T h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 368;9 nejm.org february 28, 2013

ObjectiveTo identify factors influencing the severity of epistaxis in hereditary haemorrhagic telangiectasia. Study designParticipants with and without hereditary haemorrhagic telangiectasia were recruited from a specialist UK service, and online following advertisement by the HHT Foundation International. Both groups were asked to complete a non-biased questionnaire. MethodsThe reported effects of specific treatments or lifestyle factors on epistaxis were assigned positive values if beneficial, negative values if detrimental, zero if "no difference," and summed to enable statistical analysis. ResultsEpistaxis affected 649/666 (97%) participants with hereditary haemorrhagic telangiectasia and was significantly more frequent than in control participants. Specialist invasive treatments were reported as beneficial, laser therapy more frequently than cauterisation. Medical treatments commonly used for HHT epistaxis (female hormones, anti-oestrogens, tranexamic acid, aminocaproic acid, nasal creams and bevacizumab) also had significantly positive (beneficial) scores. Lifestyle and dietary factors were generally detrimental, but room humidification, nasal lubrication and saline treatments were all reported as beneficial (95% confidence intervals greater than zero). Multiple food items were volunteered as being detrimental to epistaxis. The most frequently reported items were alcohol (n=45; 6.8% of participants) and spices (n=26, 3.9% of participants). Remaining foods 4 reported to exacerbate epistaxis were also found to be high in salicylates (including red wine, spices, chocolate, coffee and certain fruits), natural antiplatelet activity (garlic, ginger, ginseng, gingko biloba and vitamin E15) or in omega-3 acids (oily fish, salmon). ConclusionThis study supports existing treatments and suggests lifestyle and dietary manoeuvres that may also improve nosebleeds in hereditary haemorrhagic telangiectasia.