Sage Journals: Discover world-class research

Abstract

Objective: To investigate the relationship between environmental and meteorological factors and the incidence of epistaxis in different age groups in Yangzhou, as well as to provide a reference and theoretical basis for epistaxis prevention and treatment. Methods: The patients with epistaxis who were treated in Northern Jiangsu People’s Hospital of Jiangsu Province from January 2016 to December 2020 were reviewed, and the relationship between the local environmental meteorological factors at the time of onset and the incidence of epistaxis in different age groups was analyzed, and the potential environmental meteorological risk factors of epistaxis in each age group were determined by Stepwise logistic regression. Results: From 2016 to 2020, there were 24,407 cases of epistaxis, mostly males and children. The effects of O₃ concentration, average humidity, average temperature, NO₂ concentration, sunshine duration, average wind speed, CO concentration, and temperature difference on the study population were statistically significant (P < .05). Analysis by age group showed that there were differences in environmental and meteorological factors related to epistaxis in different age groups. Conclusions: In Yangzhou, epistaxis is more prevalent among males and children. The environmental meteorological factors are related to the incidence of epistaxis in Yangzhou, among which the average humidity and temperature difference are negatively correlated with the incidence of epistaxis. In contrast O₃ concentration, average temperature, NO₂ concentration, sunshine duration, average wind speed, and CO concentration are positively correlated with epistaxis occurrence. However, the impact of these environmental and meteorological factors varies in different age groups.

Keywords

epistaxis meteorological factors air pollutants

Introduction

Epistaxis is one of the common diseases in otorhinolaryngology. According to statistics, about 60% of the general population have experienced epistaxis.¹ Since the condition of the nasal mucosa is an important factor causing spontaneous epistaxis, and the condition of the nasal mucosa is usually affected by environmental and meteorological factors, it can be considered that environmental and meteorological factors may be an important factor causing spontaneous epistaxis.

Previous studies have shown that the occurrence of epistaxis is related to environmental and meteorological factors.^2-6 Lu et al³ found that epistaxis in children in Beijing was related to air pollutants. Ahn and Min⁴ found that average relative humidity, minimum temperature, sunshine duration, SO₂ concentration, and average wind speed were negatively correlated with the occurrence of epistaxis, while particulate matter (PM) 10 concentration and average temperature were positively correlated with epistaxis occurrence. Kim et al⁵ discovered that the incidence of epistaxis was positively correlated with the average temperature, average wind speed, sunshine hours, and PM10 concentration in children. In adults, cloud cover and PM10 concentration were positively correlated with the incidence of epistaxis, while minimum temperature and average relative humidity were negatively correlated with the incidence of epistaxis. All the above studies indicate that environmental and meteorological factors are related to the occurrence of epistaxis, and the influencing factors of epistaxis in different age groups may be different.

In the past, our research found that the incidence of epistaxis in Yangzhou was significantly positively correlated with air pollutants.⁶ Hence, we intend to classify epistaxis patients by age for a more detailed analysis of the association between environmental and meteorological factors and epistaxis across various age groups. It is one of the few studies on the relationship between epistaxis and environmental and meteorological factors in China, providing a reference for reducing and preventing epistaxis and rationally arranging medical and health resources.

Methods

Clinical Data

A retrospective study was conducted on patients with epistaxis who were treated in the outpatient and emergency Department of Otolaryngology, Head and Neck Surgery, Northern Jiangsu People’s Hospital of Jiangsu Province from January 1, 2016, to December 31, 2020.

Inclusive criteria: The diagnosis of epistaxis adhered to applicable diagnostic criteria.⁶ Systematic collection of patient data, including age, sex, visit time, and diagnosis. The repeated visits of the same patient within 2 weeks were counted as a single case.

Exclusion criteria: Patients with secondary epistaxis caused by hematological disorders, oral anticoagulants, foreign bodies in the nose, history of trauma, nasal surgery, or tumors were excluded from the study.

Patients were divided into 4 groups based on their age at the time of the visit: age group 1 (0-17 years old), age group 2 (18-40 years old), age group 3 (41-60 years old), and age group 4 (over 60 years old).

Environmental Data Collection and Processing

The concentration data of 6 air pollutants [sulfur dioxide (SO₂ μg/m³), ozone (O₃ μg/m³), nitrogen dioxide (NO₂ μg/m³), carbon monoxide (CO mg/m³), PM2.5 (μg/m³), and PM10 (μg/m³)] were sourced from the national urban air quality real-time publishing platform of China Environmental Monitoring Station (http://www.cnemc.cn/). Concentrations of CO, NO₂, PM2.5, PM10, and SO₂ represented 24-hour averages, while O₃ concentration denoted daily maximum 8-hour moving averages. Meteorological data from the National Oceanic and Atmospheric Administration consist of the National Center for Environmental information (https://www.ncei.noaa.gov/data/global-summary-of-the-day/archive/), meteorological data, including temperature difference (°C), average temperature (°C), average humidity (%), average wind speed (m/second), and cumulative sunshine time (hour). Data were collected every 3 hours, and daily averages were computed.

Statistical Analysis

Statistical software SPSS 25 was used to analyze the data. Data with normal distribution were expressed as x ± s. A stepwise linear regression model was constructed based on the Akaike Information Criterion to identify factors related to epistaxis. The stepwise selection method was adopted to select and delete variables according to predefined statistical criteria (input P < .05, deletion variable P > .10). Variables were chosen based on their P-value at each step, and a P-value threshold of .05 was used to limit the total number of variables included in the final model. Both were two-sided tests, and P < .05 was considered statistically significant.

Results

A total of 24,407 patients with epistaxis were included in this study, and predominantly male across all 4 age groups, with the largest number of patients in age group 1. The amount of epistaxis in age group 1 gradually increased from 2016 to 2019 and decreased in 2020. The amount of epistaxis in age groups 2, 3, and 4 gradually decreased from 2017 to 2020. The variation trend of epistaxis in age groups 1 and 2 was similar with month, and there were 2 peak periods (May and August) each year. The variation trend of epistaxis in age groups 3 and 4 was similar with month, and the peak period was in April and March, respectively (Figures 1 and 2). Annual average temperatures ranged from 3.39°C in January to 28.39°C in August, with the highest temperature difference in April (10.68°C) and the lowest in July (7.14°C). Pollutant concentrations varied, with significant fluctuations in PM2.5, PM10, and O₃, while CO concentrations showed minimal change (Figure 3).

Figure 1.

Gender and age distribution of epistaxis.

Figure 2.

Total number of epistaxis from 2016 to 2020. (A) Yearly distribution of epistaxis. (B) Monthly distribution of epistaxis.

Figure 3.

The mean values of the meteorological factors and air pollutants from 2016 to 2020. (A) Monthly mean values of PM2.5 and PM10. (B) Monthly mean values of the CO, SO₂, and NO₂ concentrations. (C) Monthly mean values of temperature difference, average wind speeds, and sunshine duration. (D) Monthly mean values of the CO concentrations, average humidity, and average temperature.

Stepwise regression analysis evaluated the relationship between environmental and meteorological factors with epistaxis. The results showed that the regression model had significant statistical significance (P < .001). O₃ concentrations, average humidity, average temperature, NO₂ concentrations, sunshine duration, average wind speed, CO concentrations, and temperature difference had statistically significant effects on epistaxis (P < .05; Table 1).

Table 1.

Stepwise Regression Models of Air Pollution and Meteorological Factors in Different Age Groups.

	Step	Label	B	SE	β	F	P
Study population	1	O₃	0.071	0.008	0.269	414.569	<.0001
	2	Average humidity	−0.258	0.021	−0.406	276.785	<.0001
	3	Average temperature	0.28	0.026	0.305	226.186	<.0001
	4	NO₂	0.067	0.014	0.145	181.308	<.0001
	5	Sunshine duration	−0.298	0.069	−0.139	154.958	<.0001
	6	Average wind speeds	0.517	0.116	0.091	133.791	<.0001
	7	CO	2.015	0.681	0.076	116.325	.003
	8	Temperature difference	−0.214	0.078	−0.083	103.083	.006
Age group 1	1	O₃	0.05	0.005	0.281	647.61	<.0001
	2	Average temperature	0.266	0.016	0.437	432.226	<.0001
	3	Average humidity	−0.132	0.012	−0.311	339.701	<.0001
	4	Sunshine duration	−0.245	0.04	−0.171	269.181	<.0001
	5	NO₂	0.032	0.007	0.105	219.455	<.0001
	6	Average wind speeds	0.236	0.074	0.062	185.233	.001
	7	SO₂	−0.019	0.009	−0.041	159.595	.047
Age group 2	1	O₃	0.017	0.003	0.177	273.476	<.0001
	2	SO₂	0.018	0.006	0.072	181.01	.003
	3	Average humidity	−0.087	0.008	−0.385	133.988	<.0001
	4	Average temperature	0.098	0.01	0.3	119.6	<.0001
	5	Sunshine duration	−0.087	0.026	−0.114	101.842	.001
	6	CO	1.226	0.237	0.131	88.07	<.0001
	7	Temperature difference	−0.104	0.028	−0.114	78.128	<.0001
	8	Average wind speeds	0.104	0.043	0.051	69.298	.015
Age group 3	1	PM10	0.004	0.001	0.101	96.168	.002
	2	Average humidity	−0.019	0.003	−0.155	73.703	<.0001
	3	Average wind speeds	0.107	0.026	0.095	54.16	<.0001
	4	Average temperature	−0.014	0.004	−0.077	43.216	.001
	5	NO₂	0.008	0.003	0.088	36.317	.005
Age group 4	1	Average temperature	−0.06	0.005	−0.298	255.794	<.0001
	2	PM10	0.004	0.001	0.105	176.536	.001
	3	Average humidity	−0.01	0.003	−0.071	123.108	.002
	4	NO₂	0.008	0.003	0.081	94.831	.005
	5	SO₂	0.008	0.004	0.052	76.854	.039

Stepwise regression analysis was performed for each age group, and the results showed that all 4 regression models had significant statistical significance (P < .001), but the association between environmental factors and epistaxis differed between the 4 age groups. In age group 1, O₃ concentration, average temperature, average humidity, sunshine duration, NO₂ concentration, average wind speed, and SO₂ concentration had statistically significant effects on epistaxis (P < .05). In age group 2, O₃ concentration, SO₂ concentration, average humidity, average temperature, sunshine duration, CO concentration, temperature difference, and average wind speed had statistically significant effects on epistaxis (P < .05). In age group 3, the effects of PM10 concentration, mean humidity, mean wind speed mean temperature, and NO₂ concentration on epistaxis were statistically significant (P < .05). In age group 4, the effects of mean temperature, PM10 concentration, mean humidity, NO₂ concentration, and SO₂ concentration on epistaxis were statistically significant (P < .05; Table 1).

Discussion

A total of 24,407 patients with epistaxis were included in this study. The number of epistaxis patients in age groups 1 and 2 showed a similar trend each month, with 2 peak periods per year (May and August). The number of epistaxis patientsin age groups 3 and 4 were similar month by month, with the peak in April and March, the amount of epistaxis was different in each age group, indicating that seasonal changes had different effects on the incidence of epistaxis in each age group.

In this study, it was found that the occurrence of epistaxis was negatively correlated with average humidity and temperature difference, whereas epistaxis was positively correlated with O₃ concentration, average temperature, NO₂ concentration, sunshine time, average wind speed, and CO concentration. This study categorized patients into 4 age groups and found that male patients are more common. However, age group analysis revealed that meteorological factors and air pollutants associated with epistaxis differed in each age group.

We discovered that the number of epistaxis in the 4 groups was negatively correlated with the average humidity, that the number of epistaxis in age groups 1 and 2 were positively correlated with the average temperature, and that the number of epistaxis in age groups 3 and 4 were negatively correlated with the average temperature. Matsumoto et al⁷ found that the number of daily cases of epistaxis was significantly negatively correlated with the average daily relative humidity. Akdogoan et al⁸ found that children’s epistaxis was negatively correlated with the daily mean humidity and the difference between daily maximum and minimum humidity. Similarly, Gatsounia et al⁹ reported a statistically significant negative correlation between the incidence of epistaxis and the average relative humidity observed on a daily and weekly basis. Low air humidity may desiccate nasal mucosa, rendering it vulnerable to bleeding. Previous research on temperature’s impact on epistaxis yields conflicting results, with some studies suggesting a predisposition to spontaneous epistaxis at low temperatures.^1,2,10,11 While others find no correlation between temperature and the incidence of epistaxis.^9,12 This study proposes a correlation between temperature and epistaxis occurrences, with varying effects across distinct age groups. Additional research is required to ascertain the significant influence of temperature on epistaxis incidence.

The impacts of other meteorological factors differ across age groups. In this study, sunshine duration, average wind speed, and temperature difference all had certain effects on the epistaxis in different groups. For example, the regression coefficients of average wind speed in age group 1, 2, and 3 were 0.062, 0.051, and 0.095, respectively. The regression coefficients of sunshine duration in age groups 1 and 2 were −0.171 and −0.114, respectively. The regression coefficient of temperature difference in age group 2 was −0.114. These results indicate that the effects of various meteorological factors on epistaxis differ in different age groups.

As the nasal cavity is the first part of the respiratory tract to come into contact with the environment, the nasal epithelium may be damaged by environmental pollutants in the air, resulting in epistaxis.^13-15 This study found that air pollution indicators except PM2.5 concentration are associated with epistaxis in different age groups. O₃ and PM10 concentration affect multiple groups. O₃ concentration is positively correlated with age groups 1 and 2. PM10 concentration was positively correlated with age groups 3 and 4. NO₂, SO₂, and CO concentrations are also positively correlated with different age groups. At present, most studies have found that PM10 is positively correlated with the occurrence of epistaxis,^4,5,16 but studies on children with epistaxis have found that PM10 is negatively correlated with the occurrence of epistaxis.³ According to the relationship between epistaxis and PM10 concentration in children of different age groups, it is found that PM10 concentration is associated with the occurrence of epistaxis in young children (0-5 years old), but PM10 is not a significant risk factor in older children (6-18 years old).¹⁶ According to the results of our study, the effects of air pollutants on epistaxis in different age groups are different, and further detailed studies are needed.

Previous studies have shown that allergic rhinitis is related to the occurrence of environmental meteorology and epistaxis.^17-22 Chen et al¹⁸ found that the risk of allergic rhinitis significantly increases at higher temperatures (19.8°C). However, as humidity increases, the number of clinic visits for allergic rhinitis decreases, suggesting that high humidity has a protective effect.²³ Additionally, increases of 10 μg/m³ in atmospheric pollutants O₃, SO₂, and PM10 correlate with an increase in clinic visits for allergic rhinitis, indicating that air pollution heightens the risk of allergic rhinitis attacks. Children diagnosed with allergic rhinitis are 2.4 times more likely to experience epistaxis.^21,22 Therefore, changes in environmental and meteorological conditions may exacerbate allergic rhinitis symptoms, leading to increased nasal mucosal congestion, edema, and erosion, which can cause the rupture of small blood vessels in the nasal cavity, triggering epistaxis. However, we could not exclude the interference of allergic rhinitis in the study results, which is also the direction of our future research.

As we all know, there is a difference between indoor and outdoor environmental meteorology,²⁴ especially in winter and summer. More time spent indoors may lead to less exposure to outdoor weather factors and allergens, leading to a lower incidence of epistaxis.¹⁶ In the future, we can further study the influence of indoor and outdoor environmental differences on the occurrence of epistaxis.

The causes of epistaxis include local and systemic factors, so this study has some limitations. First, the data of all medical institutions in Yangzhou were not included. Second, this study only excluded patients with nasal trauma, tumors, foreign bodies, surgery, and blood diseases, and did not analyze the influence of systemic diseases (such as hypertension, diabetes, arteriosclerosis, upper respiratory tract infection, allergic rhinitis, etc.) on epistaxis.

Conclusion

This study showed that the environmental and meteorological factors were related to the occurrence of epistaxis in Yangzhou, among which average humidity and temperature difference are negatively correlated with the occurrence of epistaxis, while O₃, average temperature, NO₂, sunshine duration, average wind speed, and CO are positively correlated with epistaxis occurrence. However, the impact of these environmental and meteorological factors varies in different age groups. In the future, we need further research and in-depth discussion.

Footnotes

Data Availability Statement

Some or all data, models, or code generated or used during the study are available from the corresponding author by request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Jiangsu Province natural science Foundation project (BK20201220).

Ethical Standards

According to the Ethics Committee of Northern Jiangsu People’s Hospital, this research has no harm to human body, does not involve sensitive personal information or commercial interests, and can be exempted from ethical review.

ORCID iD

Bin Zhu

References

Mangussi-Gomes

Enout

Castro

, et al Is the occurrence of spontaneous epistaxis related to climatic variables? A retrospective clinical, epidemiological and meteorological study. Acta Oto-Laryngol. 2016;136(11):1184-1189. doi:10.1080/00016489.2016.1191673

Min

Kang

Kim

, et al Minimal temperature, mean wind speed, and mean relative humidity are associated with spontaneous epistaxis in Seoul, Korea. Auris Nasus Larynx. 2020;48(1):98-103. doi:10.1016/j.anl.2020.07.012

Liang

, et al Pediatric epistaxis and its correlation between air pollutants in Beijing from 2014 to 2017. Ent-Ear Nose Throat. 2019;99(8):513-517. doi:10.1177/0145561319852581

Ahn

Min

. Age-specific associations between environmental factors and epistaxis. Front Public Health. 2022;10:966461. doi:10.3389/fpubh.2022.966461

Kim

Kwak

Min

. Particulate matter 10 (PM10) is associated with epistaxis in children and adults. Int J Environ Res Public Health. 2021;18(9):4809. doi:10.3390/ijerph18094809

Zhu

Chen

Guan

, et al Relationship between air pollutants and the incidence of epistaxis in Yangzhou. Ent-Ear Nose Throat. 2024:1455613241249540. doi:10.1177/01455613241249540

Matsumoto

Ishii

Kiuchi

, et al Effect of average relative humidity on epistaxis. Cureus. 2023;15(3):e36063. doi:10.7759/cureus.36063

Akdoğan

Hızal

Semiz

, et al The role of meteorologic factors and air pollution on the frequency of pediatric epistaxis. Ent-Ear Nose Throat. 2018;97(9):E1-E5. doi:10.1177/014556131809700901

Gatsounia

Schinas

Danielides

, et al Impact of atmospheric conditions on epistaxis incidence. Cureus. 2023;15(11):e48390. doi:10.7759/cureus.48390

10.

Sowerby

DeSerres

Rudmik

, et al Role of season, temperature and humidity on the incidence of epistaxis in Alberta, Canada. J Otolaryngol Head Neck Surg. 2014;43:10. doi:10.1186/1916-0216-43-10

11.

Nunez

McClymont

Evans

. Epistaxis: a study of the relationship with weather. Clin Otolaryngol Allied Sci. 1990;15(1):49-51. doi:10.1111/j.1365-2273.1990.tb00432.x

12.

Bray

Giddings

Monnery

, et al

Epistaxis: are temperature and seasonal variations true factors in incidence?

J Laryngol Otol. 2005;119(9):724-726. doi:10.1258/0022215054798032

13.

Gryech

Ghogho

Mahraoui

, et al An exploration of features impacting respiratory diseases in urban areas. Int J Environ Res Public Health. 2022;19(5):3095. doi:10.3390/ijerph19053095

14.

Tran

Tsai

Lee

, et al The impact of air pollution on respiratory diseases in an era of climate change: a review of the current evidence. Sci Total Environ. 2023;898:166340. doi:10.1016/j.scitotenv.2023.166340

15.

Santos

Arbex

Braga

ALF

, et al Environmental air pollution: respiratory effects. J Bras Pneumol. 2021;47(1):e20200267. doi:10.36416/1806-3756/e20200267

16.

Kwak

Kim

Min

. Differential effect of meteorological factors and particulate matter with ≤ 10-µm diameter on epistaxis in younger and older children. Sci Rep. 2022;12(1):21029. doi:10.1038/s41598-022-25630-3

17.

Yonghua

Mehrabi Nasab

Liuo

. Effect of temperature and humidity on the allegro-inflammatory factors and allergic rhinitis-related behavior. Iran J Allergy Asthma Immunol. 2022;21(6):704-710. doi:10.18502/ijaai.v21i6.11531

18.

Chen

Jiang

. Research meteorological environmental factors in children’s allergic rhinitis. J Clin Otorhinolaryngol Head and Neck Surg. 2014;28(14):1015-1019.

19.

Hong

Won

Nam

, et al Clinical manifestations of allergic rhinitis by age and gender: a 12-year single-center study. Ann Otol Rhinol Laryngol. 2020;129(9):910-917. doi:10.1177/0003489420921197

20.

Hsieh

Tseng

, et al Allergic rhinitis: association with air pollution and weather changes, and comparison with that of allergic conjunctivitis in Taiwan. Atmosphere. 2020;11:1152. doi:10.3390/ATMOS11111152

21.

Murray

Milner

. Allergic rhinitis and recurrent epistaxis in children. Ann Allergy Asthma Immunol. 1995;74(1):30-33.

22.

Purkey

Seeskin

Chandra

. Seasonal variation and predictors of epistaxis. Laryngoscope. 2014;124(9):2028-2033. doi:10.1002/lary.24679

23.

Chen

, et al Effect of daily average temperature on the incidence of allergic rhinitis in Lanzhou. Chin J Otorhinolaryngol Head Neck Surg. 2021;56(12):1300-1306. doi:10.3760/cma.j.cn115330-20210330-00158

24.

Zhou

Wang

, et al Study on the multivariate prediction model and exposure level of indoor and outdoor particulate concentration in severe cold region of China. Ecotoxicol Environ Saf. 2019;170:708-715. doi:10.1016/j.ecoenv.2018.12.031

Relationship Between Environmental Meteorological Factors and the Incidence of Epistaxis in Different Age Groups in Yangzhou

Abstract

Keywords

Introduction

Methods

Clinical Data

Environmental Data Collection and Processing

Statistical Analysis

Results

Discussion

Conclusion

Footnotes

Data Availability Statement

Declaration of Conflicting Interests

Funding

Ethical Standards

ORCID iD

References