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American Family Physician Aug 2018Epistaxis is a common emergency encountered by primary care physicians. Up to 60% of the general population experience epistaxis, and 6% seek medical attention for it.... (Review)
Review
Epistaxis is a common emergency encountered by primary care physicians. Up to 60% of the general population experience epistaxis, and 6% seek medical attention for it. More than 90% of cases arise from the anterior nasal circulation, and most treatments can be easily performed in the outpatient setting. Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency. When examining the nose, a nasal speculum and a good light source, such as a headlamp, can be useful. Compressive therapy is the first step to controlling anterior epistaxis. Oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1: 1,000 may be useful adjuncts to compressive therapy. Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source. Finally, topical therapy and nasal packing can be used if other methods are unsuccessful. Compared with anterior epistaxis, posterior epistaxis is more likely to require hospitalization and twice as likely to need nasal packing. Posterior nasal packing is often associated with pain and a risk of aspiration if it is dislodged. After stabilization, patients with posterior packing often require referral to otolaryngology or the emergency department for definitive treatments.
Topics: Ambulatory Care; Epistaxis; Humans; Nose; Patient Care Management
PubMed: 30215971
DOI: No ID Found -
Annals of Internal Medicine Dec 2020Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular...
DESCRIPTION
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications.
METHODS
The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved.
RECOMMENDATIONS
The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.
Topics: Anemia; Arteriovenous Malformations; Child; Epistaxis; Gastrointestinal Hemorrhage; Genetic Diseases, Inborn; Humans; Liver; Telangiectasia, Hereditary Hemorrhagic
PubMed: 32894695
DOI: 10.7326/M20-1443 -
The Cochrane Database of Systematic... Jul 2013Intravenous tranexamic acid reduces bleeding in surgery, however, its effect on the risk of thromboembolic events is uncertain and an increased risk remains a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intravenous tranexamic acid reduces bleeding in surgery, however, its effect on the risk of thromboembolic events is uncertain and an increased risk remains a theoretical concern. Because there is less systemic absorption following topical administration, the direct application of tranexamic acid to the bleeding surface has the potential to reduce bleeding with minimal systemic effects.
OBJECTIVES
To assess the effects of the topical administration of tranexamic acid in the control of bleeding.
SEARCH METHODS
We searched the Cochrane Injuries Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library; Ovid MEDLINE®, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily and Ovid OLDMEDLINE®; Embase Classic + Embase (OvidSP); PubMed and ISI Web of Science (including Science Citation Index Expanded and Social Science Citation Index (SCI-EXPANDED & CPCI-S)). We also searched online trials registers to identify ongoing or unpublished trials. The search was run on the 31st May 2013.
SELECTION CRITERIA
Randomised controlled trials comparing topical tranexamic acid with no topical tranexamic acid or placebo in bleeding patients.
DATA COLLECTION AND ANALYSIS
Two authors examined the titles and abstracts of citations from the electronic databases for eligibility. Two authors extracted the data and assessed the risk of bias for each trial. Outcome measures of interest were blood loss, mortality, thromboembolic events (myocardial infarction, stroke, deep vein thrombosis and pulmonary embolism) and receipt of a blood transfusion.
MAIN RESULTS
We included 29 trials involving 2612 participants. Twenty-eight trials involved patients undergoing surgery and one trial involved patients with epistaxis (nosebleed). Tranexamic acid (TXA) reduced blood loss by 29% (pooled ratio 0.71, 95% confidence interval (CI) 0.69 to 0.72; P < 0.0001). There was uncertainty regarding the effect on death (risk ratio (RR) 0.28, 95% CI 0.06 to 1.34; P = 0.11), myocardial infarction (RR 0.33, 95% CI 0.04 to 3.08; P = 0.33), stroke (RR 0.33, 95% CI 0.01 to 7.96; P = 0.49), deep vein thrombosis (RR 0.69, 95% CI 0.31 to 1.57; P = 0.38) and pulmonary embolism (RR 0.52, 95% CI 0.09 to 3.15; P = 0.48). TXA reduced the risk of receiving a blood transfusion by a relative 45% (RR 0.55, 95% CI 0.55 to 0.46; P < 0.0001). There was substantial statistical heterogeneity between trials for the blood loss and blood transfusion outcomes.
AUTHORS' CONCLUSIONS
There is reliable evidence that topical application of tranexamic acid reduces bleeding and blood transfusion in surgical patients, however the effect on the risk of thromboembolic events is uncertain. The effects of topical tranexamic acid in patients with bleeding from non-surgical causes has yet to be reliably assessed. Further high-quality trials are warranted to resolve these uncertainties before topical tranexamic acid can be recommended for routine use.
Topics: Administration, Topical; Antifibrinolytic Agents; Blood Loss, Surgical; Epistaxis; Hemorrhage; Humans; Randomized Controlled Trials as Topic; Tranexamic Acid
PubMed: 23881695
DOI: 10.1002/14651858.CD010562.pub2 -
Hematology. American Society of... Dec 2021Hereditary hemorrhagic telangiectasia (HHT), the second most common inherited bleeding disorder, is associated with the development of malformed blood vessels. Abnormal...
Hereditary hemorrhagic telangiectasia (HHT), the second most common inherited bleeding disorder, is associated with the development of malformed blood vessels. Abnormal blood vessels may be small and cutaneous or mucosal (telangiectasia), with frequent complications of bleeding, or large and visceral (arteriovenous malformations [AVMs]), with additional risks that can lead to significant morbidity and even mortality. HHT can present in many different ways and can be difficult to recognize, particularly in younger patients in the absence of a known family history of disease or epistaxis, its most common manifestation. HHT is commonly diagnosed using the established Curaçao clinical criteria, which include (1) family history, (2) recurrent epistaxis, (3) telangiectasia, and (4) visceral AVMs. Fulfillment of 3 or more criteria provides a definite diagnosis of HHT, whereas 2 criteria constitute a possible diagnosis of HHT. However, these criteria are insufficient in children to rule out disease due to the age-dependent development of some of these criteria. Genetic testing, when positive, can provide definitive diagnosis of HHT in all age groups. Clinical course is often complicated by significant epistaxis and/or gastrointestinal bleeding, leading to anemia in half of adult patients with HHT. The management paradigm has recently shifted from surgical approaches to medical treatments aimed at control of chronic bleeding, such as antifibrinolytic and antiangiogenic agents, combined with aggressive iron replacement with intravenous iron. Guidelines for management of HHT, including screening and treatment, were determined by expert consensus and originally published in 2009 with updates and new guidelines in 2020.
Topics: Adolescent; Anemia; Disease Management; Epistaxis; Female; Gastrointestinal Hemorrhage; Humans; Pregnancy; Pregnancy Complications, Hematologic; Telangiectasia, Hereditary Hemorrhagic
PubMed: 34889398
DOI: 10.1182/hematology.2021000281 -
Singapore Medical Journal Jul 2014Metastatic renal cell carcinoma (RCC) in the nose and paranasal sinuses is very rare. We report an unusual case of metastatic RCC that presented as recurrent epistaxis...
Metastatic renal cell carcinoma (RCC) in the nose and paranasal sinuses is very rare. We report an unusual case of metastatic RCC that presented as recurrent epistaxis ten years after curative nephrectomy. The purpose of this report is to draw the attention of clinicians to the possibility of metastatic RCC in patients with recurrent epistaxis and nasal mass. We also discuss treatment options and review the relevant literature.
Topics: Adult; Carcinoma, Renal Cell; Chemoradiotherapy; Diagnosis, Differential; Epistaxis; Humans; Indoles; Kidney Diseases; Male; Neoplasm Metastasis; Nose; Nose Neoplasms; Positron-Emission Tomography; Pyrroles; Recurrence; Sunitinib; Tomography, X-Ray Computed
PubMed: 24379116
DOI: 10.11622/smedj.2013185 -
CMAJ : Canadian Medical Association... Oct 2022
Topics: Epistaxis; Humans; Pharyngeal Diseases
PubMed: 36191936
DOI: 10.1503/cmaj.220391 -
BMJ Clinical Evidence Oct 2013Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but the majority grow out of the problem. (Review)
Review
INTRODUCTION
Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but the majority grow out of the problem.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for recurrent idiopathic epistaxis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 5 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiseptic cream (containing chlorhexidine hydrochloride, neomycin sulfate, or both), petroleum jelly, and silver nitrate cautery.
Topics: Anti-Infective Agents, Local; Cautery; Child; Chlorhexidine; Epistaxis; Humans; Neomycin; Petrolatum; Remission Induction; Silver Nitrate
PubMed: 24172703
DOI: No ID Found -
Frontiers in Public Health 2022Several studies have demonstrated that environmental factors, such as meteorological factors and air pollutants, are closely associated with epistaxis. However,...
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, = 19,580); age group 1 (18-40 years, = 10,978); age group 2 (41-70 years, = 13,395); and age group 3 (>70 years, = 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.
Topics: Humans; Adolescent; Infant; Child, Preschool; Child; Young Adult; Adult; Middle Aged; Aged; Retrospective Studies; Epistaxis; Air Pollutants; Particulate Matter; Age Factors
PubMed: 36339143
DOI: 10.3389/fpubh.2022.966461 -
Canadian Family Physician Medecin de... Jun 2021A child came to my clinic complaining of recurrent epistaxis with several episodes occurring every year since he was a toddler. The nosebleeds affect both nostrils,...
QUESTION
A child came to my clinic complaining of recurrent epistaxis with several episodes occurring every year since he was a toddler. The nosebleeds affect both nostrils, often lasting for an extended period of time and occurring in no apparent seasonal pattern. What interventions are safe and effective for recurrent epistaxis in children, and which patients warrant hematologic testing?
ANSWER
Epistaxis affects more than half of children by the time they are 10 years old, with 9% of children reported to have recurrent episodes. Most cases are of benign origin and will not require further workup. For those seeking intervention, nasal mucosal hydration, such as emollient application, or humidification resolves up to 65% of cases, and many novel interventions have shown promise in their respective initial studies. Standardized bleeding questionnaires have demonstrated usefulness in decision making for further coagulation studies, taking into account historical features including frequency, duration, bleeding site, seasonal correlation, and severity.
Topics: Child; Epistaxis; Humans; Male; Recurrence; Surveys and Questionnaires
PubMed: 34127465
DOI: 10.46747/cfp.6706427 -
QJM : Monthly Journal of the... Aug 2020
Topics: Anemia, Iron-Deficiency; Angiography; Embolization, Therapeutic; Epistaxis; Humans; Male; Maxillary Artery; Middle Aged; Telangiectasia, Hereditary Hemorrhagic; Vascular Malformations
PubMed: 32170936
DOI: 10.1093/qjmed/hcaa094