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latest processes to Epistaxis medication in fundamental and Secondary Care

historical past: The lifetime incidence of epistaxis is about 60%, and 6–10% of the affected people need scientific care. In rare instances, extreme bleeding requires the swift initiation of advantageous remedy.

strategies: This review is based on pertinent articles that were retrieved by using a selective search PubMed, and on the authors’ clinical event.

outcomes: There are no German instructions for the administration of epistaxis. The attainable proof consists primarily of retrospective analyses and professional opinions. sixty five–seventy five% of the patients who require remedy will also be properly cared for by means of their simple care health practitioner or by way of an emergency medical professional with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78–88% of situations with chemical or electrical cauterization. Nasal packing is used if this medication fails, or for posterior epistaxis. In a retrospective look at, surgical treatment became discovered to be more helpful than nasal packing within the treatment of posterior epistaxis (97% versus sixty two% medicine success). Percutaneous embolization is an choice medication for patients whom well-known anesthesia would put at high chance.

Conclusion: The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care general practitioner, the emergency health care provider, the practice-based otolaryngologist, and the medical institution otolaryngology provider. Uniform guidelines and epidemiological reports on this subject matter can be eye-catching.


gentle episodes of epistaxis cease spontaneously or are treated, regularly efficaciously, by way of the simple care surgeon or by means of the emergency medical professional. handiest when nosebleeds are recurrent or extreme are sufferers noted an otorhinolaryngologist or to an accident and emergency branch for additional diagnostic evaluation and treatment. No tenet exists in Germany these days on the remedy of epistaxis. The intention of the existing article is to provide an up-to-date overview of knowledge related to its epidemiology, anatomy, and risk factors. particular recommendations can be given for the medicine of epistaxis at the fundamental and secondary degrees of care.

getting to know dreams

After analyzing this text, the reader may still:

  • Have obtained a generic understanding of the epidemiology, anatomy, and reasons of epistaxis.
  • know probably the most vital primary facets of the medicine of epistaxis.
  • Be frequent with the diagnostic and therapeutic strategies performed via, respectively, conventional practitioners and emergency physicians, otorhinolaryngologists, and ear, nose, and throat (ENT) clinic departments.
  • method

    this article is in response to a selective literature search of the PubMed database, looking for the terms “epistaxis,” “epistaxis anticoagulation,” “epistaxis remedy,” “epistaxis packing,” and “epistaxis embolization” in the title of articles posted between 1 January 2000 and 1 February 2017. Some older regular publications, textbooks, and our own clinical journey were also covered.


    About 60% of the population event a nosebleed at the least once in their life (1). specific epidemiological information on incidence are unavailable, because no epidemiological reports had been performed and best about 6% to 10% of the individuals affected are looking for clinical help (1, 2). In Germany, the handiest correct facts are those gathered by way of emergency departments. One retrospective analyze mentioned an epistaxis incidence of 121 / 100 000 inhabitants treated in two emergency departments in East Thuringia (3).

    in accordance with a retrospective look at from the USA, 1 to 2 out of 200 visits to the emergency department have been as a result of epistaxis, and about 5% of the patients needed to be admitted for inpatient care (four, 5). In Germany, a total of 19 841 sufferers (11 733 male and 8108 female) got inpatient medication for epistaxis in 2015. The common health center live became three.6 days (6). Of those that bought remedy as inpatients, seventy one% were aged sixty five or over, 18% had been between forty five and 65 years of age, 5% were aged from 15 to 45, and 6% were under the age of 15 (6). No figures for treatment of epistaxis via simple care physicians had been posted.


    The arterial deliver of the nasal cavity is shown in figure 1. In 90% to 95% of cases, the bleed occurs anteriorly in the area of the anterior part of the nasal septum, the Kiesselbach area (or Little’s area) (7–10), and in 5% to 10% of cases it occurs posteriorly in the posterior place of the nasal cavity (7, 10, eleven).

    determine 1

    Arterial deliver of the nasal cavity (e34)


    probably the most regular cause of epistaxis is trauma as a result of digital manipulation (nostril choosing) (12). other motives are shown in box 1. In 2014, a scientific overview stated that the majority studies described raised blood force on the time the epistaxis took place. however, these reports were unable to display hypertension to be an instantaneous reason for epistaxis. Confounding stress and, possibly, “white coat syndrome” may have contributed to higher arterial blood force within the surroundings of epistaxis (13). a number of experiences have shown a relative enhance in epistaxis episodes right through cold, dry weather or during periods when there are marked diversifications in air temperature and pressure (14–18).

    box 1

    explanations of epistaxis*

    Ingestion of anticoagulant medication raises the chance of epistaxis (19). About 24% to 33% of all patients hospitalized for epistaxis take anticoagulants and/or antiplatelet drugs (20, 21). Ingestion of acetylsalicylic acid raises the severity and number of recurrences of epistaxis and the need for surgical intervention (22, 23). A retrospective cohort look at in Zurich, Switzerland, confirmed ingestion of diet ok antagonists to be an independent and demanding chance ingredient for recurrent epistaxis with an odds ratio (OR) of 11.6 (23). Prescription of direct oral anticoagulants for sufferers is increasing (24). there's at the moment a paucity of statistics regarding this group of medication relating to epistaxis.

    One prospective observational study showed a discount in the number of circumstances of extreme epistaxis in sufferers taking dabigatran versus diet okay antagonists. medical institution live was longer for dabigatran sufferers, however, since the lack of an effectively accessible coagulation examine and chronic oozing after elimination of packing made it vital to maintain the sufferers under continued remark (25). One retrospective look at of epistaxis in patients taking rivaroxaban confirmed a lower percentage of inpatient admissions (10.four% versus 18.0%, p = 0.033) and shorter hospital live (0.7 ± 2.2 versus 1.5 ± three.7 days, p = 0.011) in evaluation to sufferers taking vitamin k antagonists (26). a different risk aspect identified become alcohol (14–16). One randomized, managed, double-blind analyze showed that steroid nasal sprays boost the possibility of epistaxis inside 365 days in comparison to placebo from 8% to 20%. The nosebleeds that occurred had been mild to average; simplest 1 of 605 patients suffered a severe nosebleed inside twelve months (27). In a meta-evaluation of randomized, controlled reports, epistaxis become said to be essentially the most regularly occurring undesired impact of PDE-5 inhibitors, with a relative risk of 4.701 (95% self assurance interval [95% CI]: [1.314; 16.812], p = 0.017) (28).

    treatment of epistaxis

    No uniform instructions exist for diagnostic and therapeutic tactics in patients with epistaxis. however, clinically tried and confirmed medicine paths do emerge in hospitals and doctors’ places of work, based mostly largely on retrospective analyses, case sequence, and skilled opinion. simplest few potential or randomized managed stories are available for some discrete areas of epistaxis medicine.

    Epistaxis tiers from mild nosebleeds that are effortless to control using fundamental how one can life-threatening bleedings that require clinic admission and might even need surgical treatment.

    For a structured overview of the interdisciplinary management of epistaxis, in this article medication strategies are given separately for level 1 (basic care doctor/emergency health care professional), degree 2 (otorhinolaryngologist), and level three care (health facility ENT department). figure 2 shows the remedy algorithm developed with the aid of ourselves, which includes medication strategies from the foreign literature in addition to our department’s personal in-condominium general operating tactics. Some steps are important at all three degrees of care.

    figure 2

    treatment algorithm

    infection control

    Measures to steer clear of infection must all the time be followed. it's recommended that every one who've close contact with sufferers, e.g., at some point of rhinoscopy or endoscopy, should still put on shielding eye gear, lab coat, gloves, and a face mask (12).

    initial assessment of respiration and hemodynamics

    exceptionally in cases of extreme bleeding, following the ABC method, security of the airway, respiratory, and cardiovascular steadiness should be assessed (29–31). If signs of hypovolemia are found, a peripheral venous entry should be positioned and quantity replacement remedy started. Early blood power measurement is a necessary a part of the diagnostic process.

    heritage taking

    essentially the most essential parts of the heritage are first of all the intensity and direction over time of the bleed, which allow a judgment to be made about the urgency of remedy (29). The patient may still be asked about components that could predispose to epistaxis (packing containers 1, 2) (12, 29). a crucial element of the historical past is what medicine the affected person is on, chiefly any anticoagulants or antiplatelet medicine (container 2) (29).

    container 2

    scientific medicine associated with epistaxis*

    Blood checks

    in many circumstances of easy epistaxis, no blood tests are required. If the patient is on anticoagulation remedy, however, coagulation checking out with international Normalized Ratio (INR) measurement should be conducted.


    Imaging isn't constantly quintessential. despite the fact, in sufferers with recurrent epistaxis of unknown trigger, imaging should still be carried out to examine the possibility of neoplastic ailment such as juvenile nasopharyngeal angiofibroma (32).

    administration of patients on anticoagulants

    In France, guidelines on the administration of epistaxis in sufferers taking anticoagulants have existed due to the fact that 2016 (33). In acute epistaxis, these advocate screening for overdose and evaluation of the risk of thrombosis. Anticoagulation remedy may still always be persevered so long as the bleeding will also be stopped or controlled. best if bleeding is large and unstoppable, or if an anticoagulation overdose is found, should adjustment of the anticoagulation therapy be considered in consultation with a hematologist and cardiologist.

    Antiplatelet medication

    because it takes up to 10 days for hemostasis to be restored after cessation of antiplatelet remedy, stopping antiplatelet drugs in a patient with acute epistaxis isn't beneficial. If the bleeding cannot be halted, stopping antiplatelet remedy while at the same time giving platelet transfusions is an alternative (33).

    nutrition ok antagonists

    For a sufferers taking a vitamin k antagonist, the drug should be stopped and an antidote given best if the bleeding is uncontrollable. If the diet k antagonist has been overdosed and the bleeding may also be controlled, the dosage may still be altered (33).

    Direct oral anticoagulants

    Stopping treatment with direct oral anticoagulants is recommended handiest after consultation with a cardiologist. If bleeding is uncontrolled, dabigatran is the best drug for which an antidote (idarucizumab 5 mg in two consecutive 5– to 10-min intravenous infusions) is presently available (33).

    Anticoagulation treatment should no longer be altered in a patient about to endure endovascular embolization (knowledgeable opinion) (33).

    fighting recurrence

    To stay away from recurrences, intensive care of the nasal mucosa using an antiseptic nasal cream is advised. A prospective, randomized, managed study in the uk in toddlers with recurrent epistaxis in comparison medication with an antiseptic cream for 4 weeks versus a wait-and-see coverage. A vastly lessen recurrence rate become seen in the treatment group (45% versus seventy one% recurrence rate, relative risk discount 47% with 95% CI [9%; 69%]) (34). furthermore, energetic nostril blowing should be prevented for 7 to 10 days (29). bed rest isn't fundamental. in accordance with a Danish prospective, randomized examine, mobilizing the affected person does not raise recurrence in assessment to mattress relaxation (35).

    remedy by using the fundamental care surgeon and/or emergency health care provider

    the 1st step is to compress either side of the nose invariably for 15 to twenty min, the usage of two fingers or a nostril clip (29, 36, 37). The patient may still take a seat upright and lean a bit of forward to steer clear of the blood from operating down the pharynx (12). native application of ice, e.g., at the back of the neck, is meant to encourage vasoconstriction of the blood vessels of the nose. Its therapeutic price is a count number of debate and has been challenged within the literature (19, 38). No final conclusion can be drawn on the basis of latest publications. In sufferers with raised blood power that is not causing indicators (>a hundred and eighty/120 mmHg, measured a number of instances), the european Society of Hypertension and the ecu Society of Cardiology advocate oral remedy to in the reduction of the blood force. The intention is to slowly reduce the blood drive over a duration of 24 to 48 hours (39, forty). In round sixty five% to 75% of instances, these steps mixed with application of a decongestant, oxymetazoline-based mostly nasal spray will succeed in stopping the bleeding (e1, e2). If bleeding does not restart all the way through a 30-min statement duration and the affected person is hemodynamically stable, emergency specialist ENT remedy is not required.

    in the presence of any of here, we recommend consultation with an otorhinolaryngologist:

  • Epistaxis uncontrollable with the aid of the measures described above
  • Recurrent epistaxis
  • Suspected neoplasm as the source of the bleed
  • medication with the aid of an otorhinolaryngologist

    Anterior rhinoscopy

    To locate the source of the bleeding, the primary investigation is anterior rhinoscopy with a nasal speculum and headlight (29). once any clots have been eliminated by means of suction or with pincers, the nasal cavity can be inspected, including the Kiesselbach enviornment, where the bleeding commonly originates. application of a vasoconstrictor and local anesthetic, e.g., within the kind of an impregnated cotton tuft, will permit a more robust view. as a result of the local anesthetic impact, this step has therapeutic as well as diagnostic cost (12, 30, 36).


    primarily in cases where the bleeding is from the posterior nasal cavity, finding the supply of the bleeding by using anterior rhinoscopy is difficult. In such circumstances, the French guidelines on treating epistaxis suggest as a supplementary method inflexible endoscopy of the nasal cavity by way of a physician experienced in endoscopy (30, 36). Two prospective studies have proven that 80% to ninety four% of bleed sources may also be identified by means of endoscopy (eleven, e3).


    Most situations of epistaxis from an easily visible anterior supply may also be readily treated by cauterization with silver nitrate or electrocoagulation. before beginning the procedure, a vasoconstrictor and local anesthetic should still be utilized (30). determine three shows a bleeding from the Kiesselbach area earlier than and after bipolar coagulation. A Swiss retrospective look at confirmed that in terms of therapeutic success, electrocoagulation became advanced to chemical coagulation (88% versus 78%) (failure expense 12% with 95% CI [0.09; 0.16] versus 22% with ninety five% CI [0.14; 0.33]) (evidence level 2b) (e4). A US study of toddlers treated intraoperatively by way of these equal two strategies for recurrent anterior epistaxis also discovered a lower recurrence expense for electrocoagulation than for chemical cauterization all the way through the 2-12 months period after the system (recurrence hobbies 2% versus 18%) (e5). Chemical cautery is described as less difficult to make use of, more cost-effective, and greater broadly available (e6). complications of cauterization include septal perforation, infection, rhinorrhea, and improved bleeding (12). Bilateral cautery within the area of the nasal septum should be averted if viable, as this hazards septal perforation (e7). There aren't any published reviews on the incidence of septal perforation after cautery (e8, e9).

    figure 3

    Bleeding in the Kiesselbach area (right aspect) before and after bipolar cautery

    Hemostatic gauze

    As a complement to cautery, local application of gauze manufactured from oxidized regenerated cellulose will also be used. As a resorbable hemostyptic, it helps physiological hemostasis. Diffuse mucosal bleedings in certain can commonly be appropriately managed by means of the application of a thin layer of this gauze (e10).

    Nasal packing

    If cauterization is unsuccessful, the subsequent step in managing epistaxis is nasal packing. Packing takes distinctive types for anterior and posterior bleeding. Bilateral nasal packing produces an improved intranasal pressure than unilateral packing and its apply is hence widespread, despite the fact there is little facts to help this (e11)

    complete overviews of the elements and mechanism of action of probably the most usual types of nasal packing are introduced with the aid of Beule et al. of their 2004 book (e12) and via Weber in his 2009 evaluate article (e 10). The eFigure indicates a range of gadgets in typical use for nasal packing. The leading nasal packing items used in Germany are rubber-lined sponge packs or tampons (Gummifingerlingstamponaden), expandable sponge packs, and ribbon gauze impregnated with a clinical cream (e12) (for greater details see eBox 1).

    eBox 1

    Overview of essentially the most time-honored nasal packing materials


    preference of nasal packing products in ordinary use

    problems of nasal packing—probably the most serious complication of nasal packing is posterior dislocation. studies were published of fatal aspiration of nasal packs (e13). Rubber-covered sponge tampons and cotton ribbon gauze packs are liable to dislocate (e10). To avoid this, all nasal packs need to be strongly fastened to the affected person’s face, e.g., with sticking plaster on the bridge of the nostril or the cheek (e7, e12). additionally, the threads attached to some packs should be tied together in front of the columella. different mentioned problems consist of allergic reaction, mucosal necrosis, overseas physique response, tube dysfunction, paraffinoma, and decompensation of pre-current sleep apnea (e7, e10, e12). Nasal packing can additionally trigger discomfort for the patient within the sort of ache, obstructed respiratory, and a decreased feel of odor (e10). moreover, bilateral nasal packing may end up in impaired pressure equalization by means of the auditory (Eustachian) tube, resulting in the patient’s discomfort as a result of poor power within the center ear (e10). There were case reports of staphylococcal toxic shock syndrome as a serious complication (e14–e16). The unlock of poisonous shock syndrome toxin 1 (TSST1) causes symptoms reminiscent of vomiting, diarrhea, fever, myalgia, diffuse erythema, and even septic shock. treatment contains immediate removing of the packing, intravenous antibiotics, and transfer of the affected person to an intensive care ward (e10).

    Prophylactic antibiotics—The role of prophylactic administration of antibiotics with nasal packing has no longer been competently studied. wide adaptation in observe has been described in England (e17), e.g., prophylactic antibiotics in sufferers with cardiac anomalies, primarily prosthetic heart valves (30). Like every other authors, with anterior nasal packing we advocate prophylactic antibiotics best after the packing has been in region for more than 48 hours, however with posterior packing we advocate it in all situations, with the purpose of fighting migration of an infection into the sinuses and core ear and poisonous shock syndrome (e18). preferred antibiotics are amoxicillin–clavulanic acid, amoxicillin alone, and cephalosporins (e17).

    removing of packing—When to get rid of the packing is variously described in the literature, ranging from 12 or 24 hours to 3 to 5 days after placement (12, 29, 30). For anterior packing by myself, we suggest elimination after 48 hours. the place a nasopharyngeal balloon has also been positioned, this should still be at the least partly deflated after 24 hours at the latest. If clinically tremendous bleeding starts once again after packing removal, we advise surgical remedy the place viable.

    medicine in the ENT branch

    From the element of view of the ENT branch, for both unilateral and bilateral packing, inpatient admission for statement and packing elimination are counseled because of the possibility of posterior dislocation.

    different signs for inpatient admission are shown in determine 2.

    Surgical remedy

    When conservative medicine fails, surgical hemostasis is commonly required. A Swiss retrospective cohort study showed surgical intervention to be markedly sophisticated to packing in the management of posterior epistaxis (remedy failure cost 3% [0.00; 0.14] versus 38% [0.30; 0.67]) (e4).

    The formulation of choice is endoscopic clipping or coagulation of the sphenopalatine artery (e19). A British look at reviewed the evidence for endoscopic sphenopalatine artery ligation and compared it to alternate methods. the previous proved to be sophisticated to the other medicine strategies (monopolar cautery, embolization, and many others.), controlling the bleeding in ninety eight% of situations (e20). In retrospective cohort experiences, recurrence of bleeding, intranasal dryness with crust formation, sinusitis, impaired nasal and palatal sensitivity, formation of intranasal synechiae, unilateral persistent epiphora, and septal perforation have all been said as problems. One Brazilian retrospective longitudinal look at mentioned a case of amaurosis after the intervention (e21). Taken collectively, these stories show endoscopic sphenopalatine artery ligation to have few problems (e21–e25). Clinically significant hypoxia of the territory provided via this artery has no longer been described and is not anticipated, given the multiplicity of anastomoses between the sphenopalatine and ethmoidal arteries (9). for this reason, the standards for surgical medicine can be rather extensive: recurrence of bleeding after one attempt at packing and the place the supply of the bleeding is not evident (e19). Surgical hemostasis (eBox 2) may still even be regarded early on in patients with persistent bleeding despite packing. Endoscopic ligation of the anterior ethmoidal artery is indicated ordinarily in the context of revision surgical procedure. In four retrospective stories, approximately 2.9% to eight.6% of all sufferers present process surgery for extreme epistaxis had anterior ethmoidal artery ligation (e21–e23, e26).

    eBox 2

    Operative tactics


    a further possible method in patients with epistaxis this is difficult to manage is percutaneous embolization. This method has a stated success fee of 87% to 93% (e27–e29). The target vessel is imaged angiographically and then an occluding agent is injected by means of a percutaneous transarterial catheter (e30). The embolization should still be carried out by an skilled interventional neuroradiologist (e31). as a result of the capabilities for issues akin to cerebrovascular ischemia, facial nerve paralysis, and smooth tissue necrosis, some authors suggest the usage of this approach simplest in sufferers who have an extended anesthetic risk on account of other comorbidities, or in whom tried surgical medicine has failed (30). One retrospective move-sectional look at within the US in comparison embolization with surgical vascular occlusion in terms of morbidity, hospital mortality, and duration of health facility dwell. No huge ameliorations were found in relation to blood transfusions (22.8% versus 24.3%), stroke (0.5% versus 0.three%), amaurosis (0.four% versus 0.5%), and health center mortality. although, surgery is associated with decrease medical institution fees and a shorter clinic stay (e32).

    medicine of epistaxis in infants

    a top level view of recommended medication strategies in epistaxis in toddlers is given in a French systematic assessment through Béquignon et al. (e33). apart from removing of clots, bidigital compression, and (permissible from the age of 6 onwards) application of a local anesthetic and decongestant, the use of an antiseptic cream is counseled (e33). If bleeding persists, chemical cautery (silver nitrate stick) may still be favored to electrical cautery, as electrical cautery is extra painful and would for this reason require a popular anesthetic (e33).

    Conclusions for scientific follow

    In sixty five% to 70% of situations of epistaxis, elementary first aid measures offered through the simple care doctor or emergency physician stop the bleeding. If bleeding -persists, professional ENT knowledge should still be urgently consulted. as long as the supply of the bleeding is seen, most instances of epistaxis can be effectively handled the usage of electrical or chemical cautery. In circumstances the place the bleeding source is posterior, or where the bleeding continues to be refractory to packing, surgical procedure may still be considered early on and liberally. because of its high success fee and comparatively low complication expense, endoscopic ligation or coagulation of the sphenopalatine artery is the components of option. In circumstances of extreme epistaxis, where surgical treatment fails or the patient has a excessive anesthetic risk, percutaneous embolization is an affordable option.

    EpidemiologyThe lifetime incidence of epistaxis is 60%. most effective about 6% to 10% of those affected are seeking scientific support.

    AnatomyIn 90% to 95% of instances of epistaxis, the supply of the bleed is in the area of the anterior part of the nasal septum, the Kiesselbach enviornment (Little’s enviornment).

    CausesThe most conventional reason behind epistaxis is trauma because of digital manipulation.

    TreatmentThe treatment of epistaxis requires a structured interdisciplinary method with the aid of the simple care doctor, emergency health professional, otorhinolaryngologist, and clinic ENT branch.

    illness controlIt is suggested that every one who have close contact with patients, e.g., throughout rhinoscopy or endoscopy, should still put on shielding eye equipment, a lab coat, gloves, and a face masks.

    patients on anticoagulantsIf the bleeding may also be stopped or controlled, anticoagulation therapy should still be persevered. handiest if bleeding is large and unstoppable, e.g., due to anticoagulation overdose, should still adjustment of the anticoagulation therapy be considered.

    Direct oral anticoagulantsStopping medication with these medication is recommended handiest after session with a heart specialist. If bleeding is uncontrolled, dabigatran is the best drug for which an antidote is at present purchasable.

    medicine by way of the basic care health professional and/or emergency physicianImportant primary measures are compression of the nostrils, oral treatment to cut back blood power if applicable, and use of an oxymetazoline nasal spray.

    medication by an otorhinolaryngologistFor anterior epistaxis, the treatment of alternative is bipolar coagulation. the place bleeding is persistent or from a posterior supply, the first step is nasal packing.

    Nasal packingThe leading nasal packing products used in Germany are rubber-lined sponge packs, expandable sponge packs, and ribbon gauze impregnated with a medical cream.

    complications of nasal packingPosterior dislocation, allergic reaction, mucosal necrosis, international body response, tube dysfunction, paraffinoma, decompensation of pre-present sleep apnea, and staphylococcal poisonous shock syndrome.

    medicine in an ENT departmentFor posterior epistaxis, surgical intervention is markedly advanced to packing. The formulation of option is endoscopic clipping or coagulation of the sphenopalatine artery, which controls the bleeding in 98% of situations.

    EmbolizationWhere surgical medicine fails or the patient has a excessive anesthetic chance, percutaneous embolization is an affordable alternative.

    medicine of childrenIn a toddler with persistent bleeding, chemical cautery (silver nitrate stick) may still be favorite to electrical cautery, as electrical cautery is greater painful and would therefore require a customary anesthetic.

    battle of hobby commentary

    The authors declare that no battle of interest exists.

    Manuscript got on 15 may also 2017, revised version authorized on17 October 2017.

    Translated from the long-established German by way of Kersti Wagstaff, MA.

    Corresponding authorProf. Dr. med. Andreas DietzKlinik und Poliklinik für Hals-, Nasen-, OhrenheilkundeLiebigstr. 10–14,04103 Leipzig, Germanyandreas.dietz@medizin.uni-leipzig.de

    ►Supplementary materialFor eReferences please confer with:www.aerzteblatt-foreign.de/ref0118

    eBoxes, eFigure:www.aerzteblatt-foreign.de/18m0012


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    * both authors contributed equally to this paperDepartment of Otolaryngology, tuition of Leipzig: R. Beck,Dr. med. Sorge,Prof. Dr. med.DietzInstitute of normal practice, Klinikum rechts der Isar der TU München: Prof. Dr. med. Schneider


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