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Objective: To analyze the related influencing factors of epistaxis in extremely high altitude area, and to provide evidence for the prevention and treatment of epistaxis in extremely high altitude area. Methods: From January 2021 to December 2022, 206 outpatients with epistaxis, 54 inpatients with epistaxis and 69 inpatients withoutepistaxis in theDepartment of Otorhinolarygology, Naqu People's Hospital were collected. The previous history, drinking history, smoking history, serum homocysteine（Hcy）, white blood cell count（WBC）, red blood cell count（RBC）, hematocrit（HCT）, hemoglobin（HGB） and mean hemoglobin concentration（MCHC） were compared between inpatients with or without epistaxis. The factors with significant differences were analyzed by binary Logistic regression. The monthly average temperature,air pressure, humidity and 2-minute wind speed were collected from January 2021 to December 2022 in Naqu City to analyze the correlation between epistaxis and climate factors. Results: The number of patients with hypertension in the case group was more than that in the control group, and the difference was significant（ P =0.013）. Serum Hcy level in the case group was higher than that in the control group（ P <0.001）. RBC, HCT, HGB and MCHC were lower than that in the control group（ P =0.001, 0.001, 0.001, 0.039）, and the difference was significant. History of hypertension and Hcy were risk factors for epistaxis. Patients with a history of hypertension were 3.713 times more likely to suffer from epistaxis than those without a history of hypertension（ P =0.022）. Each 1 increase in Hcy concentration increased the risk of epistaxis by 13.1%（ P =0.001）. Conclusion: Patients with epistaxis in Naqu area had higher serum Hcy level and lower RBC, HCT, HGB and MCHC. History of hypertension and Hcy were risk factors for epistaxis. Patients with a history of hypertension were 3.713 times more likely to suffer from epistaxis than those without a history of hypertension. Every 1 increase in Hcy concentration increased the risk of epistaxis by 13.1%. Active intervention of hypertension and serum Hcy can effectively prevent the incidence of epistaxis., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Hemolacria is a rare condition that causes a person to produce tears that are partially composed of blood. It can be a presenting feature of certain ocular and systemic conditions. Here, the authors describe an interesting case of a 12-year-old boy with an underlying beta-thalassemia trait, who presented with a 2-day history of bilateral blood-stained tears, and an episode of epistaxis. Ocular examination was normal, and syringing showed no nasolacrimal duct blockage. Systemic examination was unremarkable. Laboratory investigations confirmed type 2 von Willebrand disease. Management of hemolacria remains a clinical challenge given the rare occurrence of the disease. In this case report, the authors discuss the differential diagnosis and management approach to hemolacria., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: the aim of this study was to investigate the possible relationship of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) and routine hematological parameters with recurrent epistaxis in children., Methods: İn this retrospective case-controlled study, 294 patients aged between 2 and 18 years who applied to the Tokat State Hopital Ear Nose Throat Clinic due to recurrent epistaxis between January 1 s t 2013 and December 31 st December 2017 and 329 sex-and age-matched controls were investigated., Results: NLR was 1.45±0.75 in the study group and the 1.35±0.7 in the control group. There was no significant difference between the groups (p>0.05). PLR values were found significantly (p<0.05) higher in the study group than in the control group (103,21±29.57 vs. 97,3±30.38). Red Blood Cell Distribution Width (RDW) values were found significantly (p<0.05) lower in the study group than in the control group (39,56±2,87 and 38,92±2,46)., Conclusion: the increase of PLR, an inflammatory marker, in epistaxis supports the effect of inflammatory factors in the etiology of epistaxis. However, more study in future is needed to support this., Competing Interests: The authors declare no competing interests.

Objective: To evaluate the serum levels of interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, tumor growth factor (TGF)-β, endothelin, and immunoglobulin (Ig)E in patients with idiopathic epistaxis, compared with healthy control individuals., Methods: Serum levels of IL-6, IL-8, TNF-α, TGF-β, endothelin, and IgE were evaluated in 110 patients with idiopathic epistaxis and 100 healthy controls using the enzyme-linked immunosorbent assay (ELISA) technique., Results: Serum levels of IL-6 (P <.001) and TGF-β (P = .001) were significantly increased in patients with idiopathic epistaxis, compared with controls. TNF-α serum levels were significantly increased in male patients, compared with female patients (P = .053). We observed decreased antihistamine levels and increased expression of TGF-β (P = .02) and TNF-α (P = .02), respectively., Conclusions: IL-6 and TGF-β appear to participate in the pathogenesis of idiopathic epistaxis. TNF-α may be considered a risk factor for male patients in developing epistaxis. Antihistamines may inhibit angiogenesis by decreasing expression of TGF-β and increasing expression of TNF-α.

Background: The management of epistaxis requires an understanding of haematological factors that may complicate its treatment. This systematic review includes six distinct reviews examining the evidence supporting epistaxis-specific management strategies relating to warfarin, direct oral anticoagulants, heparin, antiplatelet agents, tranexamic acid and transfusion., Method: A systematic review of the literature was performed using a standardised methodology and search strategy., Results: Limited numbers of articles were identified in each systematic review, with level 1 evidence only regarding the use of tranexamic acid. No studies met the inclusion criteria within the heparin, direct oral anticoagulants or transfusion systematic reviews. Many studies were limited by small sample sizes and significant risk of bias., Conclusion: The management of major bleeding and transfusion practice is well documented in national guidance from multiple sources. The guidelines include advice on anticoagulants, antiplatelet agents and tranexamic acid. In the absence of more specific evidence, these guidelines should be applied in the management of epistaxis.

Objective: This study aimed to investigate whether there is a relationship between red blood cell distribution width, mean platelet volume and epistaxis in children., Methods: Between January 2015 and July 2016, 105 children who were referred to our clinic with epistaxis and 100 sex- and age-matched controls were retrospectively analyzed. Red blood cell distribution width (RDW) and mean platelet volume (MPV) values were determined in both groups., Results: RDW values were found significantly (P < 0.05) lower in the group with epistaxis than in the control group (11.95 ± 1.31 vs. 12.74 ± 1.21). MPV was 7.49 ± 1.33 in the group with epistaxis and 7.23 ± 1.06 in the control group, and there was no significant difference between the groups (p > 0.05)., Conclusion: We found no difference between MPV values of both groups and significantly lower RDW values in children with epistaxis. Decreased RDW values were considered as an accompanying marker rather than a result of epistaxis. In addition, it may be thought that low RDW values may increase the bleeding tendency by disrupting the thrombotic activities. Further studies are needed to validate the relation of these parameters with epistaxis and its mechanisms., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives/hypothesis: This study is a pilot study evaluating the feasibility of sampling nose blood during an emergency using a commercially available rapid test device. It also compares the accuracy of rapid nasal blood test results to the results of standard laboratory methods using venous blood sampling., Methods: Nose blood was collected in patients suffering from active epistaxis. In an emergency setting, hemoglobin levels and the international normalized ratio (INR) were assessed using a rapid point-of-care test device. These results were compared to standard laboratory analyses from venous blood taken at the same time from the same patient. Twenty patients consented to and participated in these assessments., Results: Linear regression comparing venous and nasal samples revealed strong correlations between the two methods for both hemoglobin and INR measurement. A Bland-Altman analysis showed the mean difference to be 2.3 g/L when comparing hemoglobin measurements made using the rapid point-of-care device to hemoglobin measurements made using conventional lab assessment. The corresponding mean difference for INR measurements was 0.14., Conclusion: The results of this pilot study support the use of point-of-care test devices using nasal blood sampling and provide preliminary data demonstrating that a rapid testing method can be reliable, practicable, and time-efficient. In our opinion, rapid hematologic screening for nasal and capillary blood should be available in emergency wards that treat epistaxis., Level of Evidence: 4. Laryngoscope, 127:577-581, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Factor XIII deficiency (FXIIID) is an extremely rare bleeding disorder with the highest global incidence in southeast of Iran. Southwestern Afghanistan (Nimruz Province) is located near the border with Iran in the vicinity of Sistan and Baluchestan Province in southeast Iran, and there seems to be a high prevalence of FXIIID in Nimruz. Thus, this cross-sectional study was designed to assess the prevalence of FXIIID, molecular basis as well as clinical manifestations of FXIIID in Southwestern Afghanistan. During the course of the study, all patients suspected of FXIIID were clinically examined and assessed by routine coagulation tests, including bleeding time, activated partial thromboplastin time, prothrombin time, as well as platelet count and clot solubility test. Patients with normal routine coagulation tests, but abnormal clot solubility test, underwent further investigations by FXIII activity, as well as molecular analysis for FXIII-A gene mutation (Trp187Arg) by PCR-restriction fragment length polymorphism that confirmed by sequencing. Patients with confirmed FXIIID deficiency were registered to receive prophylaxis treatment. All data including demographic information, clinical manifestations, as well as therapeutic response and type and duration of treatment, were recorded, and the data were analyzed by SPSS software. In this cross-sectional study, we found five patients with abnormal clot solubility test, among whom two patients abandoned the study, whereas three patients remained for a more precise study. All the patients were residents of Zaranj city, the capital of Nimruz Province. All these patients had undetectable activity of FXIII, which indicates a severe deficiency. Molecular analysis of patients showed mutation of Trp187Arg in all of them. Hematoma was the most common clinical presentation leading to diagnosis of FXIIID in these patients (100%). Epistaxis (67%), gum bleeding (33%), and hematuria (33%) were other recurrent clinical presentations of the patients. Three cases of death due to FXIIID were detected in the family of these patients. There was a high prevalence of FXIIID in Zaranj city with a population of 50 000, which was appropriately equal to the prevalence of the disorder in southeast of Iran, which seemed to have the highest global prevalence of FXIIID, and underlines that the same mutation (Trp187Arg) in both regions is same.

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 Atatürk 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 ± 0.1 in the control group and 8.36 ± 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 ± 0.32 in the control group and 11.90 ± 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., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To establish whether, for the patient presenting with epistaxis, there is a relationship between clinical outcome and serum urea levels measured on initial attendance at the accident and emergency (A&E) department., Methodology: Records were reviewed from all patients attending a single teaching hospital A&E department between 1st January 2010 and 11st February 2011 with a diagnosis of epistaxis. Patients were analysed according to their admission serum urea and creatinine levels and then grouped according to clinical outcome., Results: We identified 278 patients (145 males, 133 females), 82 of which required hospital admission. Eleven required blood transfusion, and five required surgical arrest of the haemorrhage. No patients died. Serum urea and creatinine levels were measured in 119/278 patients. The mean serum urea level was significantly higher in patients admitted for further management of epistaxis than in patients who were discharged from the A&E department (9.35 mmol/l vs. 6.74 mmol/l, respectively; p = 0.003). There was no significant difference in mean serum urea levels between patients who were transfused and patients who were not, or between patients who went to the operating theatre and patients who did not., Conclusions: Elevated serum urea levels on hospital admission are related to more severe clinical outcome in epistaxis.

Objective: The aim of this study was to assess the effectiveness of localized treatments to persistently stop epistaxis in patients with inherited bleeding disorders., Methods: In a self-controlled comparative clinical trial, to offer the best solution to stop epistaxis at home (within 10 minutes), patients with inherited bleeding disorders were treated using three different topical hemostatic agents, including Tranexamic acid impregnated tampon, EpiCell tampon prepared from oxidized regenerated cellulose pad, and ChitoHem tampon (reinforced with chitosan). The results of using these different products on three groups of randomly selected patients were ultimately compared using the χ(2) and Fisher's exact test statistics., Results: A total of 31 patients, 5 females and 26 males with a mean age of 5.6 years, were included in the study. Twenty-three patients had Glanzmann disease, four had von-Willebrand disease, two had Bernard soulier syndrome, two had activated factor VII deficiency, and one patient had impaired secretion of adenosine deaminase. The study exhibited that statistically there was no significant difference between EpiCell tampon and Tranexamic acid impregnated tampon treatments with respect to the hemostasis duration. However, ChitoHem tampon was more efficient than Tranexamic acid impregnated tampon (P value <0.001) and EpiCell tampon (P value < 0.05)., Conclusion: ChitoHem tampon, the chitosan-reinforced product, was the best therapy solution to stop epistaxis. We recommend further research on the use of other hemostatic agents for localized bleeding in patients with inherited bleeding disorders.

Epistaxis resulted in severe anemia in an 89-year-old Caucasian woman under a therapy with dabigatran for 12 months because of atrial fibrillation. Correction of the anemia was difficult because it was impossible to assess her blood group due to polyagglutination. Since hospital records disclosed that in 2011, her blood group was O positive, acquired polyagglutination was assumed. After 66 days, it was again possible to assess the blood group as O positive. Immunologic investigations disclosed that antinuclear antibodies and antihistone antibodies were elevated, and antibodies to double-stranded DNA were negative. Drug-induced lupus was diagnosed due to the autoantibody profile detected.

Aim: To investigate the feasibility of pegylated interferon plus ribavirin treatment in cirrhotic patients who presented with, or developed while on-treatment, platelet counts ≤ 80,000/μL and/or neutrophil counts ≤ 1,500/μL., Methods: A retrospective analysis of prospectively gathered data on 123 cirrhotic patients treated with pegylated interferon and ribavirin. Adverse effects and haematological changes were monitored: bleeding and infectious events were registered and related to platelet and absolute neutrophil counts., Results: Among the 58 patients (47.2%) with nadir platelets ≤ 50,000/μL during therapy, 6 (10.3%) experienced a bleeding episode; of the remaining 65 patients with platelets constantly >50,000/μL, 3 (4.6%) bled. Of the 11 bleedings, 3 manifested during an infection, while patients had platelets >50,000/μL. Nadir neutrophils ≤ 750/μL occurred in 45 patients (38.2%) during treatment, and 14 of them (29.8%) had an infectious event. Infections were also documented in 18 of the 76 patients (23.7%) with neutrophils constantly >750/μL., Conclusions: The study reveals the feasibility of treating cirrhotic patients with cytopenia with pegylated interferon and ribavirin, as bleeding or infectious events under therapy were unrelated to platelet and neutrophil counts. Withdrawal of therapy or variations in the pre-assigned dosages of either pegylated interferon or ribavirin owing to abnormally low haematological parameters seems to no longer be tenable., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Dabigatran is an oral thrombin inhibitor which has been approved for prevention of stroke or embolism in atrial fibrillation patients as an alternative to vitamin K antagonists. Dabigatran has been introduced into clinical practice, although issues like laboratory monitoring, its use in elderly patients, drug and food interactions, and an antidote have not been completely clarified. Severe epistaxis leading to haemorrhagic shock occurred in an 89-year-old woman with atrial fibrillation and moderate renal insufficiency after 10 months of dabigatran 110 mg/b.i.d. Correction of the anaemia with blood transfusions became difficult because it was impossible to assess her blood group due to polyagglutination. The indirect Coombs test was very highly +++ positive for IgG. Investigations about previous hospital admissions disclosed that in 2011, her blood group was 0 positive. The course was complicated by an erysipela of the right upper extremity, most probably induced by an infection through a venous catheter. An increase in the knowledge about potential side effects of dabigatran-concerning infections and polyagglutination is urgently needed.

Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that typically presents as mucocutaneous bleeding in individuals with no personal or family history of bleeding disorder. Here we present a case in which a patient presented with profound epistaxis and was found to have AVWS in the setting of monoclonal gammopathy of undetermined significance (MGUS).

Arthrogryposis multiplex congenita, renal dysfunction, and cholestasis (ARC) syndrome is a rare, fatal, multisystem disorder. Bleeding problems, which occur spontaneously and post organ biopsies, have been reported in these patients. We report the case of an infant who had life-threatening spontaneous nasal bleeding. A detailed assessment of her platelet function and morphology is presented., (Copyright © 2013 Arab Journal of Gastroenterology. Published by Elsevier Ltd. All rights reserved.)

Hemophilic pseudotumors are rare but dangerous complications of Hemophilia. We hereby report a 3-year-old boy with Hemophilia B, presenting with nasal pseudotumor, showing favorable response to radiotherapy after unsuccessful treatment with factor IX replacement therapy. The diagnosis and treatment of this rare condition is also reviewed.

A 5-year-old boy presents with platelet count of 2×10(9)/L and clinical and laboratory evidence of immune thrombocytopenia. He has epistaxis and oral mucosal bleeding. Complete blood count reveals isolated thrombocytopenia without any decline in hemoglobin and he is Rh+. You are asked if anti-D immunoglobulin is an appropriate initial therapy for this child given the 2010 Food and Drug Administration "black-box" warning.

Inherited factor VII (FVII) deficiency is a rare disorder characterized by a bleeding phenotype varying from mild to severe. To date, more than 200 mutations have been described along the F7 gene encoding for FVII. The aim of this study was the identification of genetic defects underlying FVII deficiency in 10 patients belonging to eight unrelated families of the North provinces from Tunisia. Mutation detection was performed by sequencing the whole F7 gene coding region, exon-intron boundaries and about 400 bp of the promoter region. We identified 5 mutations in five unrelated families; the novel p.F328Y mutation and the reported mutations: p.R304Q, p.M298I, IVS1aG > A and p.G-39G. For the remaining 5 patients we didn't identified any mutations using PCR/Sequencing protocol. In conclusion, this study represents the first comprehensive molecular series of FVII deficiency affected patients in Tunisia from the North. We will try in the future to continue the molecular study for Tunisian patients from Center and South provinces in order to have a complete idea about the FVII deficiency mutational profile in our country., Virtual Slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1288044089753085.

Objective: To identify prevalence of previously undiagnosed bleeding disorders in children with severe epistaxis who failed medical therapy requiring intraoperative nasal cautery., Study Design: Retrospective chart review 10/15/2006-12/31/2010., Setting: Single provider outpatient otolaryngology clinic., Inclusion Criteria: children (<19 years) with epistaxis referred to otolaryngology, no known bleeding disorder, failed medical therapy and received surgical nasal cautery., Data Collected: duration/severity of epistaxis, bleeding history, family history of bleeding. A screening CBC, PT and PTT were performed on all patients., Results: Of 248 subjects referred for epistaxis, 47(19%) met inclusion criteria (mean age 9.2±0.5 years; 61.7% male). 31.9% (15/47) had abnormal coagulation studies but on repeat testing only 2 patients had persistent coagulation abnormalities. 15 patients were referred to hematology, 5 were diagnosed with a bleeding disorder (3 - type 1 von Willebrand's disease, 1 - platelet aggregation disorder, 1 - mild factor VII deficiency). Out of the entire cohort 10.6% (5/47) had a bleeding diathesis. Clinical predictive factors for having a bleeding diathesis were explored and included previous emergency room visits for epistaxis (p=0.04). A trend was found in those presenting with epistaxis at a younger age (p=0.07)., Conclusion: Children with recurrent epistaxis despite medical therapy are at higher risk of having a bleeding disorder. In this highly selected group of patients 10.6% (5/47) were found to have a bleeding disorder. Screening coagulation studies (PT, PTT) only revealed 20% (1/5) of patients with a bleeding disorder. Only a subsequent comprehensive hematology evaluation revealed the diagnosis in the majority of patients., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The constantly recurring epistaxis means a great reduction of quality of life for patients with hereditary haemorrhagic telangiectasia (HHT). As yet, an ideal treatment has not been found. Vascular endothelial growth factor (VEGF) has been described as a possible new therapy. In particular, the success of submucosal doses <100 mg has not been analysed before. We injected bevacizumab (Avastin) submucosally in addition to Nd:YAG laser therapy. Doses <7.5 mg were used. To investigate the effect of these additional injections in comparison to laser therapy alone, a retrospective analysis was done. For this purpose a standardized patient questionnaire was completed, which included recording the patients' Epistaxis Severity Score (ESS) before and after the antibody treatment. Besides, patient files were analysed to collect objective data like haemoglobin levels and the number of blood transfusions needed. Data for eleven patients could be analysed. A significant improvement in the ESS resulting from additional bevacizumab therapy was observed (p < 0.01). In particular, the frequency of epistaxis (p = 0.011), duration of epistaxis (p < 0.01), severity of epistaxis (p < 0.01) and the need for acute medical treatment (p = 0.014) decreased significantly. The haemoglobin levels increased significantly (p = 0.011) and the number of blood transfusions declined. There were no side effects caused by the antibody treatment. Additional injections of a low dose of bevacizumab seem to be superior to Nd:YAG laser therapy alone. These results justify further studies.

A short cut review was carried out to establish whether routine testing of coagulation status was necessary in adult patients who present with epistaxis. 156 papers were found using the reported searches, of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that coagulation studies are only indicated in adults with epistaxis if the history suggests a potential cause for coagulopathy.

The objective of the present study was to compare old and new bleeding scores in patients with type-3 von Willebrand disease (vWD), obligatory carriers and normal controls, and to compare the ability of bleeding scores vs. clinical and laboratory data to predict bleeding after surgery. We identified 15 patients from 12 families who had type 3 vWD. Normal controls were matched to carriers by sex and age. Two physician-administered standardized questionnaires were used to evaluate old and new bleeding symptoms. Scores for old symptoms were the same in carriers and control participants (median score 0.00 vs. 0.00, P < 0.001), and patients with vWD had a significantly higher bleeding score than carriers (median 10.00 vs. 0.00, P < 0.001). Scores for new symptoms were higher in carriers than in control participants (median score -1.00 vs. -2.00, P < 0.001), and patients had a significantly higher bleeding score than carriers (median 14.00 vs. -1.00, P < 0.001). The clinical situations associated with increased bleeding risk (old symptoms) in patients with type 3 vWD compared to obligatory carriers were epistaxis [odds ratio (OR) = 175.5; 95% confidence interval (CI) 14.55-2116.69; P < 0.001], cutaneous symptoms (OR = 108; 95% CI 10.16-1147.39; P < 0.001) and hemarthrosis (OR = 19.5%; 95% CI 4.32-156.46; P < 0.001). The clinical situations associated with increased bleeding risk according to scores for new symptoms in patients with type 3 vWD compared to obligatory carriers were epistaxis (OR = 175.5; 95% CI 14.55-2116.69; P < 0.001), cutaneous symptoms (OR = 52; 95% CI 7.65-353.09; P < 0.001) and bleeding from minor wounds (OR = 74.25; 95% CI 7.43-741.118; P < 0.001). The three groups differed significantly in the severity of epistaxis and cutaneous bleeding according to scores for new and old symptoms. The new bleeding score was more reliable than the old bleeding score in predicting bleeding after invasive procedure.

Background: Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction., Method: A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis., Results: A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both., Conclusion: The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.

Objectives/hypothesis: :To understand Glanzmann's thrombasthenia and provide insight to the management of epistaxis in children with this disease., Study Design: Retrospective chart review., Methods: All children diagnosed with Glanzmann's thrombasthenia and treated for epistaxis at Children's Hospitals and Clinics of Minnesota were identified and a retrospective chart review was performed. Outpatient charts, hospitalization records, and operative reports were reviewed from 1999 up to 2009 and appropriate data were extracted. The episodes of epistaxis, therapy used, complications, and success rates for controlling hemorrhage were noted., Results: Five children with a total of 63 clinical encounters for epistaxis were identified. Forty-seven encounters required hospitalization, close to half of which necessitated medical care in the intensive care unit. Nearly all encounters required infusion of hemostatic therapy with either single or multiple agents. Seventy-one procedures for life-threatening hemorrhage were performed. The most common (n = 24) intervention was administration of bovine collagen matrix, which was successful only half of the time (50%). Anterior and posterior nasal packing with or without hemostatic material completely resolved hemorrhage in 35% of the procedures., Conclusions: To date, no form of medical or surgical intervention in children with this condition has consistently demonstrated its ability resolve nasal hemorrhage. The role of the otolaryngologist is to control bleeding during major episodes of nasal hemorrhage that do not respond to medical management. These patients usually have remarkable improvement in the frequency and severity of epistaxis in adolescence and then require much less aggressive therapy.

Objective of the study is to investigate the role of clotting screen in adult patients presenting with epistaxis. The study is a prospective case series done in a teaching hospital in the Northeast of Scotland. Prospective data was collected for 100 consecutive patients with epistaxis admitted to the Department of Otolaryngology over 1 year (2006-2007 August). The demographics, co-morbidities, long-term medications and blood test results were noted for these patients. A retrospective audit of all patients attending the Emergency Department (ED) with epistaxis during the same study period was also performed. The following were measured: frequency of clotting screen performed in patients with epistaxis; the treatment modifying effect of clotting screen results. Of the 100 admitted patients, 45 were male and 55 were female. The majority of them had more than two co-morbidities such as hypertension, ischaemic heart disease and atrial fibrillation. Forty-seven patients were on aspirin, 19 on warfarin and 12 patients on clopidogrel. A clotting screen was done for 80 patients but only 2 patients (2.5%) had an abnormal INR. A total of 356 patients presented to the ED with epistaxis. Of 356 patients, 138 (39%) had their clotting screen checked. Of 138 patients, 42 (30%) were on warfarin. Only 7 patients (7/138 = 5%) had an abnormal result. Our data suggests that routine clotting screen check does not alter the epistaxis management in patients with no risk factors or with stable warfarin dosage. Therefore, routine clotting screen in patients with epistaxis without relevant risk factors is not an evidence-based practice.

This is a study evaluating the efficacy of Ankaferd Blood Stopper (ABS) as a hemostatic agent compared to hemostasis by phenylephrine in patients with anterior epistaxis. The study design is a prospective, randomized, controlled, nonblinded, clinical trial. In total, 49 patients were randomly seperated to receive hemostasis technique by means of either ABS wet tampon or phenylephrine impregnated gauze tampon for anterior epistaxis control. Patients were crossed over to the other technique after two unsuccessful attempts of the first technique. Measured outcomes such as number of applications, relationship of number of applications with bleeding intensity (1 = stains on napkin, 2 = soaked napkin, 3 = bowl needed), patient discomfort during hemostasis (0 = none, 9 = unbearable), and complications were assessed. Additional data were recorded for rebleeding within 7 days. 24 of the 49 patients were assigned to the new ABS group (group I) and remaining 25 were included in the standard phenylephrine group (group II). ABS was more effective than phenylephrine at control of anterior epistaxis (79.2 vs. 64%, p < 0.05). For the patients who crossed over from phenylephrine to ABS, 44.4% achieved hemostasis by ABS. ABS successfully treated all bleeding intensity 1 and 2 patients with one application (5 min). ABS patients experienced fewer rebleeding rates within 7 days compared to phenylephrine patients (8.3 vs. 20%, p < 0.05). The patients for which ABS was applied, significant differences in effective control of anterior epistaxis were observed compared to phenylephrine. ABS is effective, safe, quick, and easy alternative to the phenylephrine in patients with anterior epistaxis.

Although most cases of prekallikrein deficiency are asymptomatic, a few reports link severe prekallikrein deficiency with thrombotic phenomena and recurrent pregnancy loss. Here, we present a case of a Jamaican female patient with prekallikrein deficiency, associated with a severe bleeding diathesis. A low level of plasma prekallikrein activity, along with the presence of C529Y mutation, confirmed the diagnosis in our patient. Some animals with prekallikrein deficiency were shown to have moderate bleeding tendencies. Furthermore, the first patient with prekallikrein deficiency from the African continent was a young child who presented with severe, hemophilia-like bleeding, featuring recurrent hemarthrosis and subcutaneous hematomas. We find it intriguing that our patient is of African heritage and presented with a moderate nasal bleeding tendency in her youth, followed by severe recurrent mucosal bleeding later in life.

The current case describes epistaxis in a patient treated with a daily regimen of topiramate 100mg for migraine. The patient had not a past medical history of nosebleeds and laboratory parameters were within normal ranges. She was then advised to withdraw topiramate, and the epistaxis resolved within 12 hours after its discontinuation. Since then, the patient never complained other blood clotting disorders. The potential antiplatelet activity of topiramate is discussed.

The relationship between blood group and epistaxis among the patients coming to Tribhuvan University Teaching Hospital, Kathmandu with idiopathic epistaxis was studied. A total of 235 patients coming to the Emergency Department or Department of Otorhinolaryngology with active nose bleeding in were included. ABO blood group was performed. Nearly half (45.5%) of the patients belonged to O-group followed by A-group others. O-group people were also had longer bleeding time compared to other blood groups.

Introduction: Blood group O is associated with lower expression of von Willebrand factor suggesting a relative bleeding tendency. A lower admission rate for epistaxis among Asians compared with Caucasians has also been noted, with one explanation being higher prevalence of blood group O among Caucasians. This study investigates whether blood group O is over-represented in patients admitted with epistaxis., Methods: A retrospective study was conducted, using computerised hospital in-patient and blood bank databases to identify Caucasians admitted with epistaxis between January 2000 and December 2005 inclusive. The control group consisted of 500 consecutive patients who had a primary total hip arthroplasty and 500 consecutive patients who gave birth within the delivery suite., Results: 1261 Caucasians admitted with epistaxis were identified. Among epistaxis patients, 50.44 per cent were blood group O but among the control group this was 45.10 per cent (chi-square test p = 0.008)., Conclusion: Blood group O appears over-represented in Caucasian patients admitted with epistaxis, compared with the control population, raising the possibility that blood group O is a risk factor for epistaxis.

A 38 year old patient presented with fever, myalgic abdominal pain, nose bleeding and acute renal failure since five days. A combination of thrombocytopenia, proteinuria, elevated CrP and creatinin is common in hemorrhagic fever with renal syndrome (HFRS) due to Hantavirus infection. The benigne form is called Nephropathia epidemica. Dialysis is infrequently required by patients with the Puumala virus. Other infection (e.g. malaria, leptospirosis, yellow fever) and systemic diseases (e.g. collagenosis or vasculitis) are considered.

Objective: To investigate the pathogenesis of unknown nosebleed patients., Method: The ELISA test were used to detected plasma Urokinase-type plasminogen activator (uPA) and Urokinase-type plasminogen activator receptor (uPAR) level in 19 cases unknown factor nosebleed patients and 36 health persons., Result: The results showed uPAR and uPA level in nosebleed group (before treatment) uPAR (0.14 +/- 0.04) microg/L, uPA (0.24 +/- 0.09) microg/L; (after treatment) uPAR (0.08 +/- 0.02) microg/L, uPA (0.18 +/- 0.07) microg/L. And normal group uPAR (0.07 +/- 0.03) microg/L, uPA (0.17 +/- 0.05) microg/L. The uPAR and uPA level in nosebleed group before treatment is higher than that in normal group (P <0.05). There is no significant difference between nosebleed group after treatment and normal group (P>0.05)., Conclusion: The reasons of uPAR and uPA level high in unknown factor nosebleed patients were not clear, maybe relation to vascular endothelial cell, smooth muscle cell and neutrophil-monocytic release more uPAR and uPA. So uPAR and uPA density of nostril accumulation is more high in its microenvironment, that fibrinolytic system activated increase and result in its hyperactivity, and happened nosebleed when blood be in hypocoagulable state.

Objectives/hypothesis: Otolaryngologists are frequently consulted for the evaluation and treatment of pediatric epistaxis. There is a lack of consensus as to the optimal approach to this problem. This study evaluated an approach used to evaluate and treat patients referred on an outpatient basis., Study Design: Retrospective study., Methods: Charts from 90 patients referred for the treatment of epistaxis were reviewed., Results: Anemia was identified in 22% of patients. An abnormal coagulation study was identified in 7.8% of patients. Computed tomography (CT) imaging of the sinuses was obtained in nearly 90% of patients and revealed no suspicious masses. Opacification of the sinuses consistent with sinusitis was commonly seen. The majority of cases were resolved by the first follow-up visit with a topical nasal emollient., Conclusions: The outpatient evaluation of epistaxis should include a screen for anemia and coagulopathy. Routine CT imaging of the sinuses is unhelpful and is not recommended. The majority of cases are easily treated with rehydration of the nasal mucosa. Consideration should be given to rhinosinusitis as a co-existing factor in patients with epistaxis.

The review is dedicated to an important multidiscipline problem, nasal bleeding (NB). The presented analysis of Russian and foreign literature on the most important aspects of the problem shows the variety and complexity of the leading pathogenetic mechanisms of NB (the condition of hemostatic and lipid peroxidation systems, the activity of biologically active substances and the kinine system, the condition of local and system blood flow), contradictoriness of data on some aspects, and insufficient knowledge of a range of aspects. The collected data on the pathogenetic mechanisms of NB, despite the high quality of some studies, do not suggest the existence of a common modern theoretical base on this problem.

Thirty-two members of staff from the Ear, Nose and Throat Department at Warrington General Hospital were asked to estimate blood loss in commonly encountered epistaxis scenarios. Results showed that once the measured volume was above 100 ml, visual estimation became grossly inaccurate. Comparison of medical and non-medical staff showed under-estimation was more marked in the non-medical group. Comparison of doctors versus nurses showed no difference in estimation, and no difference was found between grades of staff.

Objective: To evaluate the anesthetic implications of the surgical resection of juvenile nasopharyngeal angiofibroma (JNA)., Design: Retrospective study., Setting: University-affiliated community hospital., Participants: Ten patients undergoing resection of JNA., Interventions: None., Measurements and Main Results: Data from the records of 10 patients undergoing resection of JNA were reviewed and analyzed with regard to demographics, history of the disease, characteristics of the tumor, surgical resection techniques, and anesthetic management. Patients were age 11 to 29 years. All had nasal obstruction as presenting symptom. There was no intracranial invasion. Eight tumors were resected via a lateral rhinotomy and 2 endoscopically (after embolization of the tumor's feeding vessels). Duration of surgery was 6 +/- 1 hours for rhinotomy and 6 and 6.5 hours for the 2 endoscopic resections. Anesthesia was induced in a rapid-sequence manner. Arterial and central venous catheters were placed in all patients. Mean arterial pressure was targeted to 55 to 65 mmHg by using increasing concentrations of isoflurane. The estimated blood loss was 4,800 +/- 1,600 mL and blood replacement was 3,200 +/- 1,400 mL in the first group. The 2 other patients lost 600 mL and 1,500 mL. Blood replacement in this group was 0 and 700 mL respectively. No mortality or major morbidity occurred., Conclusion: Resection of JNA should be considered a major procedure with many anesthetic challenges. Isoflurane may be employed to provide deliberate hypotension.

A prospective pilot study was conducted to investigate the role and relevance of clotting profiles in the management of epistaxis patients. Forty-eight per cent of the study patients had abnormal clotting profiles. Half of the abnormal clotting profiles could have been predicted from a routine history, but half could not. The coagulation screens on this group were repeated and 5% of the initial study group were found to have a persistent abnormality. The authors suggest that although coagulation screens will not predict the potential management problems associated with the epistaxis patient, they remain an important part of the clinical investigation. An epistaxis may be the only indication of an underlying coagulation disorder. The diagnosis of such a disorder following an epistaxis may lead to the treatment of an otherwise unknown condition and prevention of more serious sequelae.

Objective: By virtue of no identifiable causes in the majority of children with habitual epistaxis, it continues to be problematic in pediatric clinical practice. The purpose of this study is to explore the possible change of atrial natriuretic peptide (ANP) levels in the children with epistaxis., Methods: Both the plasma and nasal mucus ANP levels have been determined in 30 sick children by a sensitive radioimmunoassay (RIA) technique., Results: Our results revealed that the plasma and nasal mucus ANP levels were considerably decreased in 24 children with habitual epistaxis when compared with control group (P<0.05), making up 80%, and amongst the interest of these are the nasal mucus ANP levels changing inversely as the times bled from the nose., Conclusion: Although the plasma and nasal mucus ANP levels will not establish the diagnosis of its etiology, it is helpful for us to know the cardiovascular status compensating for chronic blood loss in the children with habitual epistaxis.