Nosebleeds ========== (1) Viducich RA, Blanda MP, Gerson LW Posterior epistaxis: clinical features and acute complications. Ann Emerg Med 1995 May;25(5):592-6 ABSTRACT: STUDY OBJECTIVE: To describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis. DESIGN: Retrospective chart review. SETTING: University-affiliated community teaching hospital. PARTICIPANTS: We studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded. RESULTS: Posterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as "severe" (OR, 2.53; 95% CI, .88 to 7.39; chi 2 = 2.84, 1 df, P = .92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; chi 2 = 3.66, 1 df, P = .056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon). CONCLUSION: Although posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission. Note: "You may be right about hypertension, acute or chronic, being contributory, but that article sure doesn't prove it. They report that a history of hypertension was 'associated' with posterior epistaxis because 48.1% of their patients had it. Why didn't they report that male sex was associated with epistaxis, because 46% of their patients were male? "Without a control group, there is no way to prove an association. With a population with a mean age of 64.3 years (love that decimal point -- I'm sure they counted the patients' ages to the nearest month) I'm surprised that ONLY 48.1% had hypertension. Half of the Framingham cohort had hypertension. Why, hypertension may even be protective against epistaxis. "I reviewed the literature on epistaxis/hypertension a few years ago in connection with a colleague's study. There are some papers that support an association, and some papers that do not. I do not deny the possibility of an association, but I remain unconvinced." --John Schoffstall, M.D., aka schoffstall@medcolpa.edu I agree with the above assessment. Studies have yielded conflicting results of the putative role of chronic HTN in epistaxis. Yet, my main point was that sustained HTN certainly seems to _perpetuate_ it once it occurs. For that I have even less evidence to submit aside from my personal experience. In any case, we have very little influence on the extent of pre-existing HTN that exists in the patients that walk into our EDs. What can be modified, however, and what I was advocating, was good control of HTN once epistaxis has occured. H. Louzon MD (2) Cannon CR Effective treatment protocol for posterior epistaxis: a 10-year experience. Otolaryngol Head Neck Surg 1993 Oct;109(4):722-5 ABSTRACT: Posterior epistaxis remains a serious health problem. Modification of a traditional posterior pack using a Foley catheter has proved to be an effective method of treating these sites of severe posterior bleeding. Technological advancements in the form of a PCA infuser and pulse oximetry have allowed better control of packing-associated pain and identification of potential hypoxic complications. (3) McFerran DJ, Edmonds SE The use of balloon catheters in the treatment of epistaxis. J Laryngol Otol 1993 Mar;107(3):197-200 ABSTRACT: Inflatable balloon catheters are widely used in the treatment of severe epistaxis and are designed to be filled either with air or liquid. A postal survey revealed that 87 per cent of respondents used an inflatant which was deemed inappropriate by the manufacturer. When balloons designed for water or saline were filled with air, they deflated rapidly, in some cases being virtually empty after 24 hours. Better and more accessible instruction leaflets are required if the balloons are to be used as intended. Foley catheters are frequently used as nasopharyngeal packs, in conjunction with anterior nasal packs. Paraffin in the commonly used anterior packs damages the rubber of the catheter, resulting in the balloon bursting. This should be recognized by clinicians as a possible cause of rebleeding. (4) Davis JP Respiratory obstruction associated with the use of the Brighton epistaxis balloon. J Laryngol Otol 1993 Feb;107(2):140-1 ABSTRACT: A case is reported where posterior displacement of a Brighton balloon catheter (Eschmann) is thought to have led to inhalation of clot from the nasal cavity with subsequent respiratory obstruction. Precautions in using this type of epistaxis balloon are discussed. With regards to this issue of using balloon tamponade for posterior bleeds, a study was performed evaluating the efficacy of various devices in maintaining their volume over time (1). This was not a clinical outcome study but one which merely looked at he degree of leakage of 4 devices: 1) Simpson (single nasal fossa balloon) 2) Foley (single balloon post nasal space) 3) Epistat (2 fixed balloons) and 4) Brighton (2 movable balloons). According to the manufacturers' recommendations water (or saline) is to be used to inflate the foley and Epistat balloons and air for the other two. The authors found no significant loss of volume with either air or water for the Simpson device. For the Foley catheter there was no significant loss of volume with water inflation but 50% loss with inflation of air at 24 hours. The Epistat balloon (probably the most widely used device in the U.S. for posterior bleeds) showed a precipitous drop in volume with air inflation --the posterior balloon was empty by 24 hours and the anterior balloon by 36 hours. No significant loss was noted with inflation of water. The Brighton balloon likewise showed air but not water leakage (although the manufactuer recommends that air be used). The authors also noted that a survey of clinicians revealed that a large percentage (87%) did not adhere to the manufacturer's recommendations. Fear of aspiration (as I had previously mentioned) was one factor in prefering the use of air over water with the Epistat balloon. However, they note that the volume of water is small and that a literature review failed to reveal any untoward consequences of balloon rupture. H. Louzon MD (1) McFerren et. al. The Use of Balloon Catheters in the Treatment of Epistaxis. J Laryn Otol 1993;107:197-200