An Outcomes Analysis of Anterior Epistaxis Management in The Emergency Department
An Outcomes Analysis of Anterior Epistaxis Management in The Emergency Department
An Outcomes Analysis of Anterior Epistaxis Management in The Emergency Department
Abstract
Background: Many treatment options exist for the management of anterior epistaxis. However, little is
known about treatment outcomes. The objective was to identify the currently utilised methods of
management and outcomes for patients with anterior epistaxis presenting to the emergency department
(ED) at a Canadian tertiary care center.
Methods: A retrospective review of ED visits from January 2012-May 2014 for adult patients with a
diagnosis of anterior epistaxis was performed. Patient demographic data, comorbidities, and treatment
methods were documented. The effectiveness of different treatment modalities was determined.
Results: Three hundred fifty-three primary anterior epistaxis cases were included. Mean patient age was 70
years and 49 % of patients were female. Comorbidities included hypertension (56 %), diabetes (19 %), CAD
(28 %), and atrial fibrillation (27 %). A large proportion of the cohort (61 %) was on at least one anticoagulant
or antiplatelet therapy. The most common utilised treatment modalities were silver nitrate cauterization,
Merocel®, petroleum gauze packing, nasal clip and 15 % were simply observed. Initial treatment success was
achieved in 74 % of cases. Of patients receiving specific treatment modalities, silver nitrate cauterization had
the highest success rate at 80 %. 26 % of patients returned to the ED for recurrence of epistaxis with highest
rates occurring in the nasal clip (59 %), Merocel® (26 %), and petroleum gauze packing (42 %) groups.
Conclusions: The differences in recurrence rate among the different treatment modalities observed may be
due to true differences in effectiveness or differences in treatment selection by the ED physicians based on
severity of epistaxis. Cauterization with silver nitrate, however, offers the added benefit of no need for follow
up. Further study is needed to elucidate the most efficacious treatment modality based on epistaxis severity.
Keywords: Epistaxis, Treatment, Anterior epistaxis, Tertiary care, Emergency department
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Newton et al. Journal of Otolaryngology - Head and Neck Surgery (2016) 45:24 Page 2 of 5
For each treatment modality, success was defined as pa- Comorbidities N (%)
tients who were diagnosed with anterior epistaxis, who Hypertension 198 (56)
received treatment and did not present with a recur- Diabetes 67 (19)
rence within 14 days of their original date of presenta- CAD
a 97 (28)
tion [11]. Conversely, failure was defined as the patients Afib
b 94 (27)
who had an ipsilateral recurrence of epistaxis within c
HHT 3 (1)
14 days of initial treatment. The treatment type was re-
corded based on the treatment modality used to arrest Other blood disorders 12 (3)
d 217 (62)
the bleeding that led to the patient’s discharge from the AC/AP medication use
ED. Follow-up was defined as patients who were admin- a
Coronary artery disease
istered a specific treatment and who were subsequently b
c
Atrial fibrillation
Hereditary hemorrhagic telangiectasia
booked and received follow-up care in the ED for either d
any other reason. For patients requiring an inpatient returned to the ED for a scheduled follow-up after dis-
admission, the length and reason for admission were charge from the ED. Of the individuals requiring follow-
recorded. up, 89 (95 %) returned for packing removal (53 patients
had Merocel® packing), in 3 (3.1 %) patients packing was
Analysis left in situ at the follow up visit and 2 (2.1 %) patients
All statistical calculations were done using SAS (version attended the follow up visit even though their packing
9.3). Categorical variables were summarized using fre- had fallen out on its own before their appointment. Of
quency counts and percentages, while continuous vari- the 94 patients requiring follow up, 22 (23 %) required
ables were summarized using the mean (SD) or median further intervention (10 patients with Merocel® packing)
(IQR), as appropriate. Where necessary, initial testing for for epistaxis at the time packing removal. There was no
associations between categorical variables was done using difference in bleeding rates post pack removal between
either chi-square or Fisher’s Exact tests. Modeling of cat- the different types of packing.
egorical outcomes was done using logistic regression. When silver nitrate was compared to petroleum gauze
packing, those in silver nitrate group were less likely to
Results fail (OR 0.335, 95 % CI 0.160–0.703 p = 0.0038). When
Characteristics of study subjects silver nitrate was compared to Merocel® packing, the
A total of 419 visits to the ED with a primary diagnosis odds of recurrence were lower with silver nitrate than
of epistaxis occurred from January 2012 to May 2014. with Merocel® (OR 0.694, 95 % CI 0.364–1.322, p = 0.27),
Sixty-six visits were excluded from this analysis, reasons however this was not statistically significant.
for exclusion are shown in Fig. 1. Overall, 353 anterior When evaluating potential risk factors for the devel-
epistaxis cases were included in this study; the demo- opment of epistaxis, anticoagulation was identified
graphics and comorbidities are summarized in Table 1. Table 2 Treatment outcomes for management of anterior
The individuals included in this study had a mean age of
epistaxis
70 and 49 % were women. A large proportion (61 %) of
Treatment N (%) Failure N (%)
the patients were on some type of anticoagulant or anti-
Silver nitrate 122 (35) 24 (20)
platelet medication. Of the comorbidities recorded,
hypertension, diabetes, coronary artery disease, atrial fib- Merocel 92 (26) 24 (26)
rillation, did not have a statistically significant impact on No treatment 54 (15) 11 (20)
a 45 (13) 19 (42)
treatment failure (p > 0.05). Other packing
Main results b 23 (6) 3 (13)
Other
Nasal clip 17 (5) 10 (59)
The outcome of each treatment is summarized in a
Other packing included non-dissolvable anterior packs the majority being
Table 2. In all, the overall primary treatment failure rate Vaseline gauze packing
was 26 % (91 patients) and in total 26.6 % (94 patients) b
Other included surgicel, decongestant with topical anesthetic alone
Newton et al. Journal of Otolaryngology - Head and Neck Surgery (2016) 45:24 Page 4 of 5
from the patient characteristics, through logistical re- Table 4 Outcomes of treatment success and failure
gression. The type of anticoagulant or antiplatelet based on anticoagulation/antiplatelet use profile
medication individuals in the study were receiving is Anticoagulant/Antiplatelet N Failure N (%)
summarized in Table 3. Given the large variety of None 136 25 (18)
anticoagulation and antiplatelet medications, they were Any anticoagulant/antiplatelet 217 66 (30)
grouped into 3 categories for analysis as seen in Table 4. ASA only 85 28 (33)
Overall, 61 % of the individuals were on at least one Other regimen 132 38 (29)
antiplatelet or anticoagulant medication. Of those not on
any anticoagulant or antiplatelet agent, the failure rate for
anterior epistaxis treatment was 18 %. In contrast, for
individuals on any anticoagu-lant/antiplatelet agent the In this cohort, silver nitrate treatment had the low-est
failure rate was 30 %. There was a statistically significant rate of treatment failure (20 %) of the most uti-lised
association be-tween the use of anticoagulant/antiplatelet treatment modalities and it also had the added benefit of
medication and the recurrence of epistaxis (p = 0.0119). not requiring an additional routine ED visit, as non-
73 % of all patients who failed treatment were on at least dissolvable packing did. Selection bias may have affected
one antiplatelet or anticoagulant medication. this observation as silver nitrate may have been used by
ED physicians only in less severe cases. Other literature
has described good success rates for anterior dissolvable
packing [3, 4, 11, 12] and surgical techniques [3],
Discussion however the number of individuals receiving these
Overall there were 353 cases of anterior epistaxis ana- treatments in our cohort were too small for analysis.
lyzed in this study for outcomes of treatment received in
the ED. Silver nitrate cautery was the most popular mo- Epistaxis management, as with any medical condi-tion,
dality used accounting for 35 % of initial treatment. should be tailored to the patient and the clinical situation
However, the treatment of anterior epistaxis proved to be [8]. In this study most patients with anterior epistaxis
quite variable with Merocel®, petroleum gauze pack- received successful management with silver nitrate
ing/other packing or a nasal clip commonly being used. cautery or Merocel® packing being the most commonly
The group of patients who received no treatment at the used modalities. Silver nitrate was particularly
ED was not used as a control to compare other treatment advantageous as it showed promising results insofar as
modalities given those patients not requir-ing treatment treatment success without a need for follow-up. However,
had stopped bleeding when seen by the ED physician or in these cases the site of bleeding was identifiable on an-
they did not have a bleeding episode of such a severity terior rhinoscopy examination and amenable to cautery
that it required any treatment. It would be an unfair with silver nitrate. This is in keeping with other studies
comparison due to the inherent clinical difference in which have shown that when the source of bleeding in
epistaxis severity. When the sil-ver nitrate group was epistaxis is identifiable chemical cautery has excellent
compared to the petroleum gauze packing, those in silver suc-cess in the treatment of anterior epistaxis [2, 8–10].
nitrate group were less likely to fail (p = 0.0038). Exploring the reasons for treatment failure, the use of
blood thinners is largely believed to have an effect. In our
study it was found that being on any anticoagulant or
antiplatelet agent, including ASA, significantly in-creased
Table 3 Types of anticoagulation (AC)/antiplatelet the odds of recurrence after discharge from the ED (p =
(AP) medications used by patient population 0.0106). The rate of treatment failure in pa-tients on any
Medication N (%) anticoagulant/antiplatelet agent was 30 %, in ASA alone
Any AC/AP 217 (62) was 33 % and in another regimen was 29 %, these were
ASA 122 (34) significantly greater than the failure rate of 18 % seen in
Coumadin 78 (23) the individuals not on any such therapy (p < 0.0119).
Rivaroxaban 14 (4)
As with any study, this study has some limitations. The
Dabigatran 4 (1)
population size studied was not large enough to ac-
Apixaban 4 (1) curately comment on less commonly used forms of
Clopidogrel 33 (9) management for anterior epistaxis. Similarly, there was no
Ticagrelor 2 (1) data or rating on the severity of epistaxis on arrival to the
Other anticoagulant 7 (2) ED that, in the end, may have affected physician
treatment selection and also affected recurrence. This
Newton et al. Journal of Otolaryngology - Head and Neck Surgery (2016) 45:24 Page 5 of 5
may confound the relationship between the treatment Received: 18 December 2015 Accepted: 4 April 2016
modality used and outcomes. At the institution of this
study, patients presenting acutely with anterior epistaxis References
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treatment decisions. Looking at the four most common
modalities used to treat anterior epistaxis in the ED from
this study, the use of silver nitrate appears to be an
effective management option taking into account the time
and resources used for any other modality necessi-tating a
patient to return to the ED. This suggests that if the
anterior site of bleeding is identifiable, it is likely
amenable to chemical cautery, silver nitrate be the first
line treatment. However, due to limitations of the study,
and that there was no grading system to identify epi-staxis
severity, a recommendation of silver nitrate cautery for all
occurrences of anterior epistaxis can-not be given at this
time. Further study is needed to determine the most
efficacious treatment modality based on epistaxis severity.
Competing interests
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Head and Neck Surgery, University of Ottawa, Ontario, Canada. Ottawa
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