The impact of frailty on epistaxis admission, a retrospective cohort study.

OBJECTIVES: Epistaxis is frequently managed with intra-nasal packing devices, traditionally requiring patient admission. Current COVID-19 guidelines encourage ambulatory care where possible in this patient cohort. This paper aims to establish the impact of the Clinical Frailty Scale, anticoagulant/antiplatelet therapeutics and season variation on pre-pandemic admissions to help identify patients suitable for ambulatory epistaxis management. DESIGN: Retrospective cohort study SETTING: Scottish Regional Health Board PARTICIPANTS: Adult patients attending secondary care with epistaxis between March 2019 and March 2020. MAIN OUTCOME MEASURES: Likelihood of epistaxis hospital admission based on Clinical Frailty Scale. RESULTS: 299 epistaxis presentations were identified, of which 122 (40.8%) required admission. Clinical Frailty Scale of ≥4 had an increased likelihood of admission (OR 3.15 (95% CI:1.94-5.16), P < .05). In the majority of presentations (66.2%), patients were taking either an antiplatelet or anticoagulant. Of these presentations, the use of an anticoagulant (OR: 2.00 (95% CI: 1.20-3.33), P < .05 and dual antiplatelet (OR: 2.82 (95% CI: 1.02-7.86), P < .05) demonstrated increased likelihood of admission. CONCLUSIONS: We have shown that frailty increases the risk of admission in adult patients presenting with epistaxis. Clinical Frailty Scale (CFS) could be utilised in risk stratification to identify suitable patients for outpatient management. Patients with CFS ≤ 3 could be considered for outpatient management of their epistaxis. It is likely that patients with CFS ≥4 on anticoagulant or dual antiplatelet will require admission.

The pathology of visible blood vessels on the nasal septum in children with epistaxis.

OBJECTIVE: Epistaxis is common in children, but its cause remains unknown. About half the children who present with epistaxis have prominent vessels on the nasal septum. The aim of this study was to determine the pathological nature of the prominent septal vessels in children with recurrent epistaxis. METHODS: 4mm punch biopsies of the nasal septal mucosa were taken from 5 children undergoing nasal cautery under general anaesthesia. RESULTS: Histology showed that the prominent vessels were thin-walled arterioles and capillaries with a surrounding inflammatory infiltrate. There was no evidence of venous varicosities or arterial microaneurysms. CONCLUSION: We postulate a mechanism for septal neovascularisation due to chronic low-grade inflammation as a cause for recurrent epistaxis in children.

Childhood epistaxis and nasal colonization with Staphylococcus aureus.

OBJECTIVE: Epistaxis is very common in children but its cause remains unknown. We postulate that nasal colonization with Staphylococcus aureus leads to inflammation, crusting, and ultimately new vessel formation. STUDY DESIGN: A prospective case-control study. SUBJECTS AND METHODS: Sixty-seven children were recruited, 42 with epistaxis (22 had crusting in the nasal vestibule; 20 did not) and 25 control subjects. A microbiology swab was taken from the anterior nasal cavity of each child. RESULTS: All groups were equally likely to have a positive culture. S aureus was more common in the epistaxis group (P = 0.008) compared with the control group. There was no difference in the prevalence of S aureus between crust and noncrust groups. Epistaxis patients were much less likely to have isolates of respiratory pathogens or a skin commensal. CONCLUSION: Children with epistaxis are more likely to have nasal colonization with S aureus than controls. Our data would support the hypothesis that S aureus replaces existing nasal flora and causes inflammation and new vessel formation.

Laser epiglottopexy for laryngomalacia: 10 years' experience in the west of Scotland.

OBJECTIVES: To determine the results of laser epiglottopexy and to compare them with other surgical techniques for severe laryngomalacia. DESIGN: A retrospective 10-year case note review of laser epiglottopexy for severe laryngomalacia. SETTING: Royal Hospital for Sick Children, Glasgow, Scotland. PATIENTS: The study population comprised 52 male and 24 female children who underwent surgery for laryngomalacia between January 1, 1993, and December 31, 2002. In all children except 2, the indication for surgery was stridor associated with poor feeding and failure to thrive. The age at presentation ranged from 5 days to 32 months (mean, 16 weeks). Three had neurological problems, in 3 a syndrome was diagnosed, and 2 were described as dysmorphic and no syndrome was diagnosed; 5 had a cardiac abnormality. Complete follow-up data were available for 59 children (78%). Intervention Laser epiglottopexy. MAIN OUTCOME MEASURE: Resolution of stridor and growth velocity. RESULTS: Resolution of stridor was complete in 34 children, with mild residual stridor in 4 and persistent stridor but good weight gain in 5 (73% improved sufficiently with 1 procedure). Improvement was documented objectively by measuring growth velocity. Two children required a brief period of intubation postoperatively, and 4 had postoperative respiratory tract infections. Seven children (12%) required revision endoscopic laser surgery to control symptoms. There were no cases of supraglottic stenosis. One child died of cardiac abnormalities, and 8 (14%) required a tracheostomy, of whom 6 had neurological or syndromal abnormalities and 2 had associated tracheomalacia. CONCLUSIONS: We describe a technique of laser epiglottopexy for laryngomalacia and present objective evidence of its efficacy by means of growth velocity charts in a retrospective review of laryngomalacia surgery over a 10-year period. We believe this to be a safe method for treating a self-limiting condition. We have had comparable success to other surgical techniques without having the risks of permanent scarring to the supraglottis.