Posterior Nasal Packing Research Articles

Clinical Study and Management of Epistaxis.

Epistaxis is the most common emergency in otorhinolaryngology affecting up to 60% of the population in their lifetime. There are various local and systemic cause and includes both medical and surgical management. This study has been undertaken to study various etiopathogenesis and management of epistaxis. This is a prospective hospital-based study conducted on 100 patients of all age groups and both genders presenting with epistaxis to the Department of Otorhinolaryngology both on outpatient and inpatient basis. A detailed history taking with clinical examination is done. Data is entered in a structured performa, master chart prepared and is subjected to statistical analysis by SPSS software version 23. The most common age group was first decade (26%) followed by fourth decade (15%) with male (71%) predominance. Anterior epistaxis (87%) and bilateral nasal cavity involvement (65%) was predominantly seen. Most common causes for epistaxis are trauma (20%) followed by nasal infections (18%) and hypertension (17%). Majority of the patients underwent medical line of treatment (80%) followed by anterior nasal packing (12%), surgical intervention (7%), posterior nasal packing (1%). Epistaxis needs immediate restoration of hemodynamic parameters with first aid, airway assessment and control of bleeding. Majority of the cases were managed conservatively which is safe and cost effective method. Patients should be advised to avoid strenuous activity, nose picking and vigorous nose blowing. Severe recurrent epistaxis needed invasive interventions like nasal packing and blood transfusion.

Epistaxis and its management: A prospective study in a Teritiary Care Centre

Background: Epistaxis ( nose bleed) is one of the most common ear, nose and throat (ENT) emergencies that present to the tertiary care center. Management of Epistaxis is challenging and most are managed conservatively and some by surgical intervention. There is always a need to find the prevalence of Epistaxis and to identify the etiological factors in management of Epistaxis, by different methods such as medical treatment, anterior and posterior nasal packing, and surgical intervention that includes endoscopic cauterization, endoscopic arterial ligation, SMR and Nasal bone reduction. In our study we will determine the various etiologies of epistaxis and its management options. Methodology: A prospective study was done in the Department of ENT, for duration of 18 months, total of 70 patients of both genders in age group of 18 - 60 years with clinical features of nasal bleed were enrolled in the study, and were subjected to clinical examination and history regarding onset and predisposing factors. Patients who are willing to undergo investigations to identify the cause and treatment are enrolled for the study after obtaining the written informed consent. Results: A total of 70 patients were examined in this study. Males were affected more than females. The patients distribution across different age groups shows maximum at age of 46-60 years followed by 36-45 years. The most common cause was found to be trauma followed by hypertension, rhinosinusitis, deviated nasal septum and idiopathic. In most cases, anterior nasal bleeding was observed.Majority of the cases managed conservatively 71.5% while 28.5% patients required surgical intervention. Conclusion: The study on epistaxis and its management provides valuable insights into effective strategies for addressing this common medical condition. This study emphasizes the importance of a medical and surgical approaches based on the severity and underlying causes of epistaxis. Anterior epistaxis is more common than posterior bleeds. Majority of cases of epistaxis are manageable by conservative measures and only few require surgical intervention. Overall, this study contributes to the ongoing efforts to enhance our understanding of epistaxis and refine therapeutic approaches for better patient outcomes.

RISK FACTORS, CLINICAL PROFILE, AND MANAGEMENT OF PATIENTS PRESENTING WITH EPISTAXIS: A CROSS-SECTIONAL STUDY

Objective: To analyze risk factors, clinical profile, and management strategies for patients presenting with epistaxis. Methods: This was a cross-sectional study that was undertaken in the department of otorhinolaryngology at a tertiary care medical college. 60 adult patients presenting with epistaxis were included in this study. Demographic details, such as age and gender, were noted. Patients were evaluated for the presence of risk factors such as hypertension, bleeding disorder, or clotting defects. The clinical presentation of patients was also studied. Patients were managed as per standard protocol. Statistical analysis was done using SSPS 21.0 software, and p<0.05 was taken as statistically significant. Results: There were 44 males (73.33%) and 16 females (26.67%) with a M: F ratio of 1:0.36. The mean age of male and female patients was found to be 63.48±16.18 and 58.46±13.24, respectively. Assault or road traffic accidents, which were seen in 15 (25.00%) patients. The other common causes included hypertension (18.33%), nose picking (15%), and medication (such as antiplatelet or anticoagulant drugs)-induced (10%). Out of 60 patients, the majority (60.00%) were stable hemodynamically. 11 (18.33%) patients were found to have elevated blood pressure in addition to epistaxis. 5 (11.67%) patients were in hypotension, and hence fluid resuscitation was required. In 2 (3.33%) patients, the airway needed to be secured because of a compromised airway. The majority of the patients (75.00%) responded well to conservative measures. Posterior nasal packing (in addition to anterior nasal packing), cauterization, closed reduction of facial fractures, surgery for nasal mass, and functional endoscopic sinus surgery in remaining patients. Conclusion: Facial trauma, hypertension, and nose picking were the most common cases of epistaxis. Majority of the patients were hemodynamically stable and could be treated conservatively with measures such as medical management and anterior nasal packing.

Prospective review of 188 cases of epistaxis presenting to the emergency department: Etiology and outcome.

Due to a myriad of risk factors, epistaxis is a very frequent presentation to the emergency room (ER). This study aims to ascertain the prevalence of epistaxis in our population, risk factors, effectiveness of ER treatment, complications, and ER outcome. This was a prospective observational study performed in the ER of a referral tertiary care center in south India. Data were categorized, coded, and analyzed to determine the objective of the study. During the study's six-month duration, 188 (0.6%) patients presented with epistaxis. The mean age was 42.9 (SD: 16.49) years, with a male preponderance of 143 (76.1%). A majority of these patients (n: 156; 82.9%) were triaged as priority II, with hypertension (n: 53, 28.2%) as the commonest comorbidities. Trauma-related epistaxis (n: 107, 56.9%) was the most frequent cause. Anterior nasal packing was carried out for 85 (45.2%) patients, posterior nasal packing was carried out for one (0.5%) patient, and bleeding had spontaneously resolved in the majority (n: 102; 54.3%) patients. Seven (3.7%; p-value: 0.001) patients had recurrent epistaxis, and of those, three (1.6%) required urgent resuscitation with crystalloid fluid and blood products. Two of these patients had bleeding dyscrasias, four had history of trauma, and one patient presented with uncontrolled hypertension. Two (1.1%) patients came back to us with recurrent bleeding within 12 h of discharge. Majority (69.2%; 130) were discharged stable, (23.9%; 45) were admitted for observation and (6.9%; 13) were discharged against medical advice. There was no mortality among these study populations. Middle-young, aged males most commonly presented with epistaxis. Most of them were secondary to trauma. Anterior nasal bleeding was the most common source and hemostasis could be obtained by anterior nasal packing. Majority could be discharged stable from the ER. However, this cohort had seen patients in life-threatening conditions, so the severity cannot be overlooked.

Role of Diagnostic Rigid Nasal Endoscopy in the evaluation of bleeding points and management of Epistaxis

Introduction: Epistaxis is one of the most common ENT emergencies. Causes of epistaxis can be idiopathic, local, or associated with systematic conditions. Anterior rhinoscopy gives a limited view of the nasal cavity. Difficulty in the localization of bleeding points on anterior rhinoscopy is commonly encountered. We often face difficulty in the localization of bleeding points, especially the hidden areas. Nasal endoscopy helps to identify the hidden bleeding points and specifically control the bleeding.
 Objective: The main aim of our study was to visualize bleeding points and demonstrate the efficacy of nasal endoscopy in identifying the bleeding site and controlling epistaxis without nasal packing.
 Methodology This is a cross-sectional study done on patients who presented to the ENT Outpatient Department with complaints of nasal bleeding. They were evaluated by rigid nasal endoscopy for localization of bleeding points as well as control of epistaxis.
 Results: Highest number of cases were seen in the 26-35 years of age group. 69.7% (n=53) patients presented with anterior epistaxis and 28.9% (n=22) had posterior epistaxis. Most of the patients i.e.,57.9 %(n=44) had no obvious abnormality associated with epistaxis, followed by Deviated Nasal Septum with septal spur i.e.,34.2%(n=26). On localizing the bleeding points, 77.6% (n=59) of bleeding points were seen on the septum. 57.9% (n=44) of patients developed epistaxis on the right side. 58% (n=52) of patients were managed with endoscope-assisted chemical cauterization followed by endoscope-associated electro-cauterization using bipolar cautery.
 Conclusion: Rigid nasal endoscopy not only helps in localizing bleeding points but also in managing the cases and is gradually replacing conventional techniques like anterior and posterior nasal packing.

Study of etiopathogenesis and management of epistaxis in tertiary care centre

Background: Epistaxis is one of the most commonly addressed complaints in patients visiting outpatient department of ENT. This study aimed to determine common etiologies and management of epistaxis in a Tertiary care centre. Methods: This prospective descriptive study was conducted with 60 patients selected by consecutive sampling presented to our hospital with epistaxis between the years 2021-2022. Results: Incidence of epistaxis was more in males (58.33%) with male to female ratio of 1.4:1. Most common age group was between 10-49 years (68.33%). The commonest etiology was idiopathic (30%). When the cause was present, trauma was the most common reason mainly in young adults (13.33%) followed by hypertension (11.67%). The most common site of epistaxis was noted in the anterior nasal cavity (45%) where Little’s area (20%) was the most common location. Most cases were managed by conservative non-surgical treatments alone (55%) like anterior and, or posterior nasal packing, chemical/ electro-cauterization, foreign body removal, and blood components transfusion. Almost an equal number of patients underwent Surgical management in our hospital (45%) as it is a tertiary care centre. Conclusions: Epistaxis is an ENT emergency seen in all age groups, more common in adolescents and young adults, males are affected more than females. The cause of epistaxis was not known in most cases, i.e., Idiopathic. Most of the cases can be managed by non-surgical treatment. It is necessary for the treating doctor to accurately diagnose the etiology of the case, and bleeding site and treat accordingly.

Randomized Clinical Trial to Evaluate the Efficacy and Tolerability of Nebulized Hyaluronic Acid and Xylitol Based Solution after Septoturbinoplasty.

Septoplasty and turbinate surgery are among the most frequent surgical procedures to improve nasal obstruction and quality of life. These procedures usually imply the presence of congestion, secretions, and crusting related to the movement of the instruments during surgery. However, the use of nasal lavage may reduce this situation. The addition of Hyaluronic acid or Xylitol offers advantages in these washes. This study was a randomized, double-blind, controlled trial. All patients underwent endoscopic septoplasty with inferior turbinate submucosal resection without posterior nasal packing. SNOT-22, main VAS, NOSE, Modified Lund-Kennedy endoscopic scale, number of crusts and adhesions were quantified before and on the day of the surgery, visit three (seven days), visit four (fourteen days), and visit five (twenty-eight days). Forty-seven patients completed the study, divided into a standard saline arm (group 1, 22 patients) and normal saline plus HA and Xylitol arm (group 2, 27 patients). Both treatment groups improved their quality of life and objective parameters during the four weeks of the study. All patients tolerated the nasal irrigations well, and none discontinued the treatments. The study concludes that nasal washes of Aluneb Isotónico® offer several benefits to patients as a protective and preventative agent.

Surgical management of intractable epistaxis:Endoscopic sphenopalatine artery coagulation

<b>Introduction:</b> Epistaxis is one of the most common challenges for emergency departments. Hypertension is regarded as a risk factor of epistaxis. Anticoagulant therapy in hypertensive patients increases the risk of nosebleed even more. Approximately 10% of patients with epistaxis require hospital admission for this condition, some of which need surgical intervention. Management can be problematic, mainly in case of recurrent posterior epistaxis. Over the past decade, with the widespread popularization of endoscopic sinus surgery and the deeper understanding of local regional anatomy, endoscopic control of the sphenopalatine artery (SPA) has been advocated as an effective alternative for the control of posterior epistaxis.</br></br> <b>Aim:</b> The aim of this article is to familiarize the reader with local anatomy and surgical technique of SPA ligation/coagulation.</br></br> <b>Material and method:</b> The SPA ligation or coagulation is indicated for intractable epistaxis, which is defined as recurrent bleeding despite adequate anterior and posterior nasal packing. The sphenopalatine artery (SPA) is a terminal branch of the internal maxillary artery, which is a branch of the external carotid artery. The SPA supplies the turbinates, the lateral nasal wall and nasal septum. The most important anatomical landmark enabling to identify the artery at its entry to the nasal cavity is crista ethmoidalis, which is typically located above the sphenopalatine foramen. The artery can be localized with or without creating the middle antrostomy. Locating the SPA without opening of the maxillary sinus can be challenging for inexperienced surgeon. The middle-meatal antrostomy prior to SPA ligation reveals more anatomical landmarks. Efficacy of SPA coagulation/ligation ranges between 74 to 100%. Failure to localize all the branches of the SPA is regarded as the most common reason for re-bleeding. Complications of the procedure are rare, mild and transient.</br></br> <b>Conclusion:</b> Endoscopic sphenopalatine artery coagulation or ligation is a safe and effective technique for controlling persistent posterior epistaxis. Understanding the anatomic relationships is important in performing this procedure. It has become established standard treatment for intractable epistaxis.

Epistaxis in dental and maxillofacial practice: a comprehensive review.

The lifetime incidence of epistaxis in dental and maxillofacial practice has been reported to be as high as 60% and can be caused by dental implant placement, Le Fort I osteotomy, intranasal supernumerary tooth, odontogenic tumors, blood disorders and maxillofacial trauma. Most epistaxis cases are minor and easily managed with direct compression on the nares for 10 minutes. For more significant or recurrent epistaxis, other techniques might include electrocautery, anterior or posterior nasal packing, or Foley catheter balloon. For patients with refractory epistaxis, cauterization of the sphenopalatine artery under endonasal endoscopy or embolization of the internal maxillary artery should be performed. Epistaxis control is required in patients diagnosed with inherited or acquired bleeding disorders or with drug-induced coagulopathies during dental procedures. In these cases, hemostatic system adjustment and hemostasis achieved by local and adjunctive methods are required. Dentists and maxillofacial surgeons must be aware that the nasal cavity is a potential source of perioperative hemorrhage. Depending on the invasiveness of the dental intervention, preoperative involvement of the hematologist and cardiologist is usually necessary to reverse anticoagulation or to cease anticoagulant therapy.

EPISTAXIS: CLINICAL REVIEW OF 176 PATIENTS

Objective: To carry out a retrospectively review and analyze the general data, incidence, etiological and clinical findings as well as treatment options for epistaxis patients. Patients and Methods: We reviewed the files of 176 patients with epistaxis who were treated at department of otolaryngology of the Royal Medical services of Jordan between 2017 and 2021. Data regarding Age, sex, concomitant medical disorders, medications, directly identifiable causes, epistaxis seasonal variation, and the type of management received were all recorded. Results: Epistaxis occurred in 0.52 percent of all cases and 3.2 percent of patients with nasal problems. The patients ages ranged from 5 to 85 years old, with a mean age of 43.3 years. The ratio of males to females is 1.5:1. Majority of patients (89.8%) presented with unilateral nasal bleeding and 10.2% with bilateral nasal bleeding. Intermittent nasal bleeding was recorded in 73%. In 63 cases (35.8%), the exact etiological cause couldnt be identified while in the rest of patients we could identify a causal factor infection (32.4%), hypertension (18.2%), trauma (6.8%), blood dyscrasias (2.8%), uremia (2.3%) and tumor (1.7%). Regarding the bleeding sites, more than 70% were from the anterior part of the nasal cavity. Regarding the modalities of treatment for epistaxis, anterior nasal packing being the most common technique 91 cases (51.7%) and conservative management in terms of anterior, posterior nasal packing and local cauterization of bleeding site was effective in majority of cases. Conclusion: Epistaxis is a common otolaryngologic emergency. To be able to undertake optimal care, otolaryngologists and general physicians should know the causes and features of patients and diseases, particularly in their own area of practice.

A Rare Case of Severe Post Adenoidectomy Secondary Haemorrhage

Tonsillectomy and adenoidectomy are amongst the most common surgeries performed in children. Haemorrhage, after and during these procedures, is a major and known complication. Most commonly, the haemorrhage presents intraoperatively or in the immediate postoperative period and is self-limiting. However, secondary haemorrhage presenting after adenoidectomy where adenoidectomy alone was performed have been reported in very few patients. In this case, a 10-year-old male presented with history of upper airway obstruction including sleep apnoea, adenoid facies, and bilateral moderate conductive hearing loss since four years. He had no co-morbidities, history of bleeding diathesis. The pre-operative evaluation of the adenoids (clinically and radiologically) revealed no abnormal vasculature or anatomical variations. Conventional adenoidectomy and bilateral grommet insertion was performed under General Anaesthesia (GA). The postoperative period was entirely uneventful, and the patient was discharged on postoperative day 3. Despite having no risk factors, he presented with profuse posterior epistaxis after conventional adenoidectomy on postoperative day 5. Immediate management was done by posterior nasal packing and intravenous amoxicillinclavulanate Definitive treatment was done by re-exploration and debridement of the remnant adenoid tissue using a microdebrider under GA the next day. The patients had no complaints postoperatively or at 6 months follow-up. The rarity of complications makes adenoidectomy a fairly safe procedure. However, despite being uncommon, secondary complications of adenoidectomy should be anticipated by surgeons to avoid dire consequences for the patient.

1611 Significant Epistaxis Secondary To COVID-19 Nasopharyngeal Swab

Abstract Aim This case highlights the need for appropriate training when adopting new techniques, even for relatively simple procedures. Method we report a rare complication of the innovative COVID-19 nasopharyngeal swab which is a new skill for many healthcare professionals and frequently performed with little or no training. Results We describe a case of iatrogenic epistaxis after a diagnostic nasopharyngeal swab was taken during the COVID-19 pandemic. The epistaxis was significant, causing haemodynamic and respiratory compromise. In a frail patient who is susceptible to epistaxis, the potenial for further harm is significant. After initially presenting with shortness of breath, this patient (who had no previous nasal pathology) underwent routine naso- and oro- pharyngeal swabbing to test for COVID-19. He felt immediate discomfort in his nasopharynx and epistaxis ensued. The bleeding persisted for several hours; bilateral anterior and posterior nasal packing was required to eventually cease the bleed. He was compromised with a falling haemoglobin, and aspiration of blood compounded his shortness of breath. Conclusions Epistaxis is a potentially serious side effect of nasopharyngeal swabbing; a procedural skill dramatically increasing in prevalence during the COVID-19 pandemic. We advocate for formal training of this procedure for all healthcare staff required to undertake it. Presenting such a case report can help us in understanding the complications of this procedure, and better thus inform the patient consenting process.

Clinicopathological profile and treatment outcomes of patients presenting with epistaxis: a hospital-based cross-sectional study in Southern railway headquarters hospital, Chennai

<p class="abstract"><strong>Background:</strong> Epistaxis (nose-bleed) is one of the commonest emergencies presenting to an otolaryngological emergency that affects up to sixty per cent of the population in their lifetime; in this, six per cent needs medical care.</p><p class="abstract"><strong>Methods: </strong>Hospital-based cross-sectional study carried between October 2018 to January 2020 in the department of ENT at Southern Railway Headquarters Hospitals, Perambur, Chennai.</p><p class="abstract"><strong>Results: </strong>The mean age of the subjects was 47.76±23.01. Females were less affected compared to males with 1.68:1 male: female ratio. The results of ENT examination/anterior rhinoscopic examination revealed that all 153 (100%) subjects had anterior epistaxis and 5 (3.27%) had posterior epistaxis. 143 (93.46%) had deviated nasal septum. Diagnostic nasal endoscopy revealed that 90 (58.82%) had deviated nasal septum to the left, and 55 (35.94%) had to the right. The majority of subjects, i.e., 86 (56.21%), were managed conservatively, followed by 52 (33.99%), 5 (3.27%), and 1 (0.65%) patient were given treatment with anterior nasal packing, anterior and posterior nasal packing, and cauterization respectively. Whereas 9 (5.88%) subjects needed a surgical mode of treatment to manage their epistaxis.</p><p class="abstract"><strong>Conclusions:</strong> Findings revealed that the incidence was high in elderly individuals, with male preponderance over females. Anterior epistaxis more commonly occurred in comparison to posterior epistaxis. Our research supports the conservative management methods’ credibility in the epistaxis treatment. The practice of simple nasal packing is the commonest conservative approach that has a high rate of success. As a result, this method will be the best choice for epistaxis management.</p>

Construct and Validation of a Three-Dimensional Physical Model for Training in Transnasal Office Procedures.

Most simulation models in rhinology are costly and are primarily meant to enhance endoscopic surgical skills. The present study aimed to construct a 3-dimensional model of the nose which is easily constructible with commonly available low cost plaster of Paris (POP) and assess its usefulness in training residents in basic transnasal procedures. A nose model was created using plaster of Paris and assessed for face and content validity by experts in rhinology while a construct validation was performed on five specified tasks by residents. All experts agreed with the resemblance of 10 of the 13 anatomical landmarks in the POP model and its utility in teaching basic transnasal procedures. There was a statistically significant difference in the time taken by I and III year residents in performing a diagnostic nasal endoscopy (p = 0.007), anterior nasal packing with polyvinyl alcohol tampon (p = 0.007), posterior nasal packing with Foley's catheter (p = 0) and nasopharyngeal swabbing (p = 0.025). This study demonstrates the construct of a low cost 3-dimensional POP model and validates its utility in training residents in routine transnasal rhinological procedures. Face and content validation showed a high degree of resemblance to human anatomy with good agreement that this model could increase resident competency. The significant difference in time taken by residents at various levels of experience in performing rhinological procedures also confirmed a reliable construct validity. The described model could be an affordable and easily constructible alternative tool to other simulation models in otorhinolaryngology residency programs especially in developing countries.

Correlative Analysis of Massive Epistaxis and Pseudoaneurysms in Nasopharyngeal Carcinoma after Radiotherapy and a 10-Year Review

Objective: Massive epistaxis after radiotherapy for nasopharyngeal carcinoma (NPC) is a common clinical critical illness, which often leads to death of patients. This article focuses on the relationship between massive epistaxis and pseudoaneurysm after radiotherapy in patients with NPC and discusses clinically relevant treatment strategies. Methods: A review was performed in 21 patients with massive epistaxis after radiotherapy for NPC from January 2011 to December 2019, and all of the patients were examined by computed tomography angiography (CTA). We also reviewed the English literature over the past 10 years to analyse the characteristics and related causes of pseudoaneurysms in terms of the clinical stage of NPC, course of radiotherapy, and affected artery. An analysis was performed on the methods of endovascular interventional treatment of such pseudoaneurysms. Results: Among the 21 patients with massive epistaxis after radiotherapy for NPC, 19 (90%) cases had accompanying bone destruction of the skull base; 13 cases (62%) showed tumor recurrence; 15 cases (71%) were in stage III or IV of NPC; 14 cases (67%) had combined pseudoaneurysms, including 9 cases occurring in the internal carotid artery (ICA) and 5 cases occurring in the external carotid artery (ECA). These data were consistent with the results of literature review. On analysis with imaging, we found that such pseudoaneurysms are associated with necrosis and infection of the local bone and soft tissue, and that the petrous part of the ICA was the most common predilection site. We also found that 11 of 14 pseudoaneurysms caused sentinel hemorrhage in the initial phase. In addition to anterior and posterior nasal packing, endovascular interventional therapy was the most important management option. All 14 patients with pseudoaneurysms underwent endovascular interventional therapy, but 1 patient died due to hemorrhagic shock during the procedure. Among the others, 9 patients underwent occlusion of the ICA or ECA with a stainless-steel coil, and rebleeding did not occur again. One patient underwent selected vascular embolization with a covered stent. Direct occlusion of the pseudoaneurysm was performed in 3 patients. Conclusion: Pseudoaneurysm, which was a serious complication after radiotherapy in patients with NPC, could cause massive epistaxis with high mortality. The formation of a pseudoaneurysm was closely associated with a high carcinoma stage, re-radiotherapy, and local bone destruction and infection. Most cases had sentinel epistaxis, which was considered the bleeding characteristic. The imaging material prompted that pseudoaneurysm had a predisposition to the petrous part of the ICA, while the preferred therapy was endovascular embolization treatment.

Endovascular Approach to Ruptured Sphenopalatine Artery: A Case Report and Literature Review

Epistaxis is a rare complication following the endonasal approach of skull base surgery. Conservative methods like anterior and posterior nasal packing can be useful, but when these fail, a neuro-interventional technique can be used as a last-resort measure in cases of severe bleeding. The authors identify a 22-year-old female patient with recurrent epistaxis following resection of skull-base chordoma through an endonasal approach. An endovascular catheter digital subtraction angiogram identified the cause of epistaxis as a rupture of the left sphenopalatine artery branch of the left external carotid artery. A large dissecting aneurysm in the right intracerebral artery was also incidentally found. The unique co-occurrence of vascular problems was successfully managed by neuro-interventional techniques.

Manejo de epistaxis en pacientes con terapia antitrombótica

Introducción y objetivo: la epistaxis es una de las urgencias otorrinolaringológicas más frecuentes. Una de sus causas son las alteraciones de la hemostasia provocadas por fármacos antitrombóticos. El objetivo del estudio es determinar si existen diferencias en el manejo de epistaxis entre pacientes con terapia antitrombótica y pacientes controles.
 Método: estudio observacional analítico retrospectivo de pacientes ingresados en el servicio de Otorrinolaringología de un hospital de tercer nivel, entre enero de 2010 y diciembre de 2016. Se han recogido características epidemiológicas, clínicas y terapéuticas de los pacientes a través de su historia clínica electrónica y se ha realizado análisis estadístico comparativo entre los pacientes con terapia antitrombótica y pacientes controles.
 Resultados: 85 pacientes analizados (74,1% varones) con una edad media al diagnóstico de 66,7 años. El 49,4% realizaban terapia antitrombótica. En todos los pacientes se realizó taponamiento anterior y en 16 pacientes, posterior. 37 pacientes precisaron cirugía endoscópica nasal. La embolización se realizó en cuatro pacientes. En el estudio estadístico comparativo no se han encontrado diferencias estadísticamente significativas entre ambos grupos en ninguna de las variables analizadas.
 Discusión y conclusiones: las indicaciones actuales de terapia antitrombótica son muy amplias y por ello es frecuente atender epistaxis en este tipo de pacientes. Aunque no está claramente demostrado que la terapia antitrombótica por sí sola se asocie con sangrados más graves, creemos que es fundamental realizar un manejo multidisciplinar de estos pacientes con el fin de conseguir un adecuado control del sangrado sin necesidad de recurrir a intervenciones más agresivas.

Association of Hypertension With the Risk and Severity of Epistaxis

The association between hypertension and epistaxis has long been a subject of debate. To evaluate the risk of epistaxis in patients with hypertension using a nationwide population cohort and to assess the association of hypertension with the methods of managing cases of epistaxis. In this retrospective cohort study, a hypertension cohort and comparison cohort were built using the Korean National Health Insurance Service-National Sample Cohort that represents the entire population of the Republic of Korea from January 1, 2002, to December 31, 2015. The hypertension cohort comprised 35 749 patients with a record of 3 or more prescriptions of antihypertensive medication and a diagnosis of hypertension (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I10). Patients with other diseases associated with epistaxis, such as sinonasal tumors, facial trauma, bleeding tendency, and coagulation disorder, as well as those taking anticoagulant medications, were excluded. A comparison cohort comprised 35 749 individuals without hypertension matched sociodemographically in a 1:1 ratio. Statistical analysis was performed from January 1, 2019, to March 31, 2020. The incidence and recurrence of epistaxis were evaluated in both cohorts. The risk factors for epistaxis and management strategies were also assessed. Among the 35 749 patients in the hypertension cohort (20 579 men [57.6%]; median age, 52 years [interquartile range, 45-62 years]) the incidence rate (IR) of epistaxis was 32.97 per 10 000 persons (95% CI, 30.57-35.51 per 10 000 persons); among the 35 749 individuals in the comparison cohort (20 910 men [58.5%]; median age, 52 years [interquartile range, 45-62 years]), the IR of epistaxis was 22.76 per 10 000 persons (95% CI, 20.78-24.89 per 10 000 persons) (IR ratio, 1.45; 95% CI, 1.29-1.63; adjusted hazard ratio, 1.47; 95% CI, 1.30-1.66). The IR of recurrent epistaxis was 1.96 per 10 000 persons in the hypertension cohort and 1.59 per 10 000 persons in the nonhypertension cohort (IR ratio, 1.23; 95% CI, 0.77-2.00). Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69; 95% CI, 1.70-4.25; Cohen h effect size, 0.27; 95% CI, 0.16-0.39) and receive posterior nasal packing (odds ratio, 4.58; 95% CI, 1.03-20.38; Cohen h effect size, 0.15; 95% CI, 0.03-0.26) compared with the comparison cohort. This study suggests that patients with hypertension had an increased risk of epistaxis requiring hospital visits. In addition, epistaxis in patients with hypertension appeared to need more emergency department visits and require more posterior nasal packing procedures compared with patients without hypertension. Medical counseling about epistaxis is advisable for individuals with hypertension, and the presence of hypertension should be considered in managing nasal bleedings.

The role of endoscopic sphenopalatine artery ligation in the management of persistent epistaxis - A 15-year single-center experience.

Managing persistent epistaxis poses a great challenge for the otolaryngologist. Despite continuous development in treatment methods, no universal guideline has been commonly adopted. Among the popular methods is endoscopic sphenopalatine artery ligation (ESPAL). This study aims to evaluate the impact of ESPAL integration on persistent epistaxis management over 15years in a single academic center. A retrospective study including all cases who were hospitalized due to persistent epistaxis and required intervention between 2000 and 2016. From 2011, ESPAL was routinely utilized in our center, hence the study population was divided based on admission year, prior to 2011 (pre-ESPAL) and from 2011 till the end of data collection (post-ESPAL). The pre-ESPAL group included 87 interventions and the post-ESPAL group 54 interventions. Electrocautery remained the most common intervention in both periods. However, ESPAL incorporation was accompanied by a significant decline in the use of posterior nasal packing in the post-ESPAL group. The hemoglobin recovery levels and the mortality rates were significantly improved in the post-ESPAL group compared with the pre-ESPAL group despite higher comorbidity rates among the post-ESPAL patients. This study demonstrates the shifting trend in managing persistent epistaxis, and suggests that ESPAL has successfully replaced posterior nasal packing. These findings may encourage clinicians to consider ESPAL as a valuable tool in the management of persistent epistaxis.

Haemorrhage control beyond Advanced Trauma Life Support (ATLS) protocol in life threatening maxillofacial trauma – experience from a level Ⅰ trauma centre

Maxillofacial injuries are usually not life-threatening and do not get priority over other associated injuries. However, some maxillofacial injuries with active oral or nasal bleeding need immediate management due to threatened airway and blood loss. In the case of major active vascular bleeding, measures such as local pressure, anterior nasal packing, posterior nasal packing, and balloon tamponade are ineffective. In these cases, angiography and transcatheter arterial embolisation (TAE) are used to treat life-threatening haemorrhage caused by maxillofacial trauma. We analysed the medical records of 39 patients with severe maxillofacial trauma and life-threatening haemorrhage that was a result of intractable oral or nasal bleeding. These patients were considered for TAE from January 2010 to December 2019. A total of 1668 patients was admitted, out of which 39 (2.3%) had severe maxillofacial injuries with life-threatening oral or nasal bleeding and underwent TAE. Out of a total of 39 patients, 38 were male and one female. Ages ranged from 16 to 65 years. Road traffic injury was the most common cause of injury (79.5%), Lefort I and II were the most common facial fractures, and traumatic brain injury was the most common associated injury. Embolisation and bleeding control were done successfully in all 39 patients with no procedure-related complications. A total of 17 deaths during the study period were due to severe traumatic brain injuries or haemorrhagic shock.