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Risk
factors
for
recurrent
epistaxis:
Importance
of
initial
treatment
Yuji
Ando
a,
*,
Jiro
Iimura
a,1
,
Satoshi
Arai
a,1
,
Chiaki
Arai
a,1
,
Manabu
Komori
a,1
,
Matsusato
Tsuyumu
a,1
,
Takanori
Hama
b,2
,
Yasushi
Shigeta
a,1
,
Atsushi
Hatano
a,1
,
Hiroshi
Moriyama
b,2
a
Department
of
Otorhinolaryngology,
Jikei
University
Daisan
Hospital,
4-11-1,
Izumi-honcho,
Komae-shi,
Tokyo
201-8601,
Japan
b
Department
of
Otorhinolaryngology,
Jikei
University
School
of
Medicine,
3-25-8,
Nishi-shinbashi,
Minato-ku,
Tokyo
105-8461,
Japan
1.
Introduction
Epistaxis
is
one
of
the
commonest
otolaryngological
emergen-
cies,
occurring
in
60%
of
adults
over
their
lifetimes,
but
treatment
is
required
in
only
10%
of
cases
[1].
Although
surgical
intervention
is
rarely
necessary,
refractory
recurrent
epistaxis
may
occur
in
some
cases,
and
epistaxis
is
a
common
cause
of
hospitalization
in
departments
of
otolaryngology
[2].
There
have
been
many
studies
of
epistaxis,
with
constant
debate
as
to
whether
factors
such
as
hypertension
and
antithrombotic
agent
use
constitute
risk
factors,
but
to
the
best
of
our
knowledge,
there
have
been
few
reports
addressing
risk
factors
for
recurrent
epistaxis,
and
it
is
remarkable
that
no
studies
that
have
used
statistical
analyses
for
their
investigation.
Hemostasis
is
particularly
difficult
for
posterior
bleeding
compared
with
anterior
bleeding,
and
treatment
fails
in
many
cases,
with
recurrent
epistaxis
occurring
frequently.
However,
cotton
packing,
balloon
catheters,
Foley
catheters,
and
other
such
methods
are
still
the
main
forms
of
treatment,
rather
than
pinpointing
the
bleeding
point
and
achieving
hemostasis.
In
this
study,
a
retrospective
study
of
risk
factors
for
recurrent
epistaxis
was
carried
out
in
299
patients.
Posterior
bleeding
was
treated
with
either
endoscopic
electrocautery
after
endoscopic
identification
of
the
bleeding
point
insofar
as
this
was
possible
or
endoscopic
gauze
packing,
and
their
efficacies
were
compared.
Auris
Nasus
Larynx
41
(2014)
41–45
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
3
July
2012
Accepted
23
May
2013
Available
online
19
June
2013
Keywords:
Recurrent
epistaxis
Risk
factor
Unidentified
bleeding
point
Gauze
packing
Endoscopic
electrocautery
A
B
S
T
R
A
C
T
Objective:
A
retrospective
study
of
risk
factors
for
recurrent
epistaxis
and
initial
treatment
for
refractory
posterior
bleeding
was
performed.
Based
on
the
results,
proposals
for
appropriate
initial
treatment
for
epistaxis
by
otolaryngologists
are
presented.
Methods:
The
data
of
299
patients
with
idiopathic
epistaxis
treated
during
2008–2009
were
analyzed
by
multivariate
logistic
regression
analysis.
Treatment
data
for
101
cases
of
posterior
bleeding
were
analyzed
using
the
chi-square
test.
Results:
Recurrent
epistaxis
occurred
in
32
cases
(10.7%).
Unidentified
bleeding
point
(adjusted
odds
ratio
(OR)
5.67,
95%
confidence
interval
(CI)
1.83–17.55,
p
=
0.003)
was
predictive
of
an
increased
risk
of
recurrent
epistaxis,
and
electrocautery
(adjusted
odds
ratio
(OR)
0.07,
95%
confidence
interval
(CI)
0.03–
0.17,
p
=
0.000)
was
predictive
of
a
decreased
risk
of
recurrent
epistaxis.
In
terms
of
initial
treatment
for
posterior
bleeding,
the
rate
of
recurrent
epistaxis
was
significantly
lower
for
patients
who
underwent
electrocautery
as
initial
treatment
compared
with
those
who
did
not
(6.4%
vs.
40.7%,
p
<
0.01),
and
it
was
significantly
higher
for
those
who
underwent
endoscopic
gauze
packing
compared
with
those
who
did
not
(39.5%
vs.
15.9%,
p
<
0.01).
Conclusion:
In
the
present
study,
the
risk
factors
for
recurrent
epistaxis
were
unidentified
bleeding
point.
Thus,
it
is
important
to
identify
and
cauterize
a
bleeding
point
to
prevent
recurrent
epistaxis.
The
present
results
also
suggest
the
effectiveness
of
electrocautery
and
the
higher
rate
of
recurrent
epistaxis
for
patients
who
underwent
gauze
packing
as
initial
treatment
for
posterior
bleeding.
Electrocautery
should
be
the
first-choice
treatment
of
otolaryngologists
for
all
bleeding
points
of
epistaxis,
and
painful
gauze
packing
may
be
inadvisable
for
posterior
bleeding.
More
cases
of
posterior
bleeding
are
needed
for
future
studies
involving
multivariate
analyses
and
appropriate
analyses
of
factors
related
to
hospitalization,
surgery,
and
embolization.
ß
2013
Elsevier
Ireland
Ltd.
All
rights
reserved.
*
Corresponding
author.
Tel.:
+81
3
3480
1151x3141;
fax:
+81
3
3430
3611.
E-mail
address:
andoh.ent@gmail.com
(Y.
Ando).
1
Tel.:
+81
3
3480
1151x3141;
fax:
+81
3
3430
3611.
2
Tel.:
+81
3
3433
1111x3601;
fax:
+81
3
3578
9208.
Contents
lists
available
at
SciVerse
ScienceDirect
Auris
Nasus
Larynx
jo
u
rn
al
h
om
epag
e:
ww
w.els
evier.c
o
m/lo
cat
e/anl
0385-8146/$
–
see
front
matter
ß
2013
Elsevier
Ireland
Ltd.
All
rights
reserved.
http://dx.doi.org/10.1016/j.anl.2013.05.004
2.
Patients
and
methods
2.1.
Patients
A
total
of
346
patients
visited
The
Jikei
Daisan
Hospital
because
of
epistaxis
between
June
2008
and
May
2009.
Of
these
patients,
24
children
who
were
15
years
old
and
under
were
excluded,
because,
unlike
in
adults,
the
cause
of
epistaxis
in
children
is
usually
from
picking,
rubbing,
and
hitting
their
nose,
as
well
as
an
infection
[3,4].
A
further
10
patients
with
traumatic
epistaxis,
6
with
bleeding
from
the
nasal
cavity
and
paranasal
sinus
tumors,
4
with
postoperative
epistaxis,
and
3
with
hereditary
hemorrhagic
telangiectasia
were
excluded
because
the
methods
to
stop
such
bleeding
differ
from
those
for
idiopathic
epistaxis.
Thus,
299
patients
with
idiopathic
epistaxis
were
studied.
2.2.
Methods
2.2.1.
Medical
examination
First,
to
identify
the
risk
factors
for
recurrent
epistaxis,
the
following
patient
characteristics
were
examined
at
their
first
visit
to
the
hospital:
age,
sex,
antithrombotic
agent
use
(i.e.,
aspirin,
warfarin,
etc.),
past
history
(hypertension,
hematologic
disease,
allergic
rhinitis,
chronic
sinusitis,
nasal
and/or
paranasal
surgery,
benign
or
malignant
tumor,
trauma),
and
deviated
nasal
septum.
Next,
at
the
time
of
their
second
visit
(1
week
later),
the
patients
were
interviewed
about
the
incidence
of
recurrent
epistaxis
after
their
first
treatment.
Furthermore,
tampons
were
removed
if
they
had
undergone
gauze
packing,
and
whether
the
bleeding
in
their
nose
had
stopped
was
checked.
If
epistaxis
recurred
within
a
week,
the
patients
were
told
to
come
back
to
the
hospital
so
that
the
recurrent
bleeding
point
could
be
identified
and
treated.
2.2.2.
Bleeding
point
identification
Visible
bleeding
points,
such
as
Kiesselbach’s
plexus
(Little’s
area),
were
initially
identified
with
a
nasal
speculum,
and
cotton
was
inserted
into
the
posterior
nasal
cavity
to
prevent
blood
from
running
down
the
pharynx.
If
a
bleeding
point
could
not
be
identified,
the
patient’s
nose
was
examined
in
detail
using
a
flexible
endoscope
and
a
rigid
endoscope
with
zero
degrees
of
view.
Because
blood
flows
from
top
to
bottom
when
the
patient
is
seated,
the
search
for
a
bleeding
point
with
an
endoscope
was
performed
in
the
following
order:
upper
olfactory
cleft,
upper
middle
meatus,
lower
olfactory
cleft,
lower
middle
meatus,
common
meatus,
and
inferior
meatus.
If
it
was
difficult
to
locate
a
bleeding
point
even
with
this
method,
a
rigid
endoscope
with
708
of
view
was
used
to
examine
the
lateral
wall
of
the
nasal
cavity,
for
example,
the
posterior
middle
meatus.
When
a
very
swollen
blood
vessel
was
found,
it
was
checked
for
bleeding
by
rubbing
it
and
by
applying
suction.
In
this
way,
each
patient’s
bleeding
point
was
identified
as
follows:
Kiesselbach’s
plexus,
olfactory
cleft,
middle
meatus,
inferior
meatus,
other
regions,
and
unidentified
bleeding
point.
2.2.3.
Treatment
The
treatment
used
to
stop
the
bleeding
was
classified
into
three
groups.
The
first
group,
the
hemostatic
material
group,
included
patients
with
a
very
small
amount
of
bleeding
and
those
in
whom
oxidized
cellulose
(SURGICEL
Absorbable
Hemostat
1
,
Ethicon
Inc.,
Somer-
ville,
NJ,
USA)
was
inserted
into
the
nose.
The
second
group
was
the
electrocautery
group.
Electrocautery
was
considered
the
first-choice
treatment
for
a
certain
amount
of
bleeding.
A
bleeding
point
was
cauterized
initially
using
straight
or
curved
bipolar
forceps
under
direct
vision
with
the
naked
eye,
and
then
with
endoscopy
secondarily.
A
monopolar
electrode,
as
effective
as
bipolar
forceps,
however,
causes
stronger
heating
damage
[5,6],
was
used
only
if
it
was
difficult
to
cauterize
the
bleeding
point
with
bipolar
forceps.
The
third
group
was
the
endoscopic
gauze
packing
group.
Gauze
packing
was
selected
for
treatment
of
epistaxis
only
when
the
bleeding
point
was
unidentified
or
electrocautery
was
difficult,
for
example,
in
patients
with
a
narrow
space
in
the
nasal
cavity.
Gauze
was
packed
intensively
into
all
possible
bleeding
space
with
an
endoscope.
Balloon
catheters
(e.g.,
the
Epistat
TM
,
Medtronic
Inc.,
Jackson-
ville,
Florida,
and
Storz
T-3100,
KARL
STORZ
GmbH
&
Co.
KG,
Tuttlingen,
Germany)
and
Foley
catheters
were
not
used
as
first-
choice
treatments
in
this
study.
2.2.4.
Statistical
analysis
First,
baseline
characteristics
stratified
by
the
incidence
of
recurrent
epistaxis,
including
patient
characteristics,
bleeding
points,
and
treatments,
were
analyzed.
Student’s
t-test
and
the
x
2
test
were
used
to
evaluate
differences
in
these
characteristics
between
patients
with
and
without
recurrent
epistaxis.
Next,
logistic
regression
analysis
was
performed,
defining
recurrent
epistaxis
as
the
dependent
variable,
and
patient
characteristics,
all
of
the
bleeding
points,
and
medical
treatment
as
the
independent
variables.
Of
these
risk
factors,
patients
were
classified
by
age
into
those
aged
45–65
years,
which
has
been
identified
in
the
literature
as
an
age
group
at
risk
of
epistaxis,
and
others
[7].
Finally,
the
relationship
between
recurrent
epistaxis
due
to
‘posterior
bleeding’
and
treatments
was
examined
using
the
x
2
test.
‘Posterior
bleeding’
was
defined
as
bleeding
points
other
than
those
from
Kiesselbach’s
plexus,
because
all
anterior
bleeding
in
this
study
arose
only
from
Kiesselbach’s
plexus.
All
statistical
analyses
were
performed
by
SPSS
11.0J
for
Windows
(International
Business
Machines
Corporation,,
Armonk,
NY,
USA).
A
value
of
p
<
0.05
was
considered
significant.
3.
Results
3.1.
Characteristics
and
recurrent
epistaxis
The
baseline
characteristics
of
the
patients
(126
women,
173
men;
mean
age
SD,
64.8
14.5
years),
stratified
by
the
incidence
of
recurrent
epistaxis,
are
shown
in
Table
1.
Recurrent
epistaxis
occurred
in
32
cases
(10.7%).
Overall,
94
patients
(31.4%
of
all)
had
taken
an
antithrombotic
agent.
Their
principal
past
history
included
hypertension
(155
patients,
51.8%)
and
allergic
rhinitis
(61
patients,
20.4%).
A
deviated
nasal
septum
on
the
bleeding
side
was
seen
in
149
cases
(49.8%).
However,
there
were
no
significant
differences
in
these
factors
between
patients
with
and
without
recurrent
epistaxis.
On
the
other
hand,
Kiesselbach’s
plexus
(198
cases,
66.2%),
unidentified
bleeding
point
(31
cases,
10.4%),
and
each
category
of
treatment
(i.e.,
hemostatic
material
(27
cases,
9.0%),
electrocautery
(234
cases,
78.3%),
endoscopic
gauze
packing
(38
cases,
12.7%))
were
significant-
ly
different
between
patients
with
and
without
recurrent
epistaxis
(p
<
0.05).
3.2.
Risk
factors
for
recurrent
epistaxis
The
results
of
the
univariate
and
multivariate
analyses
for
recurrent
epistaxis
according
to
each
factor
are
presented
in
Table
2.
On
univariate
analysis,
unidentified
bleeding
point
(unadjusted
odds
ratio
[OR]
20.48,
95%
confidence
interval
[CI]
8.51–49.30,
p
=
0.000),
hemostatic
material
(unadjusted
OR
4.35,
95%
CI
1.72–
10.99,
p
=
0.002),
and
endoscopic
gauze
packing
(unadjusted
OR
Y.
Ando
et
al.
/
Auris
Nasus
Larynx
41
(2014)
41–45
42
9.36,
95%
CI
4.14–21.15,
p
=
0.000)
were
predictive
of
an
increased
risk
of
recurrent
epistaxis,
whereas
Kiesselbach’s
plexus
(unad-
justed
OR
0.11,
95%
CI
0.05–0.27,
p
=
0.000)
and
electrocautery
(unadjusted
OR
0.17,
95%
CI
0.06–0.56,
p
=
0.002)
were
predictive
of
a
decreased
risk
of
recurrent
epistaxis.
On
multivariate
analysis,
after
adjustment
for
potential
confounders,
unidentified
bleeding
point
(adjusted
OR
5.67,
95%
CI
1.83–17.55,
p
=
0.003)
was
predictive
of
an
increased
risk
of
recurrent
epistaxis,
and
electrocautery
(adjusted
OR
0.07,
95%
CI
0.03–0.17,
p
=
0.000)
was
predictive
of
a
decreased
risk
of
recurrent
epistaxis.
No
other
factors
previously
described
as
risk
factors
for
epistaxis
(age,
male,
antithrombotic
agent
use,
hypertension,
chronic
sinusitis,
etc.)
were
identified
in
this
analysis.
3.3.
Hemostatic
efficacy
of
each
treatment
for
posterior
bleeding
As
described
above,
in
this
study,
all
anterior
bleeding
originated
in
Kiesselbach’s
plexus,
and
‘‘posterior
bleeding’’
was
defined
as
bleeding
from
any
point
other
than
Kiesselbach’s
plexus.
Posterior
bleeding
occurred
in
101
patients
(33.8%).
Tables
3–5
show
the
results
of
analyses
of
the
efficacy
of
each
type
of
treatment
for
posterior
bleeding.
There
was
no
significant
difference
in
the
rate
of
recurrent
epistaxis
between
patients
who
were
treated
with
hemostatic
material
and
those
who
were
not
(
x
2
=
3.68,
df
=
1,
p
=
0.055),
but
the
rate
of
recurrent
epistaxis
was
significantly
lower
for
patients
who
underwent
electrocautery
compared
with
those
who
did
not
(6.4%
vs.
40.7%,
p
<
0.01),
and
it
Table
1
Baseline
characteristics
stratified
by
the
incidence
of
recurrent
epistaxis.
Variable
Cases
(n
=
299)
p-Value
No
recurrent
epistaxis
(n
=
267)
Recurrent
epistaxis
(n
=
32)
Mean
age
(SD),
years
65.0
(14.6)
63.3
(13.3)
NS
**
Sex
Male
150
23
NS
*
Female
117
9
NS
*
Antithrombotic
agent
81
13
NS
*
Past
histories
Hypertension
138
16
NS
*
Hematologic
disease
3
0
NS
*
Allergic
rhinitis
57
4
NS
*
Chronic
sinusitis
4
1
NS
*
Surgery
18
2
NS
*
Deviated
nasal
septum
130
19
NS
*
Bleeding
points
Kiesselbach’s
plexus
191
7
.000
*
Olfactory
cleft
19
3
NS
*
Middle
meatus
17
3
NS
*
Inferior
meatus
20
2
NS
*
Other
regions
6
0
NS
*
Unidentified
bleeding
point
14
17
.000
*
Treatments
Hemostatic
material
19
8
.001
*
Electrocautery
225
9
.000
*
Endoscopic
gauze
packing
23
15
.000
*
Abbreviations:
SD,
standard
deviation
and
NS,
not
significant.
*
x
2
test.
**
Student’s
t-test.
Table
2
Unadjusted
and
adjusted
odds
ratios
for
recurrent
epistaxis
according
to
each
factor.
Variable
Unadjusted
odds
ratios
Adjusted
odds
ratios
OR
95%
CI
p
Value
OR
95%
CI
p
Value
Age
between
45
and
65
years
1.43
0.68–2.98
NS
Male
sex
1.99
0.89–4.47
NS
Antithrombotic
agent
1.57
0.74–3.33
NS
Past
histories
Hypertension
0.94
0.45–1.95
NS
Hematologic
disease
0.01
0.00–6.4E+15
NS
Allergic
rhinitis
0.53
0.18–1.56
NS
Chronic
sinusitis
2.12
0.23–19.58
NS
Surgery
0.92
0.20–4.17
NS
Deviated
nasal
septum
1.54
0.73–3.25
NS
Bleeding
points
Kiesselbach’s
plexus
0.11
0.05–0.27
.000
Olfactory
cleft
1.35
0.38–4.84
NS
Middle
meatus
1.52
0.42–5.50
NS
Inferior
meatus
0.82
0.18–3.70
NS
Other
regions
0.01
0.00–3.3E+10
NS
Unidentified
bleeding
point
20.48
8.51–49.30
.000
5.67
1.83–17.55
.003
Treatments
Hemostatic
material
4.35
1.72–10.99
.002
Electrocautery
0.07
0.03–0.17
.000
0.17
0.06–0.56
.002
Endoscopic
Gauze
packing
9.36
4.14–21.15
.000
Abbreviation:
NS,
not
significant.
Table
3
Comparison
of
hemostatic
effectiveness
of
hemostatic
material
for
posterior
bleeding.
No
hemostatic
material
Hemostatic
material
Total
No
recurrent
epistaxis
67
(78.8%)
9
(56.3%)
76
(75.2%)
Recurrent
epistaxis
18
(21.2%)
7
(43.8%)
25
(24.8%)
Total
85
(100%)
16
(100%)
101
(100%)
x
2
=
3.68,
p
=
0.055.
Table
4
Comparison
of
hemostatic
effectiveness
of
electrocautery
for
posterior
bleeding.
No
electrocautery
Electrocautery
Total
No
recurrent
epistaxis
32
(59.3%)
44
(93.6%)
76
(75.2%)
Recurrent
epistaxis
22
(40.7%)
3
(6.4%)
25
(24.8%)
Total
54
(100%)
47
(100%)
101
(100%)
x
2
=
15.93,
p
=
0.000.
Y.
Ando
et
al.
/
Auris
Nasus
Larynx
41
(2014)
41–45
43
was
significantly
higher
for
those
who
underwent
endoscopic
gauze
packing
compared
with
those
who
did
not
(39.5%
vs.
15.9%,
p
<
0.01).
4.
Discussion
Epistaxis
can
be
easily
treated
in
the
majority
of
cases,
but
refractory
epistaxis
with
repeated
recurrent
bleeding
can
be
a
problem.
In
this
study,
risk
factors
for
recurrent
epistaxis
and
refractory
posterior
bleeding
were
investigated
with
the
objective
of
reviewing
initial
treatment
methods
for
epistaxis.
In
the
present
study,
multivariate
analysis
showed
that
unidentified
bleeding
point
was
predictive
of
an
increased
risk
of
recurrent
epistaxis,
whereas
electrocautery
was
predictive
of
a
decreased
risk
of
recurrent
epistaxis.
These
results
suggest
that
the
rate
of
recurrent
epistaxis
was
lower
for
patients
who
underwent
electrocautery
and
higher
for
those
in
whom
a
gauze
tampon
was
inserted
to
treat
posterior
bleeding,
even
if
this
was
performed
intensively
with
an
endoscope.
Many
risk
factors
for
adult
epistaxis
have
been
reported,
but
most
of
them
are
generally
controversial.
In
terms
of
age,
as
mentioned
above,
epistaxis
is
believed
to
occur
more
frequently
in
the
age
range
of
45–65
years
[7].
In
terms
of
sex
ratio,
it
is
more
common
among
men
up
to
the
age
of
49
years,
but
after
that,
it
occurs
at
the
same
frequency
among
men
and
women,
suggesting
that
estrogen
may
be
involved
[8,9].
The
use
of
antithrombotic
agents
(mainly
warfarin)
is
believed
to
be
a
high-risk
factor
for
epistaxis,
but
whether
its
discontinuation
is
necessary
is
contro-
versial.
Although
one
report
stated
that
discontinuing
antithrom-
botic
agents
was
unnecessary
in
people
with
epistaxis
[10],
another
found
that
25%
of
patients
taking
antithrombotic
agents
experienced
epistaxis
ever
year
[11].
There
is
no
definitive
evidence
as
to
whether
aspirin
is
a
risk
factor
for
epistaxis
[12].
In
one
study
of
habitual
nose
bleeders,
the
recalled
rate
of
aspirin
use
did
not
differ
from
that
of
controls
[13].
In
contrast,
another
case
control
study
found
a
positive
correlation
between
aspirin
use
and
epistaxis
(RR
2.17
or
2.75,
depending
on
whether
a
community
or
hospital
control
group
was
used)
[14].
The
relationship
between
hypertension
and
epistaxis
is
also
unconfirmed.
Although
some
studies
have
found
a
correlation
between
hypertension
and
epistaxis
[2,15–18],
others
have
ruled
it
out
[9,10,19–21].
Another
report
identified
longstanding
hypertension
as
increasing
the
risk
of
epistaxis
[20].
One
expert
claims
that
although
hypertension
does
not
cause
epistaxis,
it
results
in
protracted
bleeding
[22].
On
the
other
hand,
to
the
best
of
our
knowledge,
few
articles
about
the
risk
factors
for
‘recurrent’
epistaxis
have
appeared.
Jackson
et
al.
examined
factors
associated
with
active,
refractory
epistaxis.
They
showed
that
hypertension,
aspirin,
and
alcohol
abuse
were
patient
characteristics
related
to
such
epistaxis,
posterior
floor
of
the
nasal
cavity
and
posterior
to
Kiesselbach’s
plexus
were
the
bleeding
points
related
to
such
bleeding,
and
septal
deviation,
spurring,
and
mucosal
abnormality
were
ana-
tomical
factors
[23].
Tay
et
al.
indicated
that
patients
who
had
been
prescribed
aspirin
had
a
relative
risk
of
hospital
admission
for
epistaxis
of
between
2.17
and
2.75,
depending
on
the
control
group
used
[14].
Denholm
et
al.
showed
that
patients
anticoagulated
with
warfarin
spent
significantly
longer
in
hospital
than
controls
[24].
On
the
other
hand,
Srinivasan
et
al.
demonstrated
that
there
was
no
significant
difference
in
the
mean
hospital
stay
between
the
warfarin
and
non-warfarin
groups,
and
warfarin
can
be
continued
Table
5
Comparison
of
hemostatic
effectiveness
of
endoscopic
gauze
packing
for
posterior
bleeding.
No
endoscopic
gauze
packing
Endoscopic
gauze
packing
Total
No
recurrent
epistaxis
53
(84.1%)
23
(60.5%)
76
(75.2%)
Recurrent
epistaxis
10
(15.9%)
15
(39.5%)
25
(24.8%)
Total
63
(100%)
38
(100%)
101
(100%)
x
2
=
7.09,
p
=
0.008.
Fig.
1.
Flow
diagram
for
primary
management
of
epistaxis
by
otolaryngologists.
Y.
Ando
et
al.
/
Auris
Nasus
Larynx
41
(2014)
41–45
44
safely
in
patients
with
epistaxis,
in
appropriate
circumstances
[25].
In
the
present
study,
multivariate
analysis
did
not
identify
even
a
single
patient
characteristic
as
a
risk
factor
for
recurrent
epistaxis.
No
previous
report
has
used
multivariate
analysis.
Moving
to
a
discussion
of
electrocautery,
some
articles
describe
management
of
epistaxis
and
the
importance
of
endoscopic
electrocautery,
which
was
effective
in
the
present
study.
They
showed
that
traditional
strategies
like
nasal
packing
have
been
supplemented
by
endoscopic
electrocautery
[2,26–28].
This
treatment
was
first
reported
by
Wurman
et
al.
[29],
and
it
has
become
the
primary
treatment
used
in
recent
years,
because
it
is
less
invasive
than
traditional
strategies
and
has
nearly
equivalent
failure
rates
compared
with
other
approaches
(20–33%)
[30].
Elwany
et
al.
used
suction
cautery
under
endoscopic
vision
for
38
patients
with
posterior
epistaxis,
and
they
succeeded
in
stopping
bleeding
in
30
cases.
Temporary
palatal
numbness
in
three
patients
was
the
only
complication
[31].
Police
et
al.
performed
a
retrospective
study
of
249
patients
hospitalized
due
to
epistaxis,
and
they
found
that
all
30
endoscopic
cauterizations
successfully
stopped
the
epistaxis,
demonstrating
the
usefulness
of
this
technique
[32].
In
the
present
study,
electrocautery
was
found
to
be
the
first-choice
treatment,
with
recurrent
epistaxis
seen
in
32
patients
(10.7%).
It
was
also
effective
in
treating
posterior
bleeding.
With
respect
to
unidentified
bleeding
point,
Chiu
et
al.
carried
out
a
prospective
study
of
idiopathic
adult
posterior
epistaxis
and
demonstrated
that
94%
of
bleeding
sites
was
identifiable
[33].
In
the
present
study,
the
bleeding
point
was
not
identified
in
31
cases
(10.4%).
The
rate
of
recurrent
epistaxis
was
high
when
the
bleeding
point
was
not
identified
(17
of
31
cases,
54.8%),
and
multivariate
analysis
showed
that
unidentified
bleeding
point
was
a
risk
factor
for
recurrent
epistaxis.
If
the
bleeding
point
cannot
be
identified,
electrocautery
is
of
course
impossible,
and
as
the
rate
of
recurrent
epistaxis
was
higher
for
patients
who
underwent
gauze
packing
(39.5%),
hospitalization,
arterial
embolization,
and
surgery
may
be
required
should
epistaxis
recur.
In
light
of
the
foregoing
discussion,
Fig.
1
shows
a
flow
chart
for
initial
treatment
of
epistaxis
by
otolaryngologists.
Although
this
is
only
a
proposal,
gauze
packing
is
regarded
as
inadvisable
treatment
in
light
of
the
results
of
the
present
analysis
and
the
pain
it
causes
patients.
The
number
of
patients
in
the
present
study
was
insufficient
to
carry
out
multivariate
analysis
of
bleeding
points
other
than
Kiesselbach’s
plexus,
where
hemostasis
can
easily
be
performed;
this
should
be
carried
out
and
risk
factors
identified
in
future
studies.
Analysis
should
also
cover
factors
indicating
the
need
for
hospitalization,
surgery,
or
embolization.
5.
Conclusion
In
the
present
study,
the
risk
factors
for
recurrent
epistaxis
were
unidentified
bleeding
point.
Thus,
it
is
important
to
identify
and
cauterize
a
bleeding
point
to
prevent
recurrent
epistaxis.
The
present
results
also
suggest
the
effectiveness
of
electrocautery
and
the
higher
rate
of
recurrent
epistaxis
for
patients
who
underwent
gauze
packing
as
initial
treatment
for
posterior
bleeding.
Electrocautery
should
be
the
first-choice
treatment
of
otolaryn-
gologists
for
all
bleeding
points
of
epistaxis,
and
painful
gauze
packing
may
be
inadvisable
for
posterior
bleeding.
Conflict
of
interest
None.
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