Rhinosinusitis and Comorbidities

Current Allergy and Asthma

Ryan MW, Brooks EG; 

A variety of systemic conditions impact the incidence, severity, prognosis, and treatment approach in patients with chronic rhinosinusitis (CRS). The controversy surrounding the impact of allergic rhinitis on CRS continues, but it is reasonable to consider and treat allergic sources of inflammation in any patient with CRS.
CRS is more severe in patients with aspirin sensitivity but improves-at least temporarily-to the same degree as in non-aspirin-sensitive patients, given appropriate therapy.
Polypoid rhinosinusitis in cystic fibrosis patients is characterized by compromised mucociliary clearance and infection with staphylococcal and pseudomonal organisms. Affected individuals require frequent antibiotic treatment, saline lavage, and repeated surgeries.
Rhinosinusitis is among the most common infectious complications of humoral immunodeficiency, which is not uncommon in patients with refractory CRS. The treatment approach in immunodeficiency includes aggressive antibiotic treatment and intravenous immunoglobulin. Specific diagnosis of comorbid systemic conditions with CRS will facilitate appropriate management.

Routine clotting screen has no role in the management of epistaxis: reiterating the point

European Archives of Oto-Rhino-Laryngology (Apr 2010)

 

Shakeel M, Iddamalgoda T, Supriya M, Ah-See KW, Trinidade A;

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.

Is severe epistaxis associated with acetylsalicylic acid intake?

Laryngoscope 

Soyka MB, Rufibach K, Huber A, Holzmann D; The Laryngoscope (Oct 2009)

OBJECTIVES/HYPOTHESIS:: Epistaxis represents a very common emergency in any ear, nose, and throat (ENT) department around the world. Despite other risk factors, acetylsalicylic acid (ASA) contributes to nosebleeds by its intrinsic ability to impair thrombocyte aggregation. The aim of this study was to investigate the influence of ASA on the severity of epistaxis and to compare it with other potential risk factors. STUDY DESIGN:: A prospective cohort study was performed at the ENT department of University Hospital Zurich. METHODS:: A total of 591 events were evaluated concerning surgical interventions and the length of in-hospital stay. Further analyses regarding recurrences and number of treatments and a specially designed severity score, as well as other outcome parameters, were performed. RESULTS:: Ninety-nine patients needed to stay in-hospital for at least 1 day. Nearly 30% of all patients had ASA intake, and only 18% were on vitamin K antagonist therapy. Patients on ASA showed significantly more surgical interventions, a higher recurrence rate, and a larger number of required treatments as well as an increased severity score. Duration of in-hospital stay and the complication rate, however, were not associated with drug intake. CONCLUSIONS:: We not only identified ASA to be one of the major risk factors in epistaxis, but also quantified its impact on the severity of nose bleeding. We emphasize the importance of a well-indicated antiaggregational therapy, and strongly discourage using ASA as a life-style drug for the elderly. ASA therapy needs to be discontinued whenever possible and reasonable. Laryngoscope, 2009.