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Eur Arch Otorhinolaryngol DOI 10.1007/s00405-011-1659-y RHINOLOGY Serious spontaneous epistaxis and hypertension in hospitalized patients Cyril Page • Aurélie Biet • Sophie Liabeuf Vladimir Strunski • Albert Fournier • Received: 25 February 2011 / Accepted: 25 May 2011 Springer-Verlag 2011 Abstract The aim of the study was to evaluate the role of hypertension in patients hospitalized for serious spontaneous epistaxis. This 6-year retrospective study was based on 219 patients hospitalized in a University Hospital ENT and Head and Neck surgery department for serious spontaneous epistaxis. The following parameters were recorded: length of hospital stay, history of hypertension, blood pressure (BP) recordings (on admission, during hospitalization and on discharge), epistaxis severity criteria, including medical and/or surgical management of epistaxis (blood transfusion depending on blood count, embolization, surgery), medications affecting clotting. Epistaxis was classified into two groups: serious and severe. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean arterial pressure on discharge and number of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. Overall, on univariate logistic regression analysis, no factors were independently associated with severity C. Page (&) A. Biet V. Strunski ENT and Head and Neck Surgery Department, C.H.U Amiens, Centre Hospitalier Nord, Place Victor Pauchet, 80054 Amiens cedex, France e-mail: [email protected] S. Liabeuf Clinical Pharmacology Department, CHU AMIENS - Hopital Sud, Avenue Laënnec, Salouel, 80054 Amiens cedex, France A. Fournier Nephrology Department, CHU AMIENS - Hopital Sud, Avenue Laënnec, Salouel, 80054 Amiens cedex, France of epistaxis. The pathophysiology of serious spontaneous epistaxis remains to be unclear. It concerns elderly patients ([60–70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients with no history of hypertension. However, hypertension per se does not appear to be a statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis. Keywords Epistaxis Hypertension Introduction Epistaxis is one of the commonest ENT emergencies requiring hospital admission (15% of cases according to Timsit) [1]. Although predominantly a benign condition regardless of its etiology, epistaxis can be severe, particularly in elderly and/or frail patients, requiring hospitalization and ‘‘aggressive’’ management including repeated nasal packing, blood transfusion, arterial embolization or surgery [2–6]. Epistaxis can be posttraumatic, iatrogenic (nose surgery, particularly endonasal procedures) or ‘‘spontaneous’’, resulting from numerous possible causative factors including local nasal factors (inflammation, infection…), medications, and systemic factors such as platelet and coagulation abnormalities, alcoholism, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) and hypertension [1–6]. Hypertension has been considered to be a major cause of spontaneous epistaxis for a long time [7, 8]. However, particularly in the recent medical literature, the relationship between hypertension and epistaxis appears to be more controversial [9–16]. 123 Eur Arch Otorhinolaryngol This retrospective study concerning 219 patients hospitalized for serious spontaneous epistaxis was designed to elucidate the role of hypertension in these patients managed in a university hospital ENT and Head and Neck Surgery department. Materials and methods This retrospective study was performed over a 6-year period from January 2004 to December 2009 in the University Hospital of Amiens, France. This study was approved by the Amiens University Medical Center’s institutional review board. Patient selection A total of 219 patients were included in the study. The study inclusion criteria were: – – male and female patients of any age patients admitted to the ENT and Head and Neck surgery department with a diagnosis of serious spontaneous epistaxis requiring at least one nasal pack. The exclusion criteria were: patients with minor epistaxis easily managed by first aid measures and/or immediately successful local treatment (cauterization), posttraumatic epistaxis (including iatrogenic epistaxis after nasal surgery) and patients usually followed for Hereditary Hemorrhagic Telangiectasia. Four patients hospitalized for epistaxis (two patients followed for nasal cancer, one patient with leukemia and chemotherapy-induced pancytopenia and one patient with Child-Pugh C cirrhosis were also excluded from the study. Management of epistaxis Management of epistaxis ranged from unilateral nasal packing to endoscopic surgery or embolization depending on the severity of epistaxis. Patients with systolic blood pressure (BP) higher than 160 mmHg also received nicardipine intravenous infusion (syringe pump) to control BP. Anterior nasal packing was performed with Polyvinyl Alcohol sponge (MEROCEL Standard nasal dressing); anterior and posterior nasal packing was performed with a double balloon nasal catheter (BIVONA). Nasal packs were removed after 24–48 h if the patient did not re-bleed. In cases of re-bleeding after removal of nasal packs, nasal packing was repeated. Embolization or surgery was only indicated in the case of anemia or persistent bleeding after 2 or 3 nasal packs. 123 Study protocol A history of hypertension was defined as patients treated with antihypertensive drugs. Patients with a self-reported history of epistaxis or who had been already hospitalized for at least one episode of epistaxis were considered to have a history of epistaxis. The mean of all BP measurements during hospitalization was determined, and BP that was difficult to control was defined as BP higher than 140/80 mmHg. International Normalized Ratio (INR) for prothrombin time was evaluated for 72 patients treated with vitamin K antagonists. Epistaxis was classified as grade 1 (serious) or grade 2 (severe). Serious epistaxis was defined by the need for medical management requiring hospitalization of the patient for epistaxis. Severe epistaxis (grade 2) was defined as follows: – – – – – length of hospital stay [3 days nasal packing using double balloon nasal catheter two or more nasal packs presence of hematologic consequences: anemia (hemoglobin \10 g/dl) and/or blood transfusion patients treated by embolization or surgery Statistical analysis Data were expressed as mean ± S.D., and range or frequency, as appropriate. For descriptive and analytical purposes, patients were stratified by severity of epistaxis, defined as Grade 1 or Grade 2. Between-group comparisons were performed with a v2 test for categorical variables and Student’s t test or Mann–Whitney test for continuous variables. Univariate logistic regression analysis was then performed to identify the variables independently associated with severity of epistaxis. A p B 0.05 was considered to be statistically significant. All statistical analyses were performed using SPSS (SPSS Inc, Chicago, IL), version 13.0 for Windows (Microsoft Corp, Redmond, WA). Results A total of 219 patients admitted to the ENT and Head and Neck Surgery Department were included. Table 1 shows the clinical characteristics of the patients according to the severity of epistaxis. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean BP on discharge and number Eur Arch Otorhinolaryngol Table 1 Clinical and demographic characteristics of the study population Severity of epistaxis All n = 219 Grade 1 n = 94 Grade 2 n = 125 p 0.6 Age (years) 70 ± 15 70 ± 15 69 ± 15 Male gender, n (%) 123 (57) 48 (53) 75 (60) 0.3 Systolic blood pressure on admission (mmHg) Diastolic blood pressure on admission (mmHg) 147 ± 2.9 80 ± 16 147 ± 2.5 80 ± 15 146 ± 3.2 80 ± 16 0.7 0.9 Number of patients in whom blood pressure as difficult to control, n (%) 127 (59) 51 (57) 76 (60) 0.5 Systolic blood pressure on discharge (mmHg) 128 ± 16 129 ± 17 127 ± 16 0.3 Diastolic blood pressure on discharge (mmHg) 71 ± 11 72 ± 11 70 ± 11 0.2 History of hypertension, n (%) 118 (55) 48 (53) 70 (56) 0.7 History of epistaxis, n (%) 72 (34) 29 (32) 43 (34) 0.7 Vitamin K antagonist n (%) 72 (34) 29 (32) 43 (34) 0.7 INR (n = 72) 3±1 2.9 ± 1.1 3 ± 1.6 0.6 Aspirin, n (%) 59 (27) 27 (30) 32 (26) 0.5 Clopidogrel, n (%) 11 (5) 4 (4) 7 (6) 0.7 Length of hospital stay (days) 3.1 ± 1.9 2.1 ± 0.8 3.9 ± 2 NA Hemoglobin (g/dl) 11.7 ± 2.4 13 ± 1.4 11 ± 2.7 NA Treatment with sphenopalatine artery surgical ligation or embolization n (%) 13 (3) 0 (0) 13 (4) NA Treatment with double-cuffed nasal tamponade balloon n (%) 65 (30) 0 (0) 65 (52) NA Treatment with more than 2 nasal packs n (%) 44 (20) 0 (0) 44 (35) NA of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. On univariate logistic regressions, no factors were independently associated with severity of epistaxis (data not shown). (Osler-Weber-Rendu disease), the cause of epistaxis can be identified in only about 15% of patients [4]. In the absence of documented evidence (a visible bleeding vessel on the nasal septum for example), no obvious cause-and-effect relationship can be confirmed, especially concerning hypertension. Only statistical associations between hypertension and epistaxis have been reported [7–16]. Discussion Definition of serious spontaneous epistaxis Serious spontaneous epistaxis is a challenging medical problem in otorhinolaryngology, particularly concerning its physiopathology and its relationship with hypertension. Etiologies of epistaxis Classical teaching and medical literature highlight many possible etiologic factors for epistaxis; including environmental factors (humidity, temperature), local factors (inflammation, deviated septum and/or perforation, tumors, foreign bodies, aneurysm), systemic factors (hypertension, platelet and coagulation abnormalities, renal failure, alcoholism, arteriosclerosis, hereditary hemorrhagic telangiectasia), and medications affecting clotting (anticoagulants, nonsteroidal anti-inflammatory drugs) [3]. Although some etiologies of epistaxis are obvious such as trauma (iatrogenic or non-iatrogenic), nasal inflammation and/or infection or tumors and hereditary hemorrhagic telangiectasia Epistaxis is a benign condition in the majority of cases, but can sometimes be sufficiently serious (6% of cases according to Pollice) [6] to require emergency hospitalization for medical and/or surgical management and close follow-up, especially in patients older than 65 years [2]. However, in the majority of cases, patients present themselves (often to the emergency department) with ‘‘spontaneous’’ epistaxis with no obvious cause and emergency management must be performed before determining the etiology of the nose-bleed. Classical textbooks and the medical literature do not provide a precise definition for the severity of epistaxis which is often based on subjective impressions (subjective evaluation of the volume of bleeding) or anatomic features, essentially posterior epistaxis [5]. Hoag et al. recently proposed an epistaxis severity score but specifically for hereditary hemorrhagic telangiectasia [16]. In our opinion, epistaxis should be 123 Eur Arch Otorhinolaryngol considered to be serious when it requires specific medical and/or surgical management including at least one nasal pack and hospitalization for close follow-up. The complete criteria used to classify the severity of epistaxis as serious or severe in the present study are shown in Table 1. Finally, most articles in the medical literature concerning the association between epistaxis and hypertension do not clearly define the severity of epistaxis, which, in our opinion, constitutes a major problem: is hypertension related to serious spontaneous epistaxis? In another study concerning 372 patients, Herkner et al. [14] concluded that active epistaxis in the emergency department was associated with hypertension, suggesting that hypertension was a predisposing factor for acute nosebleed. Knopfholz et al. [15] in a series of 36 patients, concluded that the incidence of epistaxis in hypertensive patients was not associated with the severity of hypertension. Moreover, BP readings in the setting of epistaxis were similar to those obtained in routine settings. Association between epistaxis and hypertension Comparison of the present series with the medical literature Epistaxis has been considered to be related to hypertension for a long time. In 1959, Mitchell [7] statistically compared two groups of patients (one group of 374 patients with a history of hypertension and another group of 162 patients with acute epistaxis but with no history of hypertension) and concluded that, in the absence of local nasal disease, epistaxis was associated with high BP. In 1977, Charles and Corrigan [8] confirmed this conclusion in a series of 194 patients and, more recently, Isezuo et al. [9] also showed a statistically significant association between epistaxis and hypertension in a series of 62 patients. However, Fuchs et al. [10] in a sample of 1,174 subjects over the age of 18 years representative of Porto Allegre general population, found no association between epistaxis and hypertension. The same group, however, [11] in a study based on 323 adults with hypertension, pointed out however that duration of hypertension and left ventricular hypertrophy were associated with epistaxis, suggesting that epistaxis might be a consequence of long-lasting hypertension. In another study of 121 hypertensive patients, Lubianca Neto et al. tried to evaluate the association between severity of hypertension and history of epistaxis. They concluded that the severity of hypertension was not associated with a history of epistaxis, but they found a statistically significant tendency towards an association between history of epistaxis with duration of hypertension and left ventricular hypertrophy, in addition they noticed that among the abnormalities detected at rhinoscopy, only the presence of enlarged septal vessels was associated with a history of epistaxis. They concluded that long lasting hypertension might contribute to epistaxis but the role of septal vessel abnormalities needed further work to be established [12]. Herkner et al. [13] in a series of 426 patients admitted at the emergency room, demonstrated that patients with epistaxis had higher BP than control patients. 79% of patients with elevated BP during epistaxis had sustained hypertension and 27% of these patients were unaware of their hypertension, indicating that epistaxis may be the presenting sign of hypertension. 123 The present series is fairly similar to other series of patients hospitalized for epistaxis published in the medical literature, but the patients of this series were slightly older with a mean age of 70 years versus 64.3 years for Viducich [5] and 60 years for Pollice (with 70% of patients [50 years) [6]. 55% of the patients in the present series had a history of hypertension versus 48% for Viducich [5] and 47% for Pollice [6]. The main bias of this retrospective series was that this study only concerned patients hospitalized for serious spontaneous epistaxis requiring medical and/or surgical management and close follow-up in hospital. The majority of cases of benign epistaxis were not considered in this study, and it would have possibly been interesting to compare the clinical features and concomitant diseases of patients with benign epistaxis versus patients with serious epistaxis. However, this study reveals interesting results, as no significant differences were observed between the two patient groups concerning the role of hypertension. A history of hypertension was not associated with severe epistaxis versus serious epistaxis. No statistically significant difference was observed between patients with a history of epistaxis in the two patient groups (with or without a history of hypertension). No statistically significant difference was observed between BP recordings on admission between the two patient groups (with or without a history of hypertension). The severity of hypertension (BP [160/100 mmHg) was not associated with severe epistaxis versus serious epistaxis. Blood pressure recordings were also not significantly different between the two groups of hypertensive versus non-hypertensive patients, which may indicate that, as suggested by Tan and Calhoun [3], hypertension at the time of treatment of epistaxis may be anxiety-related, and BP returns to normal after control of epistaxis and reassurance. However, 43 of the 127 patients with abnormal BP recordings during hospitalization had no history of hypertension. True hypertension was diagnosed in these patients, i.e 42.57% of patients with no Eur Arch Otorhinolaryngol previous history of hypertension. However, we have recorded BP only during their hospitalization and not weeks after discharge as appropriately did Herkner et al. [13] for confirming or excluding sustained hypertension with a 24-h ambulatory BP recording. In contrast to Lubianca Neto, in the present series, we found only a dozen patients who underwent septal cauterization 3 weeks after the episode of epistaxis and no local nasal factor was found on rhinoscopy performed at the D21 follow-up visit in the other patients. Overall, the very local nasal origin of epistaxis remains to be unclear in the majority if not all cases. We can conclude like Celik et al. [16] that: the debate on BP and epistaxis will continue. The potential influence of BP levels on acute episodes of epistaxis still requires investigations. Our clinical data are not sufficient to support or dismiss the idea that epistaxis is secondary to end-organ damage caused by hypertension. This is corroborated by nasal examinations after the episode of epistaxis, since they were normal in almost all cases in our ENT experience. 3. 4. 5. 6. 7. 8. 9. 10. Conclusion The pathophysiology of serious spontaneous epistaxis remains to be unclear. It mainly occurs in elderly patients ([60–70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may reveal underlying true hypertension in about 43% of patients (in this series) with no previous history of hypertension. Serious spontaneous epistaxis probably results from a combination of several local and systemic causal factors or diseases. Further prospective studies are required to elucidate the pathophysiology and the exact role played by hypertension. Conflict of interest 2. 11. 12. 13. 14. The authors declare no conflict of interest. 15. References 16. 1. 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