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The Laryngoscope C 2014 The American Laryngological, V Rhinological and Otological Society, Inc. Relation of Mean Platelet Volume and Red Blood Cell Distribution Width With Epistaxis Ozgur Kemal, MD; Togay M€ uderris, MD; Erg€ un Sevil, MD; G€okhan Kutlar, MD Objectives/Hypothesis: Mean platelet volume is the measurement of the average size of platelets in the blood, and red blood cell distribution width is the variability of the size of red blood cells in circulation. This study aimed to investigate if there was any relationship between mean platelet volume, red blood cell distribution, and epistaxis. Study Design: Prospective controlled trial. Methods: The study included 90 patients admitted to Ankara Atat€ urk Hospital and Samsun Medicana Hospital with complaints of recurrent epistaxis, and a control group of 90 healthy subjects. Blood samples were taken from all patients and control group subjects. Mean platelet volume and red blood cell distribution parameters were examined and compared between the two groups. Results: The mean platelet volume levels were determined as 8.86 6 0.1 in the control group and 8.36 6 0.1 in the patient group. The difference between the two groups with respect to mean platelet volume was statistically significant (P <.05). The mean red blood cell distribution levels were determined as 12.68 6 0.32 in the control group and 11.90 6 0.16 in the patient group. The difference between the two groups with respect to red blood cell distribution was also statistically significant (P <.05). Conclusions: The results of this study showed a clinical finding of lower mean platelet volume and red blood cell distribution levels in epistaxis. These findings could be beneficial in new investigations into epistaxis mechanisms. Key Words: Mean platelet volume, red blood cell distribution, epistaxis. Level of Evidence: 3b. Laryngoscope, 125:788–790, 2015 INTRODUCTION Epistaxis (derived from the Greek word epistazo, to bleed from the nose), is a common emergency in otorhinolaryngology, as 60% of the entire population experience epistaxis at least once in their lifetime.1 It has a greater prevalence in those under the age of 10 years and over 35 years. Within this group, 6% of patients require emergency medical attention.2 Thus, 3% to 4% of the population needs medical attention for epistaxis during their lifetime. In the majority of cases, the cause of epistaxis is unknown, although localized conditions of the nose and systemic conditions have been identified.3 Many conditions, such as the prevailing weather and oral medications, have been discussed to determine the risk factors of epistaxis.4,5 However, none can be considered as a single risk factor. From the Otolaryngology Department (O.K., G.K.), Faculty of Medicine, Ondokuz Mayis University, Samsun; and the Otolaryngology urk Education and Research HospiDepartment (T.M., E.S.), Ankara Atat€ tal, Ankara, Turkey. Editor’s Note: This Manuscript was accepted for publication September 30, 2014. This is a multicentric study performed at Samsun Medicana Hospital and Ankara Atat€ urk Education and Research Hospital. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ozgur Kemal, MD, Yesildere mah, Alaçam cad, Mimoza evleri c blok 75/41, 55200 Atakum, Samsun, Turkey. E-mail: [email protected] DOI: 10.1002/lary.24990 Laryngoscope 125: April 2015 788 Platelets are disc-shaped cells, responsible for coagulation of the blood. Their main role is to maintain the integrity of blood vessels for adequate hemostasis. Their count varies over a considerable range of 150,000 to 400,000/mm3. Platelets may differ in size and hemostatic potential.6 Mean platelet volume (MPV) is a a measurement of the average size of platelets in the blood.7 Platelets secrete and express a large number of substances that are crucial mediators of coagulation. Larger platelets may contain more granules and produce greater amounts of vasoactive and thrombotic factors, which means greater hemostatic efficiency. Therefore, it is clear that bigger platelets mean better hemostasis.8 Furthermore, higher MPV is observed in patients with diabetes mellitus, hypertension, hypercholesterolemia, smoking, and obesity.9–13 Red blood cell distribution width (RDW) is the variability of the size of the red blood cells in circulation. It is a routine component of the full blood count and is generally used in the diagnosis of hematological disorders, especially the differential diagnosis of anemia. Several studies have also shown a relationship between RDW and cardiovascular diseases, strokes, pulmonary hypertension, and peripheral arterial disease.14–19 The aim of this study was to investigate the effect of MPV on epistaxis rates. MATERIALS AND METHODS Approval for the study was granted by the ethics committee of Ankara Yildirim Beyazit University. This prospective study was conducted at Ankara Atat€ urk Hospital and Samsun Kemal et al.: Relation of MPV and RDW With Epistaxis RESULTS TABLE I. Descriptive Statistics of RDW and MPV. RDW Epistaxis Control MPV Epistaxis Statistic SE Mean 11.8978 0.15889 Median SD 11.7000 1.50736 Minimum 9.10 Maximum Mean 15.00 12.6858 Median 12.3000 SD Minimum 3.30781 9.10 Maximum 34.90 Mean Median 8.3578 8.4000 SD 0.93412 Minimum Maximum Control 0.32128 0.09846 DISCUSSION 6.00 10.30 Mean 8.8613 Median SD 8.7000 1.03386 Minimum 6.90 Maximum 12.30 The mean age of the patients was 25.42 6 1.93 years, and the mean age of the control group was 32.05 6 1.22 years. Of the 90 patients in the study group, 48 were males (53.3%) and 42 (46.7%) were females. Of the 90 subjects in the control group, 56 (62.2%) were males and 34 (37.8%) were females (Tables I and II). The mean MPV level was determined as 8.86 6 0.1 in the control group and 8.36 6 0.1 in the patient group. The difference in MPV between the two groups was statistically significant (P <.05). The mean RDW level was determined as 12.68 6 0.32 in the control group and 11.90 6 0.16 in the patient group. The difference in RDW between the two groups was also statistically significant (P <.05) (Table III). 0.10042 MPV 5 mean platelet volume; RDW 5 red blood cell distribution width; SD 5 standard deviation; SE 5 standard error. Medicana Hospital between April 2013 and April 2014. A total of 90 patients admitted to the two centers with complaints of recurrent epistaxis were included, and a control group was formed of 90 healthy subjects. Healthy subjects were selected from the checkup clinics of hospitals, and before including them in the study they were physically examined and blood tests were taken. After the tests they were considered healthy subjects. Informed consent was obtained from all study participants. All patients underwent a detailed physical examination, and those with bleeding disorders, chronic diseases, acute infection, or a history of hypertension were excluded. Blood samples were taken from all patients and control group subjects. MPV and RDW parameters were examined and compared between the two groups. In our laboratory, the normal value for MPV ranges between 6 and 11 mm3, and for RDW, the normal range is 7% to 16%. Statistical analyses were performed with SPSS software (SPSS 15.0, SPSS, Inc., Chicago, IL). All parameters were expressed as mean 6 standard deviation. The normality of distribution was checked initially by the Shapiro-Wilk test; the Mann-Whitney U test was used to compare the parameters between the epistaxis and control subjects. The results were expressed as mean 6 standard deviation. A value of P <.05 was considered statistically significant. To the best of our knowledge, this is the first study to show an association between RDW and MPV values and epistaxis. The results of this study showed that the MPV and RDW levels of the epistaxis patients were lower than those of the healthy control group, and the differences were statistically significant. Epistaxis is a common bleeding event that may be a symptom of a coagulopathy. Sandoval et al. showed that children with recurrent epistaxis have more severe coagulopathy than healthy children. In a study of 178 children with recurrent epistaxis, 33% coagulopathy was determined, the most common of which was von Willebrand’s disease (56%).20 It is also clear that coagulation problems are not the only reason for epistaxis, as there may be different reasons such as weather conditions or septum deviation.4,21 RDW and MPV have not been considered as a reason of epistaxis. MPV is a simple way to assess platelet function.22,23 Platelets are formed via cytoplasmic fragmentation of bone marrow–derived megakaryocytes. They are heterogeneous in size, density, and reactivity, with granules responsible for aggregation. In comparison to small platelets, large platelets have more granules, which means aggregation will be more rapid with collagen, have a higher tromboxane A2 level, and more glycoprotein Ib and IIa/IIIa receptors will be expressed.24–26 Many studies have investigated the relationship between MPV and thrombotic disorders such as coronary artery disease, risk of coronary stent restenosis, peripheral artery disease, diabetes mellitus, and metabolic syndrome.8,27 A normal RDW range means that the red cells have a normal distribution pattern. Increased RDW, known as TABLE III. Comparison of the Parameters of MPV and RDW. TABLE II. Age and Gender of Patients and Control Subjects. Patients Controls 90 90 25.42 6 1.93 32.05 6 1.22 42/48 34/56 No. of patients Age (mean 6 SD) Patients Gender (female/male) Laryngoscope 125: April 2015 Controls P Value MPV 8.36 6 0.98 8.86 6 0.10 .005 RDW 11.90 6 0.16 12.69 6 0.32 .040 The Mann-Whitney U test was used in the comparison. MPV and RDW are both statistically significant. MPV 5 mean platelet volume; RDW 5 red blood cell distribution width. Kemal et al.: Relation of MPV and RDW With Epistaxis 789 anisocytosis, indicates increased variability of red blood cell size. Elevated RDW is commonly found in iron deficiency, folate deficiency, vitamin B12 deficiency, or after transfusion.28 Several studies have shown a relationship between RDW and cardiovascular events. Lappe et al. reported an association of RDW with mortality in patients with angina pectoris; therefore, RDW can be a prognostic factor for peripheral arterial disease.19,29 It has been shown that both RDW and MPV levels are higher in patients who experience thrombotic events such as atherosclerosis or cerebrovascular events. In the current study, these levels were found to be lower in epistaxis patients. Higher MPV levels are associated with low rates of epistaxis. The mechanisms responsible are not clearly elucidated, but high MPV levels are known to be associated with more thrombosis. The probable mechanism of lower epistaxis rates with high MPV levels is the better hemostasis of large platelets. The relationship between RDW and epistaxis is not clear, but the increase in RDW may be a result of recurrent epistaxis, as recurrent bleeding events may increase erythropoietic activity and thereby result in increased RDW. The current study is a clinical study, and the mechanism of the relationship between MPV, RDW, and epistaxis is still not fully understood. Pathophysiological mechanisms can only be speculative, and further studies are required to investigate and clarify the mechanisms. It is possible that a higher level of RDW and MPV plays a role in thrombosis and may play a role in the hemostasis of epistaxis patients. Also MPV and RDW levels may be a prognostic factor after the consensus of further studies. At the present time, it is not possible to resize the platelets or correct the RDW levels for the treatment of epistaxis. But it may be possible in the future, and that possibility may play a role in the treatment of epistaxis. CONCLUSION The results of this study have shown a clinical finding of lower MPV and RDW levels in recurrent epistaxis patients. However, the pathophysiological mechanism of the relationship requires further studies for full clarification. BIBLIOGRAPHY 1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg 2006;64:511–518. 2. Schlosser RJ. Epistaxis. N Eng J Med 2009;360:784–789. 3. Smith J, Siddiq S, Dyer C, Rainsbury J, Kim D. Epistaxis in patients taking oral anticoagulant and antiplatelet medication: prospective cohort study. J Laryngol Otol 2011;125:38–42. Laryngoscope 125: April 2015 790 4. Nunez DA, Mc Clymont LG. Evans RA. Epistaxis: a study of the relationship with weather. Clin Otolaryngol 1990;15:49–51. 5. Stopa R, Schonweiler R. Causes of epistaxis in relation to season and weather status. HNO 1989;37:198–202. 6. Frojmovic MM, Milton JG. Human platelet size, shape, and related functions in health and disease. Physiol Rev 1982;62:185–261. 7. Şahin DY, G€ ur M, Elbasan Z, et al. Mean platelet volume associated with aortic distensibility, chronic inflammation, and diabetes in patients with stable coronary artery disease. Clin Appl Thromb Hemost 2014;20:416– 421. 8. Vizioli L, Muscari S, Muscari A. The relationship of mean platelet volume with the risk and prognosis of cardiovascular diseases. Int J Clin Pract 2009;63:1509–1515. 9. Bath PM, Butterworth RJ. Platelet size: measurement, physiology and vascular disease. Blood Coagul Fibrinolysis 1996;7:157–161. 10. Papanas N, Symeonidis G, Maltezos E, et al. Mean platelet volume in patients with type 2 diabetes mellitus. Platelets 2004;15:475–478. 11. Pathansali R, Smith N, Bath P. Altered megakaryocyte-platelet haemostatic axis in hypercholesterolaemia. Platelets 2001;12:292–297. 12. Kario K, Matsuo T, Nakao K. Cigarette smoking increases the mean platelet volume in elderly patients with risk factors for atherosclerosis. Clin Lab Haematol 1992;14:281–287. 13. Coban E, Ozdogan M, Yazicioglu G, Akcit F. The mean platelet volume in patients with obesity. Int J Clin Pract 2005;59:981–982. 14. Isik T, Kurt M, Ayhan E, et al. Relation of red cell distribution width with presence and severity of coronary artery ectasia. Clin Appl Thromb Hemost 2012;18:441–447. 15. Gul M, Uyarel H, Ergelen M, et al. The relationship between red blood cell distribution width and the clinical outcomes in non-ST elevation myocardial infarction and unstable angina pectoris: a 3-year follow-up. Coron Artery Dis 2012;23:330–336. 16. Majercik S, Fox J, Knight S, Horne BD. Red cell distribution width is predictive of mortality in trauma patients. J Trauma Acute Care Surg 2013;74:1021–1026. 17. Uyarel H, Ergelen M, Cicek G, et al. Red cell distribution width as a novel prognostic marker in patients undergoing primary angioplasty for acute myocardial infarction. Coron Artery Dis 2011;22:138–144. 18. Ani C, Ovbiagele B. Elevated red blood cell distribution width predicts mortality in persons with known stroke. J Neurol Sci 2009;277:103–108. 19. Ye Z, Smith C, Kullo IJ. Usefulness of red cell distribution width to predict mortality in patients with peripheral artery disease. Am J Cardiol 2011; 107:1241–1245. 20. Sandoval C, Dong S, Visintainer P, Ozkaynak MF, Jayabose S. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol 2002;24:47–49. 21. Bray D, Giddings CE, Monnery P, Eze N, Toma AG. Epistaxis: are temperature and seasonal variations true factors in incidence? J Laryngol Otol 2005;119:724–726. 22. Park Y, Schoene N, Harris W. Mean platelet volume as an indicator of platelet activation: methodological issues. Platelets 2002;13:301–306. 23. Boos CJ, Lip GY. Assessment of mean platelet volume in coronary artery disease—what does it mean? Thromb Res 2007;120:11–13. 24. Varol E, Aksoy F, Ozaydin M, Erdogan D, Dogan A. Relationship between mean platelet volume and mitral annular calcification. Blood Coagul Fibrinolysis 2013;24:189–193. 25. Martin JF, Trowbridge EA, Salmon G, Plumb J. The biological significance of platelet volume: its relationship to bleeding time, platelet thromboxane B2 production and megakaryocyte nuclear DNA concentration. Thromb Res 1983;32:443–460. 26. Jakubowski JA, Thompson CB, Vaillancourt R, Valeri CR, Deykin D. Arachidonic acid metabolism by platelets of differing size. Br J Haematol 1983;53:503–511. 27. Turfan M, Erdogan E, Ertas G, et al. Usefulness of mean platelet volume for predicting stroke risk in atrial fibrillation patients. Blood Coagul Fibrinolysis 2013;24:55–58. 28. Evans TC, Jehle D. The red blood cell distribution width. J Emerg Med 1991;1:71–74. 29. Lappe JM, Horne BD, Shah SH, et al. Red cell distribution width, Creactive protein, the complete blood count, and mortality in patients with coronary disease and a normal comparison population. Clin Chim Acta 2011;412:2094–2099. Kemal et al.: Relation of MPV and RDW With Epistaxis