A Clinical Study on Etiological Factors and Management of Epistaxis at a Tertiary Level Hospital

Abstract

Background: Epistaxis is a common otolaryngological emergency worldwide affecting up to 60% of the population in their lifetime. This study was conducted to describe the etiological profile and treatment outcome of epistaxis at Dhaka Medical College Hospital, a tertiary care hospital in BANGLADESH. Objective: The study is carried out with an objective to evaluate on etiological profile and management of epistaxis. Methods: This cross sectional study was conducted among the emergency and admitted patient with epistaxis at Dhaka Medical College Hospital from 1 November 2013 to 30 April 2014. Results: During the period under study, a total 104 patients were studied. The etiology of the cause of epistaxis was grouped into traumatic and nontraumatic. Among them 46 (44.23%) patient were in traumatic epistaxis and 58 (55.77%) patient were in non traumatic epistaxis. Male were affected more frequently than female in this study. There were 74 (71.15%) male and 30 (28.85%) females with a male female ratio of 2.47:1 Majority of the patients in this study were in 2 decade (21.15%) followed by 6 decade (19.23%) and 3 decade (17.31%). Among the 104 patients with epistaxis 78 (75%) were urban habitat and 26 (25%) were rural habitat. Significantly more patients were from urban resident. Regarding etiology and sex distribution there were no significant differences between urban and rural habitat. The present study shows that the most common cause of epistaxis was trauma (44.23%) followed by idiopathic (25%) and hypertension (17.31%). Local pain (41.31%), nasal obstruction (13.04%), 1 Medical Officer, National Institute of ENT, Tejgaon, Dhaka. 2 Medical Officer, Dept. of Otolaryngology and Head-Neck Surgery, BSMMU, Dhaka. 3 Resident Surgeon (ENT), Dept. of Otolaryngology and Head-Neck Surgery, DMCH, Dhaka. 4 Assistant Registrar, Dept. of Otolaryngology and Head-Neck Surgery, DMCH, Dhaka. 5 Assistant Prof.(ENT), National Institute Of Ophthalmology & Hospital, Dhaka 6 Professor of ENT and Line Director Medical Education & Health Manpower Development, DGHS, Dhaka. 7 Professor & Ex-Head, Dept. of Otolaryngology and Head-Neck Surgery, DMCH, Dhaka. Address of Correspondence: Dr. Rashedul Islam, Medical Officer, National Institute of ENT, Tejgaon, Dhaka. Mob:+88-01718033316, E-mail: irashedul2532@gmail.com Introduction: Epistaxis, active bleeding from the nose, is a common ear, nose and throat emergency and can be severe or even fatal. The causes can be from local or systemic illness. Epistaxis is classified as anterior or posterior on the basis of the primary bleeding site. Haemorrhage is most commonly anterior, originating from the nasal septum. A common source of anterior epistaxis is the kiesselbach’s plexus, an anastomotic network of vessels on the anterior portion of the nasal septum. Epistaxis occurs in up to 60% of general population at some point in their life time. About 6% of these people will seek medical attention. Usually it is spontaneous and stops by itself or may be controlled with home remedies. However at times it could be massive and may be fatal. The etiology of epistaxis is divided into local and systemic causes. Local causes: Inflammatory-infectious (rhinitis, rhinosinusitis) , traumatic (digital, fractures, nasal surgeries), anatomic (Septal deviation and perforation), foreign body, chemical or Climatic agents, and nasal tumors (nasopharyngeal angiofibroma , nasal polyposis, inverted papilloma, carcinoma). Systemic causes: The arterial hypertension in the most frequently associated clinical factor, blood dyscrasis, drugs (acetylsalicylic acid, anticoagulants, non hormonal antiinflammatory, antibiotics), neoplasms etc. It is important to find the bleeding site and define its etiology (local or systemic) for indication of the best treatment. The severe epistaxis, associated to prevailing factors such as systemic arterial hypertension and coagulopathy may need a surgical approach in the cases refractory to conservative treatment, such as cauterization and nasal splint. Traumatic epistaxis is more common in younger individual (under age 35 years) and is most often due to digital trauma, facial injury, or a foreign body in the nasal cavity. Non-traumatic epistaxis is more nasal deformity (17.39%) associated other injury (13.04%) was more frequent in traumatic patient. Significant raise of blood pressure (Systoloic BP >160 mm Hg and diastolic BP > 100 mm Hg) were found in 58 (55.77%) non-traumatic patient. Severity of the nasal bleeding was mild to severe degree in both the groups. Significantly anterior epistaxis is common among the traumatic epistaxis group (69.57%) and posterior epistaxis in non-traumatic epistaxis group (46.55%). About 27.59% patient the exact site was not detected as there was diffuse bleeding. In case of nasal bleeding, bleeding from septum 42 (40.38%), from lateral wall 32 (30.76%) and from floor of the nose 23 (22.15%). Control of bleeding by the direct method was possible in 11 (10.57%) patients. Anterior nasal packing was given in 86 (82.69%) patients and post nasal packing was given in 3 (2.89%) patients. Conclusion: A high incidence in young adults was reported with preponderance of males over females. Occurrence of different types of epistaxis was strongly related with the certain demographic factors like age, sex and habitat of the patient. This study supports the credibility of conservative management procedure in the treatment of epistaxis. Simple nasal packing is the commonly practice conservative method with high success. Hence, this approach should be the preferred option in the management of epistaxis especially in developing countries.