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A clinical study of epistaxis

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DOI: 10.18203/issn.2454-5929.ijohns20180724

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International Journal of Otorhinolaryngology and Head and Neck Surgery
Sampigethaya S et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):555-558
http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20180724
Original Research Article

A clinical study of epistaxis

Sawanth Sampigethaya*, Elizabeth Cherian, Deepika Pratap,
Ivan Mani, Vadisha Srinivas Bhat

Department of ENT, KS Hedge Medical Academy, Mangaluru, Karnataka, India

Received: 29 December 2017

Revised: 09 February 2018
Accepted: 10 February 2018

*Correspondence:
Dr. Sawanth Sampigethaya,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Epistaxis is one the common emergencies in Oto-rhino-laryngology. It may occur in any age and in
either gender. Cause of epistaxis range from simple self-limiting condition to more sinister malignancy which needs a
radical approach. Hence, one should evaluate these patients appropriately and identify the cause to treat them
accordingly. The present work was undertaken with the aim of studying the demographic profile of patients with
epistaxis, its causes and management.
Methods: The present study consisted of 60 patients who came with complaint of epistaxis. The patient’s detailed
history was obtained. Detailed systemic examination and ENT examination was performed on patients in the study.
Patients were investigated and treated as per the standard hospital protocol.
Results: Out of the total 60 cases of epistaxis, 65% were males and 35% were females. Most of our cases were aged
more than 50 years (31.7%) with mean age of 38.56 years. Most common etiology of epistaxis in present study was
hypertension (20%), followed by acute rhino-sinusitis (15%). Commonest cause in children was deviated nasal
septum and acute rhinosinusitis while in young adults, trauma was the common cause. Most common cause in elderly
was hypertension. Medical management was done in most of the cases (65%) while anterior and posterior packing
was done in 20% and 10% cases respectively. Three cases underwent electro-cauterization of bleeding point.
Conclusions: Epistaxis can be seen in anyage. However the etiology of this condition varies with age. Understanding
of the etiology helps in better evaluation and treatment of the case.

Keywords: Epistaxis, Etiology, Hypertension, Acute rhinosinusitis

INTRODUCTION either anterior or posterior. Anterior epistaxis is bleeding

from a source anterior to the plane of piriform aperture
Epistaxis is defined as bleeding from the nose. It is the and posterior epistaxis is from vessel posterior to this
most common oto-rhino-laryngological emergencies plane. In general, posterior epistaxis occurs in older
worldwide and affects 60% of the population in their life patients who have fragile vessels because of
time, though only 6% of them require medical attention. hypertension, atherosclerosis, coagulopathies or
This condition is common in childhood and becomes less weakened tissue. Key areas of epistaxis are the Little’s
in adult life, again showing a peakin 6th decade. Between area and the ‘Woodruff’s plexus. Little’s area lies in the
70-80% of all cases of epistaxis are idiopathic.1 antero-inferior part of septum supplied by the kiesselbach
plexus which is a common site of anterior epistaxis in
Clinical classification of epistaxis is based on the patterns children and young adults.2Woodruffs plexus is located
of presentation of epistaxis. It is broadly classified as on the posterior aspect of the lateral nasal wall just

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 Sampigethaya S et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):555-558

inferior to the posterior end of inferior turbinate; gives past history was seen in 58.3% cases. Most common
rise to posterior epistaxis in adults.3 etiology of epistaxis in present study was hypertension
(20%), followed by acute rhino-sinusitis (15%). Other
Epistaxis results from a multitude of causes, both local common causes included: trauma (10%), septal spur
and systemic. Common local causes are Trauma, (8.3%), infected polyp (8.3%), nose picking (8.3%), sino-
Infections, Foreign bodies, Deviated nasal septum and nasal papilloma (5%) and nasopharyngeal carcinoma
Neoplasm. General causes are Hypertension, blood (5%). No cause was identified in 8.3% cases (Table 2).
dyscrasias, chronic liver disorders, chronic kidney Commonest cause in children was deviated nasal septum
diseases, overuse of salicylates and anticoagulants.2 and acute rhinosinusitis; in young adults trauma was the
common cause. Most common cause in elderly was
The management of epistaxis starts with resuscitative hypertension.
measures in conjunction with assessment by history
taking and clinical methods. Both conservative and Table 2: Etiology of epistaxis in the present study.
surgical modalities have been used in treatment of
epistaxis. Conservative management includes local Etiology Cases (n=60) %
cauterization of bleeding site, anterior and posterior nasal Hypertension 12 20.0
packing. Surgical approaches include arterial ligation Acute rhino-sinisutis 9 15.0
techniques, nasal septal surgery and arterial Trauma 6 10.0
embolization3. Inflammatory polyp 5 8.3
Septal spur 5 8.3
The present work was undertaken with the aim of Nose picking injury of
studying the demographic profile of patients with 5 8.3
septum
epistaxis, its different etiologies and management.
Naso pharyngeal carcinoma 3 5.0
Sino nasal papilloma 3 5.0
METHODS
Rhino-sporidiosis 2 3.3
This is an observational study was conducted in K S Allergic fungal sinositis 1 1.7
Hegde Hospital, Mangalore, from October 2014 to Haemangiomatous polyp 1 1.7
September 2016, where 60 consecutive patients with Capillary hemangioma of
1 1.7
complaint of nasal bleeding were studied, after written septum
informed consent. The consent was obtained from the Alcoholic liver diseases 1 1.7
parent if the patient is a minor. Approval from Drug induced 1 1.7
institutional ethics committee was obtained before Idiopathic 5 8.3
conducting the study.
Medical management without packing was done in most
The patient’s detailed history about the onset, site of of the cases (65%) while anterior and posterior packing
epistaxis and any predisposing factors was obtained. was given in 20% and 10% cases respectively. Three
Detailed systemic examination and ENT examination cases required electro-cauterization of bleeding point
performed. Investigatons and treatment undertaken was (Table 3).
noted. The observations were tabulated and analysed. The
results obtained were represented as frequency and Table 3: Management of epistaxis cases.
percentage.
Management Cases (n=60) %
RESULTS Medical (without packing) 39 65.0
Anterior/ Posterior Packing 18 30.0
Out of the total 60 cases of epistaxis, 40 were males and Electrocautrization 3 5.0
20 were females (Table 1).
DISCUSSION
Table 1: Gender distribution of study subjects.
Epistaxis is estimated to occur in 60% of population
Gender Number Percentage (%)
worldwide during their lifetime, and about 6% of those
Male 40 65 with nose bleeds seek medical treatment.4-8 The present
Females 20 35 hospital based observational study was thus planned to
observe the clinical profile of patients with epistaxis, its
Most of our cases were more than 50 years of age varied etiologies and management strategies.
(31.7%) with mean age of 38.56 years. Anterior epistaxis
was observed in 73.3% cases while in 26.7% cases In our study, most of the cases were aged more than 50
bleeding were from posterior compartment. Past history years (31.7%) followed by 21-30 years of age (20%). The
of nasal bleeding was given by 23.3% cases, and 18.3% mean age of study participants was 38.56 years. Study of
cases were known cases of hypertension. No significant

International Journal of Otorhinolaryngology and Head and Neck Surgery | March-April 2018 | Vol 4 | Issue 2 Page 556
 Sampigethaya S et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):555-558

literature suggests that prevalence of epistaxis is more for nose (8.3%), papilloma (5%), nasopharyngeal carcinoma
children less than 10 years of age and then rises again (5%) and fungal infections (5%). No causes was
after the age of 35 years of age.8 In a review by Gilyoma identified in 8.3% cases. Hypertension being the
et al, epistaxis was found to be more prevalent in the commonest cause in this study shows epistaxis results
young adults <40 years, which is also in agreement with from poor blood pressure control. Much greater role has
Eziyi et al.9,10 Varshney and Saxena in an Indian study been attributed to hypertensive etiology in epistaxis in
reported most of their patients to be around 40 years.11 In Indian, as well as a Thai study.11,20 The need for regular
a study by Jain et al. most common age group affected in blood pressure check-up in epistaxis patients and due
epistaxis was 31-40 years.12 In another study by Pandey address to hypertension is thus emphasized. Chaiyasate et
D et al., ages of patients ranged from 5 year to 72 years, al. reported hypertension to be the commonest cause of
with mode 34 years.13 Similar results were also observed epistaxis followed by idiopathic causes.21 Varshney and
by Shah et al, where mean age was 32.24±12.54 years (4 Saxena from India reported that hypertension and
to 82 years).14 The increased incidence of epistaxis in arteriosclerosis is the leading cause of epistaxis followed
younger age is because of sports injuries and road traffic by trauma.11
accidents due to their aggressive life style. On the other
hand, the increased incidence in old age is likely to be In a study by Shah et al, most common cause of epistaxis
due to vascular pathologies, hypertension and was trauma followed by hypertension.14 Trauma is the
malignancy. commonest etiology for epistaxis as shown in various
other studies of developing countries.12,13,18 This trauma
In present study, 65% of the cases of epistaxis were varied from minor injury such as digital trauma to nasal
males while 35% were females. Generally, males are injury from road traffic injury. The nose is highly
more affected than females until the age of 50, but after susceptible in craniofacial injury. Most of our patients
50, there was no difference between sexes in the with epistaxis from trauma were actually victims of RTA.
literature.5,7,8 In a study by Shah et al, epistaxis was found Trauma being a common cause of epistaxis can partly
to affect more males than females, with a male to female explain the frequency of this problem in males.
ratio of 1.8:1.14 Jain et al also observed that males are
affected more than females, with a male to female ratio of The management of epistaxis is summarized as follows:
2.9:1.12 This male preponderance has also been found in resuscitate the patient, establish the bleeding site, stop the
other studies.15,16 bleeding and treat the cause12. Dealing with a patient
with active severe epistaxis can be bloody. The universal
In present study, we found that anterior epistaxis was precautions for all health care personnel involved in the
more common than posterior (73.3% vs 26.7%). These care of these patients is thus recommended. The goal of
findings are in tandem with existing literature.15,17 treatment include: hemostasis, short hospital stay, low
Anterior epistaxis arises of damage to Kesselbachs plexus complication rate and cost effectiveness.14,21 Treatment
at lower part of anterior nasal septum. Posterior epistaxis modalities can be separated as: non-surgical/
arises from damage to posterior nasal septal artery.18 In a /conservative and surgical/ interventional approaches.
study by Shah et al. anterior epistaxis was more common Non-surgical approach has been reported to stop the
(69.29%) than posterior type (21.05%).14 bleeding in more than 80-90% of cases.21 In present study
medical management was done in most of the cases
Pandey et al in their study also observed that anterior (65%) while packing was required in 30% cases (20%
nasal bleed occurred in 37 of 42 cases.13 In a similar anterior and 10% posterior). Electro-cauterization was
study by Jain et al, 92.2% had anterior nasal bleeding, done in 3 (5%) cases. In 39 (65%) cases with medical
3.3% had posterior bleeding and the remaining 4.4% management, anti-hypertensive drugs were started in 12
patients had non-identifiable bleeding sites.12 patients (30.7%). Injection Vitamin K was required in 5
(12.8%) cases and was given for an average duration of 3
Past history of nasal bleeding was seen in 23.3% of our days while Tranexamic acid was required in 6 (15.4%)
cases. About 56% of the cases of epistaxis had a positive cases for an average duration of 4 days. Decongestant
history of nasal bleed in a study by shah et al.14 Past drops were prescribed for 9 (23%) cases. Other drugs
history of bleeding was also given by 55.6% of patients given were anti-histaminics (43.5%) and antibiotics
in a study by Bhatta et al.19 Differences in our findings (33.3%).
may be due to such patients having past history of
epistaxis and having minimal and infrequent symptoms, Anterior nasal packing was done in most patients. Those,
may have opted for home based remedial measures of requiring posterior packing were all hypertensive cases.
cases with severe disease may have opted for consultation As adjunct to nasal packing, the normotensive patients
at private hospitals. This could also be due to the were prescribed nasal decongestants. The packs were
relatively small study sample. soaked in antibiotic for local effect as otherwise infection
is likely. Systemic prophylaxis with antibiotic was also
Most common etiology of epistaxis in present study was provided. When bleeding points were visualized,
hypertension (20%), followed by acute rhino-sinusitis electrocautery was used successfully, without adverse
(15%). Other common causes included: trauma (10%), consequences of septal injury and these patients had
septal spur (8.3%), polyp (8.3%), injury during picking shortest hospital stay.

International Journal of Otorhinolaryngology and Head and Neck Surgery | March-April 2018 | Vol 4 | Issue 2 Page 557
 Sampigethaya S et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):555-558

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cases.12 Wait and watch, without active intervention to investigation of Scottish hospital admissions 1995-
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Anterior and posterior nasal packing was used in 31.57% hospital in Northwestern Tanzania: a prospective
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Hospital in Rural Setup: a Prospective Review of 90
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2009;28:165-8. Cite this article as: Sampigethaya S, Cherian E, Pratap
D, Mani I, Bhat VS. A clinical study of epistaxis. Int J
Otorhinolaryngol Head Neck Surg 2018;4:555-8.

International Journal of Otorhinolaryngology and Head and Neck Surgery | March-April 2018 | Vol 4 | Issue 2 Page 558

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