ENT - September 2020 - 516

516

Ear, Nose & Throat Journal 99(8)

Table 2. Correlation Analysis Between Visits of Epistaxis in Children
and Air Pollutants.a
r Value
lag0
lag1
lag2
lag3
lag4
lag5
lag6
lag7
lag8
lag9
lag10
lag11
lag12
lag13
lag14

PM2.5

PM10

SO2

NO2

CO

O3

À.248b
À.249b
À.232b
À.222b
À.222b
À.206b
À.201b
À.191b
À.166b
À.173b
À.176b
À.186b
À.180b
À.181b
À.182b

À.159b
À.151b
À.164b
À.170b
À.183b
À.181b
À.170b
À.164b
À.133b
À.130b
À.145b
À.146b
À.146b
À.148b
À.138b

À.294b
À.294b
À.287b
À.281b
À.287b
À.266b
À.266b
À.253b
À.232b
À.237b
À.223b
À.226b
À.207b
À.224b
À.229b

À.275b
À.281b
À.287b
À.267b
À.292b
À.262b
À.257b
À.247b
À.234b
À.239b
À.232b
À.229b
À.233b
À.246b
À.226b

À.283b
À.282b
À.264b
À.252b
À.262b
À.242b
À.224b
À.213b
À.191b
À.197b
À.187b
À.198b
À.206b
À.220b
À.223b

.508b
.463b
.446b
.431b
.416b
.379b
.364b
.343b
.328b
.313b
.309b
.307b
.301b
.305b
.289b

Abbreviations: CO, carbon monoxide; NO2, nitrogen dioxide; O3, ozone;
PM2.5 particulate matter less than 2.5 mm in diameter; PM10, particulate matter less than 10 mm in diameter; SO2, sulfur dioxide.
a
All values listed are r values. The values marked in bold are absolute maximum.
Values with superscript b are P < .01.

In other words, there are some correlations between air pollutants and the incidence of epistaxis in children. The onset of
epistaxis due to air pollution has not obvious delayed effect.

Discussion
Epistaxis in the pediatric population is a common problem faced
by both pediatricians and otolaryngologists. Most childhood epistaxis is spontaneous, anterior and self-limiting, unlikely to require
nasal packing or hospital admission. Gently pressing the nasal ala
for 5 to 10 minutes is usually all that is required. Up to 60% of
children will have had at least one nosebleed by age of 10.1
Most cases occur due to vascular fragility aggravated by
local inflammation of Little's area on the anterior nasal septum.2 Other causes include allergic rhinitis, infections, trauma,
and bleeding disorders. Some studies suggested that there were
other causes of recurrent nosebleed in children in addition to
idiopathic Little's bleeding. Iranian scholar RahmanzadehShahi S. reported that interleukin-6 and tumor growth factorb were risk factors for idiopathic epistaxis.3 Korean scholar
Kim J. pointed out that F11 gene mutation leaded to congenital
factor XI deficiency (hemophilia C), which could cause recurrent nose bleeding.4 Since recurrent epistaxis can be troublesome and alarming for parents and children, it is important to
understand the pathogenesis and regularity of epistaxis.
In our study, we found that the incidence of nosebleed in
infants under 1 year of age was very low, gradually increased
with age, reached the peak at the age of 4 to 5, and then
gradually decreased with age. The average age was 5.5 years
of age. The average age in our results was closely to the
4.99 years of Yu et al,5 but slightly lower than the 7.3 years
of Damrose et al,6 7.8 years of Brown et al.7 This condition has

a universal predilection for males in our study and a similar
predominance of male patients reported in other studies.1,6-9
In our study, it was found that the incidence of nasal hemorrhage in children in Beijing had obvious seasonal variation, the
annual medical visits showed a double-peak trend in May-June
and August-September, and this trend was particularly significant in 2017. This result is inconsistent with many previous
studies. Some studies proved that the incidence of nasal hemorrhage was the highest in winter due to cold weather, repeated
respiratory infection and dry air created by indoor heating,10,11
while other studies presented that there was equal frequency of
nasal hemorrhage throughout the seasons.1,6,7 In this regard, we
believe that it is related to regional climate and environmental
factors.
In May-June and August-September of 2014 to 2017, the
number of visits of nasal hemorrhage in children in Beijing
was significantly higher than that in other months. Meanwhile, the 4 months are exactly the months with the highest
pollen concentration in Beijing,12,13 the onset of allergic rhinitis increases correspondingly,14 suggesting that allergic rhinitis may be correlated with nasal bleeding to some extent.
This is consistent with a recent American study15 about epistaxis in pediatric population. Clinically, we also found that
children with allergic rhinitis often blow their nose due to lots
of clear watery secretion or rub and dig their noses fiercely
due to severe nasal itching. These behaviors tend to cause
damage to the mucous membrane of Little's area, and lead
to nasal bleeding. After antiallergic treatment, the nosebleed
symptoms were significantly decreased. It is suggested that
allergic rhinitis should be considered a risk factor for pediatric
nasal hemorrhage, especially in allergic seasons. Early antiallergic treatment may reduce the occurrence of nasal
bleeding.
In July, however, the number of visits for nosebleed in children was significantly lower than in the 4 months adjacent to.
The possible reasons were as follows: the rainy season in Beijing occurs in July every year, with high humidity and relative
low pollen concentration.12,13 Therefore, the number of visits
for nosebleed in this month is slightly lower, form a bimodal
distribution for the calendar year.
In this study, we found that annual visits of epistaxis in
children in recent 4 years increased year by year, especially
in 2017. At the same time, PM2.5, PM10, SO2, NO2, and CO
showed an overall decline from 2014 to 2017, slightly lower in
summer, while O3 was significantly higher in 2016 and 2017
than in the previous 2 years, and significant increase in summer. The incidence of epistaxis in children was negatively
correlated with PM2.5, PM10, NO2, SO2, and CO concentration, and was positively correlated with O3 concentration. With
the strong oxidation and corrosive characteristics, the increased
concentration of O3 near the ground can stimulate nasal mucosa
and cause acute injury.16 Szyszkowicz et al pointed out that
exposure to O3 and PM10 would increase the risk of emergency
department visits for epistaxis.9 It would increase by 1.05 times
or each 14 ppb increase in O3, and 1.02 times for each 15 mg/m3
increase in PM10. Therefore, combined with the above, it is



ENT - September 2020

Table of Contents for the Digital Edition of ENT - September 2020

The Creation of a Sustainable Otolaryngology Department in Malawi Nathan Douglas Vandjelovic, Eric Masao Sugihara, Wakisa Mulwafu, and David Nathan Madgy
Hazardous Grilling Due to Wire Brushes Nima A. Vahidi, Brenna A. Keane, Paul J. Whalen, and Anita Jeyakumar
Guns n’ Noses: Endoscopic Removal of an Air-Gun Pellet Retained in the Frontal Sinus Dylan A. Levy, Andrew Y. Lee, Waleed M. Abuzeid, and Nadeem A. Akbar
Vitamin D Status in Egyptian Children With Allergic Rhinitis Khaled Saad, Abobakr Abdelmoghny, Mohamed Diab Aboul-Khair, Yasser Farouk Abdel-Raheem, Eman Fathalla Gad, Ahmed El-Sayed Hammour, Bahaa Hawary, Asmaa M. Zahran, Mohamd A. Alblihed, and Amira Elhoufey
Pediatric Epistaxis and Its Correlation Between Air Pollutants in Beijing From 2014 to 2017 Ying-Xia Lu, Jie-Qiong Liang, Qing-Long Gu, Chong Pang, and Chun-Lei Huang
Otomycosis With Tympanic Membrane Perforation: A Review of the Literature Petros Koltsidopoulos and Charalampos Skoulakis
Simultaneous Bilateral Same-Day Endoscopic Myringoplasty Using Tragal Cartilage From One Ear Baklaci Deniz, Kuzucu Ihsan, Guler Ismail, Kum Rauf Oguzhan, and Ozcan Muge
A Preliminary Report on the Investigation of Prestin as a Biomarker for Idiopathic Sudden Sensorineural Hearing Loss Changling Sun, Xiaolin Xuan, Zhi Zhou, Yuan Yuan, and Fei Xue
A Retrospective Study to Identify the Relationship Between the Dimension of Osseous External Auditory Canal and Chronic Otitis Media Yi-Fang Lee, Pei-Yin Wei, Chia-Huei Chu, Wen-Huei Liao, An-Suey Shiao, and Mao-Che Wang
Investigation of the Effectiveness of Surgical Treatment on Respiratory Functions in Patients With Obstructive Sleep Apnea Syndrome Burak Kersin, Murat Karaman, Engin Aynacı, and Ahmet Keles
Changing Trends of Color of Different Laryngeal Regions in Laryngopharyngeal Reflux Disease Chen Du, Paige Thayer, Yan Yan, Qingsong Liu, Li Wang, and Jack Jiang
ENT - September 2020 - Intro
ENT - September 2020 - Cover1
ENT - September 2020 - Cover2
ENT - September 2020 - 489
ENT - September 2020 - 490
ENT - September 2020 - 491
ENT - September 2020 - 492
ENT - September 2020 - 493
ENT - September 2020 - 494
ENT - September 2020 - 495
ENT - September 2020 - 496
ENT - September 2020 - 497
ENT - September 2020 - 498
ENT - September 2020 - 499
ENT - September 2020 - 500
ENT - September 2020 - The Creation of a Sustainable Otolaryngology Department in Malawi Nathan Douglas Vandjelovic, Eric Masao Sugihara, Wakisa Mulwafu, and David Nathan Madgy
ENT - September 2020 - 502
ENT - September 2020 - Hazardous Grilling Due to Wire Brushes Nima A. Vahidi, Brenna A. Keane, Paul J. Whalen, and Anita Jeyakumar
ENT - September 2020 - 504
ENT - September 2020 - Guns n’ Noses: Endoscopic Removal of an Air-Gun Pellet Retained in the Frontal Sinus Dylan A. Levy, Andrew Y. Lee, Waleed M. Abuzeid, and Nadeem A. Akbar
ENT - September 2020 - 506
ENT - September 2020 - 507
ENT - September 2020 - Vitamin D Status in Egyptian Children With Allergic Rhinitis Khaled Saad, Abobakr Abdelmoghny, Mohamed Diab Aboul-Khair, Yasser Farouk Abdel-Raheem, Eman Fathalla Gad, Ahmed El-Sayed Hammour, Bahaa Hawary, Asmaa M. Zahran, Mohamd A. Alblihed, and Amira Elhoufey
ENT - September 2020 - 509
ENT - September 2020 - 510
ENT - September 2020 - 511
ENT - September 2020 - 512
ENT - September 2020 - Pediatric Epistaxis and Its Correlation Between Air Pollutants in Beijing From 2014 to 2017 Ying-Xia Lu, Jie-Qiong Liang, Qing-Long Gu, Chong Pang, and Chun-Lei Huang
ENT - September 2020 - 514
ENT - September 2020 - 515
ENT - September 2020 - 516
ENT - September 2020 - 517
ENT - September 2020 - Otomycosis With Tympanic Membrane Perforation: A Review of the Literature Petros Koltsidopoulos and Charalampos Skoulakis
ENT - September 2020 - 519
ENT - September 2020 - 520
ENT - September 2020 - 521
ENT - September 2020 - Simultaneous Bilateral Same-Day Endoscopic Myringoplasty Using Tragal Cartilage From One Ear Baklaci Deniz, Kuzucu Ihsan, Guler Ismail, Kum Rauf Oguzhan, and Ozcan Muge
ENT - September 2020 - 523
ENT - September 2020 - 524
ENT - September 2020 - 525
ENT - September 2020 - 526
ENT - September 2020 - 527
ENT - September 2020 - A Preliminary Report on the Investigation of Prestin as a Biomarker for Idiopathic Sudden Sensorineural Hearing Loss Changling Sun, Xiaolin Xuan, Zhi Zhou, Yuan Yuan, and Fei Xue
ENT - September 2020 - 529
ENT - September 2020 - 530
ENT - September 2020 - 531
ENT - September 2020 - A Retrospective Study to Identify the Relationship Between the Dimension of Osseous External Auditory Canal and Chronic Otitis Media Yi-Fang Lee, Pei-Yin Wei, Chia-Huei Chu, Wen-Huei Liao, An-Suey Shiao, and Mao-Che Wang
ENT - September 2020 - 533
ENT - September 2020 - 534
ENT - September 2020 - 535
ENT - September 2020 - 536
ENT - September 2020 - Investigation of the Effectiveness of Surgical Treatment on Respiratory Functions in Patients With Obstructive Sleep Apnea Syndrome Burak Kersin, Murat Karaman, Engin Aynacı, and Ahmet Keles
ENT - September 2020 - 538
ENT - September 2020 - 539
ENT - September 2020 - 540
ENT - September 2020 - 541
ENT - September 2020 - 542
ENT - September 2020 - Changing Trends of Color of Different Laryngeal Regions in Laryngopharyngeal Reflux Disease Chen Du, Paige Thayer, Yan Yan, Qingsong Liu, Li Wang, and Jack Jiang
ENT - September 2020 - 544
ENT - September 2020 - 545
ENT - September 2020 - 546
ENT - September 2020 - 547
ENT - September 2020 - 548
ENT - September 2020 - 549
ENT - September 2020 - 550
ENT - September 2020 - 551
ENT - September 2020 - 552
ENT - September 2020 - Cover3
ENT - September 2020 - Cover4
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