Original Research
Otolaryngology–
Early and Late Recurrent Epistaxis
Admissions: Patterns of Incidence and
Risk Factors
Oded Cohen, MD1,2*, Hagit Shoffel-Havakuk, MD1,2*,
Meir Warman, MD1,2, Sharon Tzelnick, MD, MPH1,
Yaara Haimovich1, Gavriel D. Kohlberg, MD3,
Doron Halperin, MD, MHA1,2, and Yonatan Lahav, MD1,2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. Epistaxis is a common complaint, yet few studies
have focused on the incidence and risk factors of recurrent
epistaxis. Our objective was to determine the patterns of
incidence and risk factors for recurrent epistaxis admission
(REA).
Study Design. Case series with chart review.
Settings. Single academic center.
Subjects and Methods. The medical records of patients admit-
ted for epistaxis between 1999 and 2015 were reviewed. The
follow-up period was defined as 3 years following initial
admission. REAs were categorized as early (30 days) and late
(31 days to 3 years) following initial admission. Logistic
regression was used to identify potential predictors of REAs.
Results. A total of 653 patients were included. Eighty-six
patients (14%) had REAs: 48 (7.5%) early and 38 (6.5%) late.
Nonlinear incidence curve was demonstrated for both early
and late REAs. Based on logistic regression, prior nasal sur-
gery and anemia were independent risk factors for early
REAs. According to multivariate analysis, thrombocytopenia
was significantly associated with late REAs.
Conclusion. Early and late REAs demonstrate different risk
predictors. Knowledge of such risk factors may help in risk
stratification for this selected group of patients. All patients
at risk should be advised on possible preventive measures.
Patients at risk for early REA may benefit from a more
proactive approach.
Keywords
epistaxis, recurrent epistaxis, outcomes research, incidence,
admissions
Received January 3, 2017; revised February 24, 2017; accepted March
29, 2017.
Head and Neck Surgery
1–8
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2017
Reprints and permission:
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DOI: 10.1177/0194599817705619
http://otojournal.org
E
pistaxis is a common complaint, affecting approxi-
mately 60% of the general population, of which about
6% will seek medical care.1 Many minor cases of
epistaxis are preventable with lifestyle and diet modification,2
and the majority of cases may be managed by compression
and/or topical treatment.3,4 Nevertheless, epistaxis is still a
common cause for emergency department (ED) visits, esti-
mated to represent 0.5% of all ED visits5 and up to 33% of
all otolaryngology-related visits.6 Approximately 6% of epis-
taxis ED visits will result in admission.5 Costs of epistaxis
admissions are extremely high, ranging from $6282 to
$22,347 when arterial embolization is performed.6-8
Different studies have delineated several risk factors for
epistaxis-related ED visits and hospital admissions.5,9-14 The
majority of these factors are patient related, such as age,10
sex,10-12 sinonasal disease, coagulopathy, hematologic malig-
nancy, and cardiovascular disease, including hypertension.10,14
Other epidemiologic factors include winter season6,14 and low
environmental temperature.13 In addition, epistaxis is a known
complication following sinonasal surgery, with an incidence
ranging 0.9% to 5.8%.15,16
Although risk factors for individual episodes of epistaxis
have been extensively studied, only scarce reports address
risk factors for recurrent epistaxis.17-19 Abirch et al investi-
gated 461 cases of recurrent epistaxis that required medical
consultation in the community.17 They found that local ana-
tomic factors (nasal perforation, nasal septum deviation)
and inflammatory factors (rhinitis, sinusitis, and upper
respiratory tract infection) did not increase the risk for
1
Department of Otolaryngology–Head and Neck Surgery, Kaplan Medical
Center, Rehovot, Israel
2
Hadassah Medical School, Hebrew University, Jerusalem, Israel
3
Department of Otolaryngology–Head and Neck Surgery, New York
Presbyterian Hospital–Columbia and Weill Cornell Campuses, New York,
New York, USA
*
These authors contributed equally to this study.
Corresponding Author:
Oded Cohen, MD, Department of Otolaryngology–Head and Neck Surgery,
Kaplan Medical Center, POB 1 Rehovot 76100, Israel.
Email: oded915@gmail.com
2 Otolaryngology–Head and Neck Surgery
recurrence, while systemic risk factors (eg, congestive heart
failure, diabetes mellitus, hypertension, and history of
anemia) were associated with an increased risk of recurrent
epistaxis. Regarding medication use, warfarin was found to
increase the risk of recurrence, while aspirin and clopidogrel
were not associated with increased risk. Their results imply
that risk factors for recurrent episodes requiring medical
care may differ from the known risk factors for primary
epistaxis episodes. Although extensive in its investigation of
.50 potential risk factors, their study did not address risk
factors for recurrent admission to the hospital.
The aims of our current study were to assess rates and
patterns for recurrent epistaxis admissions (REAs), as well
as to assess and identify predictors for REAs. Knowledge of
such evidence-based risk factors may help in recognizing
the high-risk patients among all admitted patients and may
influence risk stratification for this select group of patients.
To the best of our knowledge, this would be the first study
to address these issues.
Materials and Methods
Electronic medical record data were queried retrospectively
over a 16-year period (1999-2015, inclusive) for all adult
patients who were admitted to or discharged from the medi-
cal or surgical departments at Kaplan Medical Center
(Rehovot, Israel), a tertiary academic medical center, with 1
of the following diagnoses (International Classification of
Diseases, Ninth Revision [ICD-9]): epistaxis (784.7), control
of epistaxis by anterior nasal packing (Z2101), control of
epistaxis by transantral ligation of the maxillary artery
(Z2105), and control of epistaxis by other means (Z2109).
The follow-up period was defined as follows: patients who
were admitted prior to January 1, 2013, were followed for 3
years from the initial epistaxis admission. Patients admitted
after January 1, 2013, were followed until the end of the
study period (December 31, 2015). The study’s main out-
come measurement was defined as recurrent admission due
to epistaxis during the follow-up period. Admission was
defined as any referral of patients by our institution’s ED
doctors for hospitalization in the medical or surgical inpati-
ent wards, resulting in at least 1 overnight observation.
REA was defined for any patient who was admitted with an
epistaxis-related aforementioned ICD-9 category to any
medical or surgical department in our institution, within 3
years following initial epistaxis-related admission or until
the end of the study period (December 31, 2015). Early
REA was defined as any epistaxis-related admission up to
30 days following discharge of initial epistaxis admission.
Late REA was defined as any epistaxis-related admission
between 30 days following discharge of initial epistaxis
admission and the end of the follow-up period.
Patients \18 years old and patients with missing data in
the electronic medical records were excluded. The study
was approved by the Kaplan Medical Center Institutional
Review Board and Ethical Committee.
For analysis of epistaxis episode predictors, data were
retrieved for subjects in terms of the following: age, sex, length
of hospitalization, season (for interseason variability analysis,
we defined the following 3-month periods: winter [January-
March], spring [April-June], summer [July-September], and fall
[October-December]),12 smoking history, and medication list.
Status for the following comorbidities was documented
according to the patient’s problem list or if a medication for
this condition was documented in his or her drug list (ICD-
9): hypertension (401.X) and diabetes (250.X, insulin depen-
dent and non–insulin dependent separately). Categories based
on the patients’ medication list were as follows: current antic-
oagulant use (antiplatelet aggregation medications included
aspirin and clopidogrel; anticoagulation medications included
warfarin and enoxaparin sodium), insulin-dependent diabetes,
and non–insulin dependent diabetes. Prior surgery was defined
as any of the following operations held within 1 month preced-
ing admission, with documentation based on the patient’s
admission chart or if it appeared in the prior surgery section
with the appropriate ICD-9 categories (in parentheses): septo-
plasty (Z215), which was grouped with turbinate surgery (tur-
binate reduction or resection; Z2169), and functional
endoscopic sinus surgery (Z22190). A surgical intervention for
epistaxis during admission was categorized into arterial liga-
tion, embolization, posterior packing, or other. The following
laboratory results at admission were collected: hemoglobin,
platelets, prothrombin time:international normalized ratio, and
partial thromboplastin time. Anemia was defined as a hemo-
globin value \14 g/dL for men and \12.3 g/dL for women,
in accordance with our institution’s and local population hema-
tologic laboratory references. Similarly, thrombocytopenia was
defined as a platelet count \150 K/mL.
Categorical variables were reported by percentages, and
continuous variables were reported as median and interquar-
tile range (IQR). Continuous variables were tested for normal
distribution. Kaplan-Meier curve was used to describe inci-
dence of readmission during follow-up. Univariate and multi-
variate Cox regressions were performed to evaluate the crude
and adjusted association between various predictors and read-
mission. Age, sex, and variables with P values \.2 on the
univariate analysis were included in the multivariate analysis.
Two-tailed analyses with P values .05 were considered sta-
tistically significant. Analyses were performed with SPSS
21.0 (IBM Corp, Armonk, New York).
Results
During the 16-year study period, 716 patients were admitted
for epistaxis events to our institutional wards. Sixty-three
patients (8.8%) were excluded due to insufficient medical
records; 653 patients were included in the study. Excluded
patients had male predominance when compared with included
patients (73% vs 56%, P = .009) and were younger (53.31 vs
65.14 years, P \ .001). No significant difference was found
regarding rate of epistaxis-related readmission (12.7% vs
13.2%, P = .067, respectively). None of the patients had died
due to epistaxis during the study’s follow-up period, in both
REA groups and in the no-readmission group.
Eighty-six percent of the patients (n = 567) had a single
epistaxis admission during the follow-up period of the
Cohen et al
Figure 1. Schematic representation of the study’s cohort. REA,
recurrent epistaxis admission. *Patients were excluded due to
insufficient data available in their medical records.
study. Eighty-six patients (13%) had REAs, of which 48
(55.8%) were early and 38 (44.2%) were late (Figure 1).
The study’s cohort characteristics and data collected are
shown in Table 1. The median age for both the no-
readmission group and the early REAs was 70 years (IQRs,
56-78 and 55-74, respectively) and for the late REAs, 78
(IQR, 67-82). Each group demonstrated male predominance.
Median hospitalization length was 2 days (IQR, 2-4) for the
no-readmission group and the early REAs and 3 days (IQR,
2-4) for the late REAs. Most admissions were in the winter
season for all groups (29.2%-36.8%). Smoking history was
noted in 7.7% of the study group (2.6%-12.5% among
groups). Hypertension was noted in 63.6% of the study’s
cohort. The median hemoglobin level of the study group
was 12.7 (IQR, 11.3-13.8); the late REAs demonstrated the
lowest values (median, 11.8; IQR, 10.2-12.95). A total of 50
patients (7.7%) underwent surgical intervention during their
hospitalization, of which 34% underwent sphenopalatine
artery ligation (n = 13) or embolization (n = 4); 33% (n =
16), posterior packing; and 34% (n = 17), electrocautery or
other intervention.
The incidence of early and late REAs is displayed in
Figure 2. Early REAs demonstrated a nonlinear incidence
curve, with a higher incidence during the first 3 days and
a gradual decrease afterward. The mean interval between
admissions in the early REA group was 5.9 days (range,
0-26). By the third day following discharge, 50% of early
REAs were readmitted, and 75% were readmitted by the
end of the first week (Figure 2a). In the late REA group,
similar incidence patterns were noted: 40% of the patients
were readmitted by the first 3 months (ie, 30-120 days
following initial admission), and 66% were readmitted
within the first year following discharge (Figure 2b).
The mean interval between admissions was 316 days
(range, 31-934).
Univariate analysis of REA-related variables is shown in
Table 2. Prior septoplasty and/or turbinate procedure sur-
gery (hazard ratio [HR], 3.479; 95% CI, 1.47-8.26; P =
.007) and anemia (HR, 2.518; 95% CI, 1.26-5.05; P = .009)
were associated with early REA versus no REA. Older age
3
(for each additional year of age: HR, 1.030; 95% CI, 1.01-
1.05; P = .01), hypertension (HR, 3.121; 95% CI, 1.31-7.47;
P = .011), diabetes (HR, 2.258; 95% CI, 1.19-4.27; P =
.012), and thrombocytopenia (HR, 2.779; 95% CI, 1.44-
5.37; P = .002) were all associated with late REA versus no
REA. Late REA patients demonstrated significantly lower
values of hemoglobin (11.8 vs 12.7 g/dL; P = .004) and pla-
telet levels (171 vs 229 K/mL; P \ .001) at admission when
compared with patients without REA.
Adjusted multivariate analysis of early REA is shown in
Table 3. Prior septoplasty and/or turbinate procedure sur-
gery (HR, 3.634; 95% CI, 1.416-9.324; P = .007) was sig-
nificantly associated with early REA. Finally, anemia (HR,
2.563; 95% CI 1.258-5.221; P = .010) was associated with
an increased risk for early REA. Adjusted multivariate anal-
ysis of late REAs is presented in Table 4. Only thrombocy-
topenia (HR, 2.309; 95% CI, 1.185-4.498; P = .014) was
significantly associated with recurrent admissions.
Discussion
In this study we investigated REAs. Analysis of the data
identified 2 subtypes of recurrences: early and late, repre-
senting 56% and 44% of REAs, respectively. Both groups
demonstrated a nonlinear incidence curve (Figure 2). In
both groups, recurrent admissions had an increased inci-
dence during the early period, with a gradual decrease over
time. Early and late REAs differed in their risk factors.
REAs were not shown to affect epistaxis-related mortality
between groups, yet it is most probable that REAs have a
direct effect on patients’ quality of life.
Early recurrent bleeding episodes are likely the result of
a residual active bleeding source that was not eliminated in
the initial admission. On both uni- and multivariate analysis,
only prior sinonasal surgery and anemia were associated
with early REAs. Early recurrence of epistaxis following
sinonasal surgery may suggest an unresolved iatrogenic
cause of bleeding. Anemia as a predictor for early REAs
concurs with the work of Abrich et al, who found that of
the noncardiovascular risk factors examined, only a history
of anemia was associated with recurrent epistaxis.17 The
presence of anemia at presentation may stand for a pattern
of prolonged recurrent bleeding, which may suggest a resis-
tant source of bleeding with a tendency for recurrence or
which may relate to the severity of the bleed and its origin
(arterial vs venous).
While the nonlinear incidence of early REA could be
explained by residual active bleeding, other explanations
should be suggested for the nonlinear incidence (Figure
2b) demonstrated for late REA, as 60% of the patients were
readmitted within the first year. A possible explanation
could be a ‘‘learning curve’’ for the patients in better pre-
vention and management of bleeding events or, alterna-
tively, a better control on systemic diseases, such as
hypertension and diabetes, which were associated with late
REA on univariate analysis. A ‘‘step’’ was noticed 12
months following initial admission, demonstrating a much
higher incidence of admission when compared with
4 Otolaryngology–Head and Neck Surgery

Table 1. Characteristics of Epistaxis Patient Population and Recurrent Epistaxis Admissions.a

Readmission

Category Study Group (N = 653) None (n = 567) Earlyb (n = 48) Latec (n = 38)

Age, y 70 (56-78) 70 (56-78) 70 (55.25-74) 78 (67-82.25)

Female 287 (44) 254 (44.8) 19 (39.6) 14 (36.8)
Hospitalization length, d 2 (2-4) 2 (2-4) 2 (2-4) 3 (2-4)
Season
Winter 218 (33.4) 190 (33.5) 14 (29.2) 14 (36.8)
Spring 188 (28.8) 170 (30) 12 (25) 6 (15.8)
Summer 112 (17.2) 63 (16.4) 10 (20.8) 9 (23.7)
Fall 135 (20.7) 114 (20.1) 12 (25) 9 (23.7)
Comorbidity
Smoking history 50 (7.7) 43 (7.6) 6 (12.5) 1 (2.6)
Hypertension 415 (63.6) 352 (62.1) 31 (64.6) 32 (84.2)
Diabetes 188 (28.8) 158 (27.9) 12 (25) 18 (47.4)
Prior surgery
Total 80 (12.3) 62 (11) 12 (25) 6 (15.8)
FESS 50 (7.7) 40 (7.1) 6 (12.5) 4 (10.5)
Septoplasty/turbinate 30 (4.6) 22 (3.9) 6 (12.5) 2 (5.3)
Anti-PLT aggregation
Total 183 (28) 168 (27.8) 15 (31.2) 10 (26.3)
Aspirin 156 (23.9) 134 (23.6) 13 (27.1) 9 (23.7)
Clopidogrel 27 (4.1) 24 (4.2) 2 (4.2) 1 (2.6)
Anticoagulation
Total 134 (19) 113 (18.2) 10 (20.8) 11 (29)
Warfarin 97 (14.9) 82 (14.5) 6 (12.5) 9 (23.7)
Enoxaparin 27 (4.1) 21 (3.7) 4 (8.3) 2 (5.3)
Laboratory
Hb, g/dL 12.7 (11.3-13.8) 12.7 (11.3-13.9) 12.1 (11.15-13.3) 11.8 (10.2-12.95)
PLT, K/mL 227 (175-273) 229 (178-277.5) 238.5 (192-277.2) 171 (130-220)
INR 1.03 (0.97-1.20) 1.03 (0.97-1.20) 1.02 (0.99-1.16) 1.08 (1.00-1.36)
PTT 26.9 (24.7-30.9) 26.75 (24.6-30.7) 26.7 (24.7-30.15) 28.2 (25.7-32.50)
Anemiad 403 (61.7) 335 (59.1) 38 (79.2) 30 (78.9)
Thrombocytopeniae 116 (17.8) 95 (16.8) 7 (14.6) 14 (36.8)
Surgical intervention for epistaxis
Total 50 (7.7) 40 (7.1) 6 (12.5) 4 (10.5)
ESPAL/embolizationf 17 (34) 13 (2.3) 3 (6.3) 1 (2.6)
Posterior packing 16 (33) 13 (2.3) 1 (2.1) 2 (5.3)
Electrocautery/other 17 (34) 14 (2.5) 2 (4.2) 1 (2.6)
Abbreviations: ESPAL, endoscopic sphenopalatine artery ligation; FESS, functional endoscopic sinus surgery; Hb, hemoglobin; INR, international normalized
ratio; PLT, platelets; PTT, partial thromboplastin time.
a
Values are presented as either n (%) or median (interquartile range).
b
Early: epistaxis-related admission up to 30 days following discharge of initial epistaxis admission.
c
Late: any epistaxis-related admission between 30 days following discharge of initial epistaxis admission and the follow-up period.
d
Hb \14 g/dL for men and \12.3 g/dL for women.
e
PLT \150 K/mL.
f
Embolization of the bleeding vessel of the distal part of the internal maxillary artery.

preceding and following months. Though interesting, our
team could not explain this change in observed incidence.
Other factors that were associated with late REA on univari-
ate analysis were older age, anemia, and thrombocytopenia.
Yet, after adjusting for confounders, only thrombocytopenia
was significantly associated with late REA. While it is obvi-
ous why thrombocytopenia may aggravate bleeding events,
this would have been expected to have a greater effect on
the early REAs. Moreover, studies have shown that only a
minority of patients suffering from chronic thrombocytope-
nia suffer from epistaxis. Altomare et al20 studied the rate
of bleeding-related episodes in adult patients with primary
immune thrombocytopenia (n = 6651). Only 5% (n = 362)
had epistaxis, similar to the percentage in the general
Cohen et al
Figure 2. Incidence rate for early and late recurrent epistaxis
admission (REA). A, Incidence of early REA. Half of the patients
with early REA were admitted by the third day following discharge.
B, Incidence of late REA. After 1 year following discharge, 66% of
late REAs were readmitted.
population seeking medical counsel.1 Yet, these 362 patients
had 560 epistaxis events in the study period, implying ten-
dency for recurring events. The results of this study also
suggest that some thrombocytopenic patients are more sus-
ceptible to epistaxis than others. Further studies investigat-
ing the causes for this susceptibility may contribute to
lowering the rate of REA among these patients.
The use of antiplatelet medications and anticoagulants
have been found to be associated with higher rates of pri-
mary admission for epistaxis and for aggravated bleed-
ing.7,21-23 In our study, however, we did not find that
anticoagulants or antiplatelet drugs increased the risk for
recurrent epistaxis admission. Similar to our study, Purkey
et al12 found that anticoagulant utilization was not signifi-
cantly associated with an increased number of epistaxis
cases. They suggested that the large prevalence of anticoa-
gulation use in the study’s population may have contributed
to this surprising result. This could be projected to our
study’s results as well, as the prevalence of anticoagulation
and antiplatelets use was much higher than reported in stud-
ies on primary epistaxis admissions (Table 1). This in turn
could be explained by the fact that our study population was
composed of previously hospitalized patients and not the
general population. Another possible explanation for the
lack of association between anticoagulation use and read-
mission for epistaxis relates to lifestyle modifications. Since
lifestyle and diet have been shown to influence severity of
nosebleeds,2 it is possible that following initial admission
5
for epistaxis, better education and use of preventive mea-
sures among patients, including those using anticoagulation
medications, contributed to similar rates of REAs when
compared with nonusers of anticoagulation. Moreover, the
initial epistaxis admission may have resulted in reevaluation
of the need for anticoagulation medications in these patients
and in cessation of these drugs. This observation warrants
additional research in the future.
This study has several limitations. It is a single-institute
retrospective study, which is exposed by its nature to several
biases. The decision of whether to hospitalize a patient is
based on the clinical impression of the otolaryngologist, as
no clear guidelines exist in the literature,4 hence potentially
exposing our data to selection biases. Our study did not
address all known risk factors for epistaxis admission, such
as nasal pathologies, anatomic abnormalities, and existence
of hematologic disease. The latter might have influenced our
results, as these patients tend to have recurrent epistaxis epi-
sodes. Nevertheless, given the 3.1% prevalence of leukemia
in the general population in our region24 and the estimated
incidence of hereditary hemorrhagic telangiectasia (1:5000-
8000),25 it is reasonable to assume that these patients would
represent a small sample in our cohort. Our excluded patients
demonstrated significant differences in sex and age, which
could have influenced our results, as age and sex were shown
to influence incidence for ED visits.11-13
Despite these limitations, our study may contribute to our
current knowledge of epistaxis by identifying the subgroup
of patients at risk who will benefit from preventive mea-
sures, which may include a more proactive approach upon
initial admission, better medical education, as well as a
strict follow-up regimen. Proactive approaches may dictate
the first treatment of choice. Ando et al19 studied the risk
factors for recurrent epistaxis and the impact of initial treat-
ment on refractory posterior bleeds. They found that the use
of electrocautery as initial treatment for posterior bleeds
was associated with lower rates of recurrence when com-
pared with gauze packing. They recommended that electro-
cautery be the first-choice treatment of otolaryngologists for
all bleeding points of epistaxis. Sphenopalatine artery liga-
tion has been shown to have variable range of success
between 67% and 93%.26,27 Large-scale prospective studies
are needed to better evaluate this intervention as an initial
treatment for decreasing recurrent bleeds.
Recently, Silva et al2 published their work on lifestyle
and dietary influences on nosebleed severity in hereditary
hemorrhagic telangiectasia. Their findings suggest that
avoiding or monitoring intake of high-salicylate foods and
other dietary items may affect the severity and frequency of
epistaxis. The most commonly reported item was alcohol,
which has been shown to be associated with an increased
risk for admission.3 Other foods include various spices, cho-
colate, and omega-3 fatty acids, all of which have been
shown to have different antiplatelet activity.27-29 Use of
humidification and regular lubrication of the nostrils were
considered beneficial by the consensus statement for man-
agement of hereditary hemorrhagic telangiectasia.30 Hence,
6 Otolaryngology–Head and Neck Surgery

Table 2. Univariate Analysis for REA.a

Early REAb (n = 48) Late REAc (n = 38)

Crude HR (95% CI) P Valued Crude HR (95% CI) P Valued

Age 0.998 (0.98-1.01) .848 1.030 (1.01-1.05) .01

Female 0.815 (0.46-1.46) .488 0.723 (0.37-1.40) .334
Hospitalization length 0.949 (0.84-1.08) .425 1.003 (0.93-1.08) .936
Season
Winter 1 .63 1 .241
Spring 0.967 (0.45-2.09) 0.146 (0.19-1.28)
Summer 1.454 (0.65-3.27) 1.302 (0.56-3.01)
Fall 1.429 (0.66-3.09) 1.074 (0.47-2.48)
Comorbidity
Smoking history 1.667 (0.71-3.92) 0.339 (0.47-2.47) .286
Hypertension 1.105 (0.61-1.98) .741 3.121 (1.31-7.47) .011
Diabetes 0.864 (0.45-1.66) .66 2.258 (1.19-4.27) .012
Prior surgery
Total 1.998 (1.05-3.80) .035 1.461 (0.65-3.30) .361
FESS 1.993 (0.84-4.73) .091 1.542 (0.55-4.36) .123
Septoplasty/turbinate surgery 3.479 (1.47-8.26) .007 1.463 (0.35-6.11) .092
Clopidogrel 0.973 (0.24-4.01) .97 0.608 (0.08-4.43) .623
Anticoagulation
Warfarin 0.847 (0.36-2.00) .703 1.737 (0.82-3.67) .148
Enoxaparin 2.210 (0.80-6.62) .128 1.452 (0.35-6.03) .608
Laboratory
Hb 0.938 (0.83-1.06) .318 0.823 (0.72-0.94) .004
PLT 1.0 (1.00-1.00) .974 0.993 (0.99-0.97) \.001
INR 0.883 (0.65-1.21) .435 0.991 (0.76-1.29) .945
PTT 0.995 (0.97-1.02) .744 1.008 (0.98-1.03) .523
Anemiae 2.518 (1.26-5.05) .009 2.533 (1.16-5.53) .02
Thrombocytopeniaf 0.847 (0.38-1.89) .985 2.779 (1.44-5.37) .002
Surgical intervention for epistaxis
Total 1.790 (0.76-4.21) .182 1.513 (0.54-4.26) .434
ESPAL/embolizationg 2.524 (0.78-8.14) .121 1.184 (0.16-8.65) .868
Posterior packing 1.271 (0.17-9.30) .991 2.32 (0.56-9.67) .247
Electrocautery/other 1.735 (0.42-7.17) .446 1.066 (0.17-7.79) .950
Abbreviations: ESPAL, endoscopic sphenopalatine artery ligation; FESS, functional endoscopic sinus surgery; Hb, hemoglobin; HR, hazard ratio; INR, interna-
tional normalized ratio; PLT, platelets; PTT, partial thromboplastin time; REA, recurrent epistaxis admission.
a
Values are presented as either n (%) or median (interquartile range). For parameters except seasons, the reference for the calculated crude HR values was
the no-readmission group. For seasons analyses, the reference for the calculated crude HR values was the winter admissions in the same study group.
b
Early: epistaxis-related admission up to 30 days following discharge of initial epistaxis admission.
c
Late: any epistaxis-related admission between 30 days following discharge of initial epistaxis admission and the follow-up period.
d
P values were calculated with Cox logistic regression. Bold indicates significance (P  .05).
e
Hb \14 g/dL for men and \12.3 g/dL for women.
f
PLT \150 K/mL.
g
Embolization of the bleeding vessel of the distal part of the internal maxillary artery.

preventive measures appear to be feasible for patients at
risk and should be advised by all caregivers.
Conclusion
Early and late REAs have been found to have different inci-
dence patterns and to be associated with different risk factors.
Three quarters of early REAs occur during the first week, and
patients at risk should be advised accordingly. Patients with
anemia at presentation are at increased risk for early REA,
while patients with thrombocytopenia are at an increased risk
for late REA. Patients at high risk for early REAs may benefit
from a more proactive approach and early intervention, such
as electrocautery or arterial ligation. All patients at REA risk
should be advised on lifestyle and dietary modifications.
Author Contributions
Oded Cohen, designed the work; collected data, analysis and
interpretation of data for the work; drafting the work; approved
Cohen et al 7

Table 3. Adjusted Multivariate Analysis for Early Recurrent are appropriately investigated and resolved; Doron Halperin, inter-
Epistaxis Admission. preted the data for the work; revised it critically; approved final ver-
sion to be published; agreed to be accountable for all aspects of the
Category Hazard Ratio (95% CI) P Valuea
work in ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and resolved;
Age 1.001 (0.985-1.018) .894
Yonatan Lahav, Designed study; interpretation of data for the
Female 0.975 (0.542-1.752) .932 work; drafted the work and revised it critically for important intel-
Septoplasty/turbinate surgery 3.634 (1.416-9.324) .007 lectual content; approved final version to be published; agreed to be
Functional endoscopic 2.130 (0.887-5.116) .091 accountable for all aspects of the work in ensuring that questions
sinus surgery related to the accuracy or integrity of any part of the work are
Enoxaparin treatment 1.529 (0.521-4.486) .439 appropriately investigated and resolved.
Anemiab 2.563 (1.258-5.221) .010
Disclosures
a
P values were calculated with Cox logistic regression. Bold indicates signifi- Competing interests: None.
cance (P  .05).
b
Hemoglobin \14 g/dL for men and \12.3 g/dL for women. Sponsorships: None.
Funding source: None.

Table 4. Adjusted Multivariate Analysis for Late Recurrent
Epistaxis Admission.
Category Hazard Ratio (95% CI) P Valuea
Age 1.024 (0.998-1.051) .074
Female 0.729 (0.374-1.419) .352
Hypertension 1.934 (0.780-4.799) .155
Diabetes 1.865 (0.987-3.527) .055
Anemiab 1.723 (0.768-3.867) .187
Thrombocytopeniac 2.309 (1.185-4.498) .014
a
P values were calculated with Cox logistic regression. Bold indicates signifi-
cance (P  .05).
b
Hemoglobin \14 g/dL for men and \12.3 g/dL for women.
c
Platelets \150 K/mL.
paper; agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved; Hagit
Shoffel-Havakuk, designed the work; analysis and interpretation
of data for the work; drafting the work; approved paper; agreed to
be accountable for all aspects of the work in ensuring that ques-
tions related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved; Meir Warman, inter-
preted data for the work; revised it critically; approved final ver-
sion to be published; agreed to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integ-
rity of any part of the work are appropriately investigated and
resolved; Sharon Tzelnick, analysis of data for the work; revised
it critically for important intellectual content; approved final ver-
sion to be published; agreed to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or integ-
rity of any part of the work are appropriately investigated and
resolved; Yaara Haimovich, data collection; revision of draft;
final approval of the version; approved final version to be pub-
lished; agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved;
Gavriel D. Kohlberg, analysis and interpretation of data for the
work; revised it critically; approved final version to be published;
agreed to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work
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