ORL 39: 155-160 (1977)

Is High Blood Pressure an Aetiological Factor in Epistaxis?

Bjorn Petruson, R olf Rudin and Kurt Svardsudd

Key Words. Hypertension • Epistaxis • Clinical study

Abstract. In the present investigation, 391 men born in 1913 were examined. The
blood pressure was registered in a standardized way and the subjects were questioned about
epistaxis. The aim of the investigation was to analyze whether habitual nose-bleeders or
subjects with recent bleedings had higher blood pressure than the other subjects in the
population study.
All attempts to find a correlation between epistaxis and elevated (or high) blood
pressure were unsuccessful. When high blood pressure is found in a patient with nose-bleeds
it is probably an incidental finding and not an aetiological factor.

Hypertension has been considered to be one of the most common causes of

nose-bleeds. The incidence of hypertension in patients with nose-bleeds varies
between 14 and 47% (Hallberg, 1952; liara, 1962; Pierce and Chasin, 1962;
Trucker, 1963; Grabowski, 1965; Serafini, 1965; Harder, 1966; Popiel, 1969;
Juselius, 1974). It is, however, difficult to evaluate these reports because they
lack essential information on the different methods employed.
Mitchell (1959) found that the diastolic blood pressure was significantly
higher in patients who had epistaxis (with no other nasal disease) than in the
general population. The blood pressure in the general population, however, has
been measured by another author some years prior to recording it in patients.
Furthermore, an age-adjusted score was used, the blood pressure of 25% of
patients was not recorded and the method is not described. In the USA Health
Examination Survey of adults in 1960-1962 the blood pressure of 6,672 sub­
jects was measured in a standardized way. There was no correlation between
subjects with low and those with high blood pressure and a history of epistaxis
(H'e/'ss, 1972). Petruson (1974) registered the blood pressure of 155 patients
with epistaxis, some weeks after bleeding, in the morning and in a standardized
way. The distribution of different blood pressures at different ages has been

Received: August 26, 1976; accepted: April 1, 1977.

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 Petruson/Rudin/Svärdsudd 156

compared with that of a population sample of 23,000 subjects. The blood pres­
sure was recorded in the same way as in the patients. There was no difference
between patients and the population sample. Shaheen (1970) has found no
difference in blood pressure between patients with nose-bleeds and a control
group investigated in the same way.
The aim of the present investigation was to ascertain whether habitual nose-
bleeders or subjects with recent epistaxis had a higher blood pressure than other
subjects in the population study.

Study Group and Methods

From the census register every third man bom in 1913 and living in Göteborg was
selected systematically. Of those selected, 829 (81%) subjects were examined with regard to
several parameters. From October 1973 to June 1974, 391 male subjects were examined in
the present study. All were questioned about epistaxis by the examining physician (Petruson
and Rudin, 1975). Subjects with several nose-bleeds every year were called habitual
bleeders. Those with nose-bleeds in the previous 7 days were considered as having had a
recent bleed. Persons with frequent nose-bleeds when they were tired and/or stressed were
considered as having a correlation stress - epistaxis. A subject is defined as having high
blood pressure if he has been treated for hypertension or had a systolic blood pressure of
175 mm Hg or more, or a diastolic blood pressure of 115 mm Hg or more. All blood
pressures were recorded at the same time of the day, according to Rose and Blackburn
(1968) in the seated position after a 5-min rest. The blood pressure was measured in 2-mm
intervals. The systolic pressure was measured as the appearence of the Korotkoff sounds and
the diastolic pressure as phase 5, i.e. the disappcarence of the sounds. Calculations were
performed with an IBM 360/65 computer using the Osiris programme system for statistical
methods (1973). For the statistical analyses one-way analysis of variance was used.

Results

A total of 77 subjects (20%) had high blood pressure according to the

definition. The frequency of habitual bleeders was identical in subjects with high
blood pressure (table I) and in subjects without high blood pressure. The mean
values calculated for subjects with different frequency of epistaxis (table 1)
showed no difference between those who never suffered from epistaxis and the
habitual bleeders.
As shown in figure 1, the distribution of blood pressures was the same in the
habitual bleeders as in the other subjects. 13 subjects had had a recent bleeding;
9 of them were habitual bleeders and only 1 of them had been treated for
epistaxis. The mean value for blood pressure was the same in recent bleeders as
in other subjects (table II).
Among 77 subjects with high blood pressure, 3 subjects (3.9%) had had
recent bleedings. The same frequency (3.2%) of recent bleedings was found in
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 Is High Blood Pressure an Aetiological Factor in Epistaxis? 157

subjects without high blood pressure. A correlation between stress and epistaxis
was noted in 27 subjects (7%). The mean value was the same in those who had
reported the correlation as in the other subjects (table II). High blood pressure
was observed in 6 of these subjects (22%) (table II). 37 subjects (10%) have been
treated for epistaxis by a physician; 7 of these subjects (19%) had high blood
pressure (table III), and only 5 of the treated subjects were habitual bleeders.

Fig. 1. The systolic and diastolic blood pressures in 29 habitual bleeders (hatched) and
362 subjects (solid) without habitual bleeding.

Table I. The mean blood pressure and the number of subjects with high blood pressure
correlated to the frequency of epistaxis

Frequency of epistaxis Mean blood pressure Subjects with

systolic diastolic high BP no high BP

n % n %

Never had any nose-bleeds 147.4 ± 22.5 90.1 ± 13.9 21 27 120 38

Occasional nose-bleeds
many years ago 152.2 ± 24.9 92.4 ± 13.5 34 44 91 29
Occasional nose-bleeds formerly 147.6 ± 24.0 90.7 ± 13.4 15 20 63 20
Occasional nose-bleeds every year 135.0 ± 13.9 88.2 ± 7.6 1 1 17 5
Several nose-bleeds every year
(habitual bleeding) 145.8 ± 25.3 88.4 ± 13.8 6 8 23 8

F (4.386) = 2.47 NS F = 0.91 NS 77 20 314 80

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 Petruson /R udirt/S vardsudd 158

Table II. The mean blood pressure and number of subjects with high blood pressure correlat­
ed to recent bleeders, subjects who had noted a correlation stress epistaxis and subjects
treated for epistaxis by a physician

Groups of subjects Mean blood pressure Subjects with

systolic diastolic high BP no high BP

n % n %

Recent bleeding 151.5 ± 31.9 90.9 ± 13.2 3 23 10 77

No recent bleeding 148.2 ± 23.4 90.7 ± 13.5 74 20 304 80
F (1.389) = 0.248 NS 0.0 NS
Correlation stress 145.6 t 22.2 90.1 ± 12.7 6 22 21 78
No correlation stress 148.5 ± 23.8 90.8 i 13.5 71 20 293 80
F (1.389) = 0.367 NS 0.051 NS
Treated epistaxis 146.0 ± 23.9 89.2 ± 15.2 7 19 30 81
Not treated epistaxis 148.5 ± 23.7 90.9 ± 13.3 70 20 284 80
F (1.389) = 0.386 NS 0.491 NS

Comments

Hypertension has been considered an important aetiological factor in epi­

staxis. Various studies supporting this postulate have been carried out on nose­
bleeding, mostly hospitalized patients (Hallber, 1952; Hara, 1962; Pierce and
Chasin 1962; Trucker, 1963\ Grabowski, 1965\ Serafini, 1965; Harder, 1966;
Popiel, 1969; Juselius, 1974). A high proportion of the hospitalized patients
were old people. From population studies (Roberts, 1975) it is known that
hypertension is a common disease among older persons. When older adults hospi­
talized for epistaxis are examined it is not unusual to find that some of them
suffer from hypertension, as they are part of the population. In the above-
mentioned studies the blood pressure of patients with nose-bleeds has not been
compared with that of control groups. In order to establish a correlation be­
tween high blood pressure and epistaxis it must be shown that the occurrence of
high blood pressure is higher among nose-bleeders than among other individuals
in the population as studied by Weiss (\912) and Petruson (1974). In both these
studies there was no correlation between high blood pressure and epistaxis.
In the present investigation the frequency of epistaxis and high blood pres­
sure was studied in the same population sample. In contrast to Weiss (1972) the
subjects were questioned about recent bleedings and habitual bleeding. Among
391 60-year-old male subjects, 20% were found to have high blood pressure and
8% of all males to be habitual bleeders. If high blood pressure is of importance
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 Is High Blood Pressure an Aetiological Factor in Epistaxis? 159

Table III. Number of subjects with high blood pressure

Groups Treat­ Blood pressure Total

of subjects ment
hyper­ systolic > 175 < 175 > 175 < 175
tension diastolic < 115 > 115 > 115 < 115

All yes 9 3 5 23
(n = 391) no 28 3 6 - 37 J
40 1 77
77
Habitual bleeders yes 1 1 1 0 3 "I 6
(n = 29) no 3 0 0 - 3 J 6
Recent bleeders yes 1 0 0 0
2 J
11 3
(n = 13) no 2 0 0 - 3
Correlation stress yes 1 0 0 2
3 J
3 1 6
(n = 27) no 2 1 0 - 6
Treated epistaxis yes 1 0 0 2
(n = 37) no 3 1 7
3 0 1 4 j 7

for the occurrence of nose-bleeds it seems reasonable to assume that subjects

with high blood pressure would have repeated nose-bleeds every year (habitual
bleeding). The frequency of habitual bleeders was, however, the same in those
with high blood pressure as in those whose blood pressure was normal. High
blood pressure thus does not predispose habitual bleeding.
In order to investigate whether the blood pressure of habitual bleeders was
higher than in those who never suffered epistaxis, one-way analyses of variance
were performed and showed the same range of blood pressures in both groups.
Recent bleeding was noted as frequently in those with high as in those with
normal blood pressure. The mean blood pressure was also identical. High blood
pressure thus did not increase the risk of suffering an occasional nose-bleed
either. Some of the subjects had noted a correlation between stress and epistaxis.
The blood pressure in this group was statistically analyzed to ascertain whether
such subjects had higher blood pressures. The same mean blood pressure was,
however, found in both groups and so was the frequency of high blood pressure.
Subjects who had been treated for epistaxis by a physician did not suffer from
hypertension more frequently than those not treated. The mean blood pressures
were also identical.
All attempts to find a correlation between epistaxis and elevated (or high)
blood pressure have proved unsuccessful. When high blood pressure is found in a
patient with nose-bleeds it is probably an incidental finding and not an aetiolog­
ical factor.
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References

Bevan, A.T.; Honour, A.J., and Stott, F.H.: Direct arterial pressure in unrestricted man.
Clin. Sei. 36: 329-344 (1969).
Grabowski, M.: Nose bleeding, causes and management. Otolar. Polska 19: 235-240
(1965) .
Hallberg, O.: Severe nose bleed and its treatment. J. Am. med. Ass. 148: 355- 360 (1952).'
Hara, J. : Severe epistaxis. Archs Otolar. 75: 258- 269 (1962).
Harder, P. von: Ursachen von Nasenblutungen in stationärer Behandlung. HNO 14: 56
(1966) .
Juselius, H.: Epistaxis a clinical study of 1,724 patients. J. Lar. Otol. 88: 317 327 (1974).
Mitchell, J.R.A.: Nose bleeding and high blood pressure. B. med. J. i: 25-27 (1959).
Osiris III: Institute for Social Research, University of Michigan (1973).
Petruson, B.P.: Epistaxis. A clinical study with special reference to fibrinolysis. Acta oto­
lar., suppl 317, p. 44 (1974).
Petruson, B.P. and Rudin, R.: The frequency of epistaxis in a male population sample.
Rhinology 13: 129-133 (1975).
Pierce, D.L. and Chasin, W.D.: Treatment of epistaxis.'New Engl. J. Med. 267: 768 771
(1962).
Popiel, L.: Epistaxis requiring hospitalization. Otolar. Polska 23: 671-676 (1969).
Rickardson, D. W.; Honour, G. W.; Fenton, G. W.; Stott, F.H., and Pickering, G. W.: Variations
in arterial pressure throughout the day and night. Clin. Sei. 26: 445- 460 (1964).
Roberts, J.: Blood pressure of persons 18-74 years. United States 1971-72. Vital and
Health Statistics, Series 11, No. 150 (1975).
Rose, G. and Blackburn, H.: Cardiovascular survey methods (World Health Organisation,
Geneva 1968).
Serafini, The epistaxis. Clinical and experimental researches on the essential epistaxis
pathogenesis. Archo ital. Otol. Rinol. Lar. 76: 459-476 (1965).
Shaheen, O.: Studies of the nasal vasculature and the problems of arterial ligation for
epistaxis. Ann. R. Coll. Surg. 47: 30-44 (1970).
Trucker, W.N.: The investigation and treatment of epistaxis: A report of one hundred and
sixty-four cases. N. Z. med. J. 62: 283-287 (1963).
IVms, N.S.: Relation of high blood pressure to headache, epistaxis, and selected other
symptoms. New Engl. J. Med. 287: 631-633 (1972).

Björn Petruson, MD, ENT Department, Sahlgren’s Hospital, S -413 45 Göteborg

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