contributing to epistaxis severity and QoL., Methodology: This is a cross-sectional study, including adult patients with HHT with epistaxis. All patients underwent an otolaryngological evaluation with nasal endoscopy. Epistaxis severity was graded using the FID score, and QoL was evaluated with the Short-Form Health Survey (SF-36). Descriptive statistics were produced for demographic characteristics; the Shapiro-Wilk test was used to test the normal distribution of quantitative variables. Correlation between the quantitative variables was evaluated with Pearson's correlation coefficient. Both univariate and multivariate linear regression models were fitted to find associations between demographic or clinical factors and the FID score or SF-36., Results: A total of 234 patients with HHT were included in the study. The univariate analysis highlighted the association between high blood pressure, septal perforation, nocturnal epistaxis, surgery, blood transfusion, hormonal therapy and both FID score and QoL. Sex, allergic rhinitis and nasal polyposis were neither related to epistaxis severity nor perceived health., Conclusions: Epistaxis severity and QoL in patients with HHT are influenced by several clinical factors both dependent and independent from HHT. Some of the results are consistent with those already published, but for the first time, we extended the analysis to different clinical parameters, such as endoscopic findings, never assessed before.

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)., (Copyright © 2021 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)

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., (© 2021 John Wiley & Sons Ltd.)

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., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Stamm's S-point is gaining importance as a bleeding focus in severe epistaxis. However, prevalence and features of S-point bleeding compared to non S-point bleeding have not been studied., Objective: To investigate the characteristics of patients with S-point bleeding among those with severe epistaxis and to compare the factors involved in the treatment of epistaxis., Methods: We retrospectively analyzed medical records of 268 patients admitted to the otorhinolaryngology department of Konkuk University Hospital and Chung-Ang University Hospital with epistaxis of which the bleeding focus clarified. Patients with anterior nasal bleeding (n=129) were excluded. The study was conducted at the department of otorhinolaryngology from January 2008 to August 2019. Collected data included patients' demographic information, bleeding focus, body mass index underlying medical and sinonasal diseases, laboratory test results (initial hemoglobin, platelet count, and triglyceride level), use of anticoagulants, direction of epistaxis, initial and final treatments, and need for blood transfusion., Results: The prevalence of S-point bleeding was 28.8% of non-anterior bleeding cases. Mean body mass index score was lower in the S-point group (23.41±3.71) compared to the non S-point group (24.93±3.97) (p=0.039). Underweight patients tended to show a greater incidence of S-point bleeding (15.0%) than non S-point bleeding (2.0%) (p=0.010). Incidence of anemia was higher in the S-point group (67.5%) than in the non S-point group (36.4%). Anemia (Odds ratio [OR]: 3.635; 95% confidence interval [CI]: 1.669-7.914, p=0.001) and underweight (body mass index<18.5, OR: 8.559, CI: 1.648-44.445, p=0.011) were significantly associated with S-point bleeding., Conclusion: Prevalence of S-point bleeding was significant, underlining the importance of examining the S-point in patients with severe epistaxis. Patients with S-point bleeding had lower body mass index scores and a higher incidence of anemia than those with non S-point bleeding., (Copyright © 2020 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

Introduction: von Willebrand Disease (vWD) is the most prevalent bleeding disorder. Women are more likely to manifest abnormal bleeding symptoms due to physiologic events and menorrhagia is the most common presenting symptom., Methods: this case-control study included 168 women aged between 18 and 45. The cases had menorrhagia whilst the controls did not. Blood grouping, activated partial thromboplastin time and von Willebrand factor activity tests were performed on samples collected from consenting study participants., Results: the mean age was 29.96 ± 7.37. Mean vWF activity of cases was 66.6% and of controls 97.8%. The mean activated Partial ThromboplastinTime (aPTT) of cases was 31.09s and of controls was 30.40s. There was no difference in the vWF activity between blood group O (86.3%) and non-blood group O (88.0%) participants. Eight women were diagnosed with von Willebrand disease, 6 cases and 2 controls. Higher odds of von Willebrand disease were seen in the cases (OR = 6.6). Epistaxis, von Willebrand and factor activity levels and family history of menorrhagia were associated with an increased risk for menorrhagia., Conclusion: von Willebrand factor activity levels were associated with menorrhagia while activated partial thromboplastin time was not. vWF activity levels did not depend on any specific blood group. The prevalence of von Willebrand disease was significantly higher in participants with menorrhagia and repeated epistaxis and family history of menorrhagia pointed to a higher risk of menorrhagia., Competing Interests: The authors declare no competing interests., (Copyright: Miyoba Melinda Munsanje et al.)

Objectives: To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED)., Design: Prospective multicentre national audit over 12 weeks from 6th April 2020., Setting: UK secondary care ENT departments., Participants: Adult patients with acute epistaxis., Main Outcome Measures: Re-presentation within 10 days for patients discharged from the ED., Results: Eighty three centres from all four UK nations submitted 2631 valid cases. The majority of cases were ED referrals (89.7%, n = 2358/2631). 54.6% were discharged from the ED following ENT review (n = 1267/2322), of whom 19.5% re-presented within 10 days (n = 245/1259) and 6.8% were ultimately admitted (n = 86/1259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n = 1099/2355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n = 332/1125), 18.2% re-presented (n = 60/330); dissolvable products, 71.1% discharged (n = 488/686), 21.8% re-presented (n = 106/486); cautery only, 89.2% discharged (n = 247/277), 20.0% re-presented (n = 49/245); and no intranasal intervention, 85.5% discharged (n = 200/234), 15.2% re-presented (n = 30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10 days., Conclusions: Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis., (© 2021 John Wiley & Sons Ltd.)

The impact of atmospheric concentration of particulate matter ≤10 μm in diameter (PM 10 ) continues to attract research attention. This study aimed to evaluate the effects of meteorological factors, including PM 10 concentration, on epistaxis presentation in children and adults. We reviewed the data from 1557 days and 2273 cases of epistaxis between January 2015 and December 2019. Eligible patients were stratified by age into the children (age ≤17 years) and adult groups. The main outcome was the incidence and cumulative number of epistaxis presentations in hospital per day and month. Meteorological factors and PM 10 concentration data were obtained from the Korea Meteorological Administration. Several meteorological factors were associated with epistaxis presentation in hospital; however, these associations differed between children and adults. Only PM 10 concentration was consistently associated with daily epistaxis presentation in hospital among both children and adults. Additionally, PM 10 concentration was associated with the daily cumulative number of epistaxis presentations in hospital in children and adults. Furthermore, the monthly mean PM 10 concentration was significantly associated with the total number of epistaxis presentations in the corresponding month. PM 10 concentration should be regarded as an important environmental factor that may affect epistaxis in both children and adults.

Background: The primary objective was to describe outpatient treatment of epistaxis among different physicians based on a large patient population over a period of 10 years. The secondary objective was to evaluate the value of the practice fee as an instrument of allocation in patients with epistaxis., Methods: Anonymized statutory health insurance data (AOK Lower Saxony) of patients with a diagnosis of epistaxis treated between 2007 and 2016 were examined. Demographic data, accompanying diagnoses, medication and involved medical groups (general practitioners (GP), pediatricians, ear, nose and throat (ENT) specialists or other) were analyzed. Furthermore, we assessed whether the use of specialist groups changed after abolition of the practice fee in 2013., Results: Epistaxis was responsible for 302,782 cases (160,963 patients). The distribution of cases was slightly in favor of ENT specialists vs. GP (119,170 vs. 110,352). The cases seen by GP and ENT specialists were comparable with regard to age and sex distribution. Hypertension, atrial fibrillation/flutter and an antithrombotic therapy were slightly more common among cases consulting a GP. The GP recorded more co-diagnoses than the ENT. The use of outpatient care and the proportions of the involved physicians scarcely fluctuated during the study period. Overall, 23,118 patients (14.4%) were diagnosed by both, GP and ENT during a relatively short time period. The practice fee remuneration had no impact on the consultation of the physician groups., Conclusion: The outpatient treatment of epistaxis constitutes a considerable medical and economic burden in Germany. Strengthening the primary medical sector (GP-centered care) is necessary to reach the goal of initially directing patients to primary care, providing specialists more time for severe cases and reducing the impact on public health balance sheets.

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., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Epistaxis is a common symptom in the medical practice. It is associated with various comorbidities and the use of medications, especially anticoagulants. Despite the high lifetime prevalence, there is limited data on prevalence and possible risk factors., Methods: The study examines epistaxis care in a large patient population (AOK Lower Saxony) over a ten-year period (2007-2016). Risk factors, age at diagnosis, concomitant medication and comorbidities were analysed and the prevalence in the study period calculated., Results: 162,167 patients visited their doctors between 2007-2016 (308,947 cases). Most patients were treated as outpatients (96.6%) and 54% of patients were men. Over the study period, the prevalence of epistaxis rose by 21% (increase from 8.6 to 9.3 per 1000 insured persons per year) with a comparatively stable prevalence for the inpatient setting (0.2 per 1000 insured persons per year). In 54,105 of all epistaxis cases (17.5%), the use of antithrombotic drugs was recorded (oral anticoagulants: 9.5%). During the study period, increased prescribing of oral anticoagulants (from 7.7% of cases in 2007 to 11.8% in 2016), especially of NOAC was documented (from 0.1% of cases in 2011 to 5.1% in 2016)., Conclusion: In addition to arterial hypertension, the predominant male sex and the typical age distribution, we found that cases of epistaxis often received anticoagulation therapy. This study showed an increase of epistaxis along with rising prescriptions of NOAC. In contrast, no increase of severe epistaxis cases leading to hospitalization was found.

Background: For nasotracheal intubation, the nasal pathway between the inferior turbinate and hard palate (lower pathway) is preferred for patient safety. However, selecting the lower pathway can be challenging because passage of the tube through the nasal pathway is usually performed blindly., Objectives: We investigated whether facing the bevel of the tracheal tube in the cephalad direction of the patient could help in advancing the tracheal tube through the lower pathway during nasotracheal intubation., Design: A randomised, blinded trial., Setting: SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea from January 2019 to March 2020., Patients: Sixty-eight adult patients undergoing oromaxillary surgeries were enrolled in this study., Interventions: Patients were randomly allocated to undergo nasotracheal intubation with the bevel of the tube facing the cephalad direction (intervention group) or to the left (conventional group)., Main Outcome Measures: The effects of bevel direction on the pathway of the tube in the nasal cavity, and the incidence of epistaxis were evaluated by fibreoptic bronchoscopy., Results: The success rate of the tracheal tube passing through the lower pathway was significantly higher in the intervention group than the conventional group (79.4 vs. 55.9%, relative risk 1.421, 95% CI 1.007 to 2.005, P = 0.038). The incidence of epistaxis was also lower in the intervention group than in the conventional group (41.2 vs. 73.5%, relative risk 0.560, 95% CI 0.357 to 0.878, P = 0.007)., Conclusions: Facing the bevel of the tracheal tube in the cephalad direction of the patient facilitated selection of the lower pathway and reduced the incidence of epistaxis during nasotracheal intubation in patients undergoing oromaxillary surgery., Trial Registration: ClinicalTrial.gov, NCT03740620., (Copyright © 2020 European Society of Anaesthesiology. All rights reserved.)

Introduction: Postoperative bleeding after orthognathic surgery is a rare but life-threatening complication. Maxillary surgery is the main cause of bleeding, after which excessive epistaxis can occur until the 10th postoperative day. Due to the risk of secondary bleeding, the patient discharge process may be complicated for both the patient and clinician. Thus far, no studies have explored massive intra- and postoperative bleeding in patients undergoing orthognathic surgery. Therefore, this study was performed to determine the prevalence of postoperative secondary bleeding and its correlation with intraoperative massive bleeding in patients undergoing orthognathic surgery., Materials and Methods: A total of 206 orthognathic surgery patients were included in this retrospective study. Perioperative data was collected by determining the number of patients who referred to the clinic for treatment of secondary bleeding. The following parameters were recorded: occurrence of intraoperative massive bleeding, pre- and postoperative haemoglobin and haematocrit values, intraoperative projected bleeding, amount of intravenous liquid needed, and length of hospital stay. In addition, the association between secondary and intraoperative massive bleeding was investigated., Results: Two of 206 patients (0.97%) experienced both massive intraoperative bleeding and massive postoperative bleeding., Conclusion: Intra- and postoperative massive bleeding occurred only in a small number of patients; thus, longer hospitalisation and strict follow-up of this small group of patients may be required., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: Epistaxis is a commonly encountered condition; however, factors that have been associated with epistaxis are controversial. Although several previous studies have evaluated the relationship between meteorological factors and epistaxis, studies conducted in Korea has been nearly reported. We attempted to evaluate the meteorological factors associated with the frequency of patients presenting with epistaxis in a tertiary hospital., Methods: We retrospectively reviewed the medical records of patients presenting with spontaneous epistaxis in an urban tertiary medical center, during one year. Patients with a clear etiology for epistaxis (such as trauma, previous surgery) were regarded as cases of secondary epistaxis and were excluded from this study. Daily climatic data were collected from the website of Korea Meteorological Administration. Meteorological factors affecting the frequency of patients presenting with epistaxis were statistically analyzed., Results: Among 350 enrolled subjects, 219 were males and 131 were females, and the mean age was 44.94 ± 26.02 years. Univariate and multivariate regression analyses revealed that minimal temperature and mean wind speed were significant factors that affected the presence of patients presenting with epistaxis to the hospital. Furthermore, ordinal logistic regression analysis showed that decreases in minimal temperature and mean relative humidity were associated with a increase in the number of patients presenting with epistaxis., Conclusion: Minimal temperature and mean wind speed were significantly different between days with epistaxis and days without epistaxis patients presenting with epistaxis, and minimal temperature and mean relative humidity were associated with number of patients presenting with epistaxis. Our findings suggested that these meteorological factors might affect the spontaneous epistaxis in Seoul, Korea., Competing Interests: Declaration of Competing Interest Not applicable., (Copyright © 2020. Published by Elsevier B.V.)

Background: Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre., Methods: After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019., Results: An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients., Conclusions: Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns.