recurring anterior epistaxis

04/03/2011 1

Faculty Disclosure

I advise that the following presentation will NOT include discussion on any commercial products or service and that there are NO financial

interests or relationships with any of the Commercial Supporters of The Asia-Oceania Otolaryngology Congress.

04/03/2011

12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania Association of Oto-Rhino-Laryngological Societies

2

Recurring Anterior Epistaxis: Long-Term Follow-Up

Edoardo Cervoni, M.D. Central Lancashire PCT

NHS

Anatomy

04/03/201112th Asia-Oceania ORL-HNS Congress - Ethical

Outcomes, Asia-Oceania Association of Oto-Rhino-Laryngological Societies 3

FrequencyData on the true incidence of epistaxis may

be difficult to obtain due to the fact that not all cases are seen in A&E or by a GP/FP.1

Epistaxis is estimated to occur in 60% of persons worldwide during their lifetime, and approximately 6% of those with nosebleeds seek medical treatment2.

04/03/2011

12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania Association of Oto-Rhino-Laryngological Societies

4

Background and AimBackground: Epistaxis mostly (80–90%)

originates from Little's area and it is self-limiting. However, clinical intervention is often seek and the long-term outcomes of the different form of intervention may vary.

Aim: the objective of this study is to retrospectively analyse what the long-term outcomes may be.

04/03/2011

12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania

Association of Oto-Rhino-Laryngological Societies 5

Material and MethodsA cluster sample of 8275 subjects, 4206

males (50.8%) and 4069 females (49.2%), was selected to undergo a complete review of computerized GP medical records for diagnosis of epistaxis (2008 ICD-9-CM Diagnosis Code 784.7), and looked for recurring epistaxis.

The full medical records were then scrutinized for type of epistaxis, intervention, co-morbidities, and medications.

04/03/2011

12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania

Association of Oto-Rhino-Laryngological Societies

6

Population demographic characteristics

04/03/2011

12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania Association of Oto-Rhino-Laryngological Societies 7

UK Census 2001 – Official data

Population cluster characteristics

04/03/2011


Age distribution

04/03/2011 12th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania Association of Oto-Rhino-Laryngological Societies

9

ResultsComplete prevalence of recurring epistaxis

was 1% in males and 1% in females. Total recurring epistaxis prevalence was 1%. All ages were affected with a peak incidence

in children and young adults aged 5-24 years and in the adults above 55.

04/03/2011


Medical History: active problems

04/03/2011


Medical History: Medications

04/03/201112th Asia-Oceania ORL-HNS Congress - Ethical Outcomes, Asia-Oceania Association of Oto-

Rhino-Laryngological Societies 12

Clinical outcomes

04/03/2011


Treatments comparisonSilver nitrate cauterization seems to be

associated with higher long-term prevalence of re-bleeding when compared to other forms of intervention, including simple advice.

The amount of data was not large enough to compare effectiveness of Mupirocin vs. Naseptin in recurring anterior epistaxis.

Naseptin had been most commonly used.Only Naseptin was applied after silver nitrate

cautery.04/03/2011


Other observationsAt a mean follow-up of 90 months, recurrence

rate post-intervention was 13%, being higher in the group treated with silver nitrate cauterization, with or without antibiotic cream.

The average interval of re-bleeding post cautery was 2 years.

Hypertension and allergic rhinitis were the most commonly reported co-morbidities, but they did not appear to have an impact on the risk of re-bleeding.

04/03/2011


Previous studiesMcNeill (1974) preferred the use of a silver

nitrate particularly in children3.Ludman (1981) described silver nitrate

tipped stick as the treatment of choice for persistent epistaxis when the bleeding vessel is visible4.

Toner and Walby (1990) with a prospective randomized study showed that there was no statistically significant difference between galvanocautery and cautery with silver nitrate in either controlling the epistaxis or in the incidence of complications5.

04/03/2011


Subsequent StudiesSilver nitrate cautery offers no added advantage

when compared to antiseptic nasal cream (Murthy P et coll., 1999) 6.

Antiseptic cream is an effective treatment for recurrent epistaxis in children and silver nitrate cautery with antiseptic cream in the short term (4 weeks) appears to give a small but statistically significant benefit when compared to antiseptic cream alone (Kubba H et coll., 2001; Calder N et coll., 2009) 7,8.

Children treated for recurrent epistaxis who had undergone cautery and received cream had the highest on-going bleeding rate (Robertson S et coll., 2008)9.

04/03/2011


Study limitationsThis study relies heavily on the fact that

episodes of recurring anterior epistaxis had been reported to either Primary Care or Secondary Care practitioner.

Some episodes of epistaxis may have been reported, but not coded in the electronic clinical records.

Subjects that underwent cauterization rather than being treated with cream or observed may have had different characteristics, such as more obvious varices.

04/03/2011


Prospective studiesRCT comparing Naseptin® antiseptic cream

with Mupirocin cream 2%.RCT comparing varices cauterization

followed by application of Mupirocin vs. Naseptin® antiseptic cream .

Sub-analysis of patients with diagnosis of hypertension and not taking anti-platelets, nor anti-coagulants.

04/03/2011


References1. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North

Am. Jun 2008;41(3):525-36.2. Cummings CW. Epistaxis. In: Cummings: Otolaryngology: Head and Neck

Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005:Chap 40.3. McNeill J. Coping with nose-bleeds. BMJ 13 April 1974; 118 (letter).4. Ludman H. ABC of ENT: nose bleeds. BMJ (1981) 282, 967-9.5. Toner JG, Walby AP. Comparison of electro and chemical cautery in the

treatment of anterior epistaxis. J Laryngol Otol. 1990 Aug;104(8):617-8.6. Murthy P, Nilssen EL, Rao S, McClymont LG. A randomised clinical trial of

antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Otolaryngol Allied Sci. 1999 Jun;24(3):228-31

7. Kubba H, MacAndie C, Botma M et al. A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol Allied Sci. 2001 Dec;26(6):465-8.

8. Calder N, Kang S, Fraser L et al. A double-blind randomized controlled trial of management of recurrent nosebleeds in children.Otolaryngol Head Neck Surg. 2009 May;140(5):670-4

9. Robertson S, Kubba H. Long-term effectiveness of antiseptic cream for recurrent epistaxis in childhood: five-year follow up of a randomised, controlled trial. J Laryngol Otol. 2008 Oct;122(10):1084-7.

04/03/2011


recurring anterior epistaxis

Health & Medicine