Clinical correlates of epistaxis management in ENT emergency

Epistaxis is defi ned as bleeding from the nose [1]. The term epistaxis was coined by William Cullen. Historically, this condition has been known to mankind since early times. The simplest and familiar “Hippocratic Technique” of pinching the ala nasi to control bleeding is well mentioned in literature. Morgagni, in his writings about epistaxis even predicted endoscopy in 18th century [2]. Epistaxis or nasal bleeding is a common emergency condition routinely faced by otorhinolaryngologists throughout the world which necessitates prompt intervention to reduce morbidity and prevent mortality. Though the global incidence is diffi cultto ascertain, it is believed to affect 7-14% of adult population in their lifetime [3]. Epistaxis can present with varied etiologies, with contributions from both local and systemic factors. Several other factors like age, sex, weather and site of bleeding have been shown to associatestrongly with epistaxis. Treatment modalities generally tend to progress from non invasive conventional methods to more invasive procedures. Though most of the patients respond to prompt and appropriate intervention by fi rst attending physician, a small proportion especially the elderly require hospital admission [4]. Identifi cation of the site of bleeding is a vital determinant of epistaxis management and advancements in endoscopic and radiological modality have aided this aspect of management protocol.


Introduction
Epistaxis is defi ned as bleeding from the nose [1]. The term epistaxis was coined by William Cullen. Historically, this condition has been known to mankind since early times. The simplest and familiar "Hippocratic Technique" of pinching the ala nasi to control bleeding is well mentioned in literature. Morgagni, in his writings about epistaxis even predicted endoscopy in 18 th century [2]. Epistaxis or nasal bleeding is a common emergency condition routinely faced by otorhinolaryngologists throughout the world which necessitates prompt intervention to reduce morbidity and prevent mortality. Though the global incidence is diffi cultto ascertain, it is believed to aff ect 7-14% of adult population in their lifetime [3].
Epistaxis can present with varied etiologies, with contributions from both local and systemic factors. Several other factors like age, sex, weather and site of bleeding have been shown to associatestrongly with epistaxis. Treatment modalities generally tend to progress from non invasive conventional methods to more invasive procedures. Though most of the patients respond to prompt and appropriate intervention by fi rst attending physician, a small proportion especially the elderly require hospital admission [4].
centers. There are scopes for controversies and non standardized practice persists. This situation needs to be dealt with in an evidence based fashion.This article attempts to discuss riskfactors associated with epistaxis and critically scrutinizeand evaluate the pathway of management based onthe higher level of evidence available.

Material and methods
This retrospective descriptive observational study was conducted at Patna Medical College and Hospital which is a tertiary care referral hospital cum teaching institute situated in the district of Patna, India. Records were collected from the emergency register of the otorhinolaryngology wards for a period of 1 year. This included the entire group of patient seen or admitted in ENT emergency ward that were treated for nasal bleeding in this period. The data collected included the demographics (age, gender), history of other concurrent illness, medications and pathologies with hemorrhagic risk, similar episodes of epistaxis (any prior incident over previous 6 months, nasal procedures or surgeries).The treatment protocol includes recording of vitals parameters, clinical examination, amount (copious or non copious) and pattern (continuous or discontinuous) of nasal bleed, initial stabilization and if required, resuscitation of the patient. Initial maneuvers comprised of head posture, suction of clot, use of vasoconstrictor and local procedures like bidigital pressure, chemical cauterization and anterior nasal packing. Surgical management like endoscopic sinus surgery and open surgery if required were done according to the severity and pathology of epistaxis. The required investigations and diagnostic procedures for evaluation like diagnostic nasal endoscopy and radiological investigations were carried out subsequently as indicated. Management of epistaxis was accomplished in a stepwise approach.
The records collected were utilized to retrieve admission records and case notes from medical records department which were reviewed in totality. The data collected was statistically interpreted and presented in tabular and descriptive formats.

Results
A total of 621 patients were treated in the ENT emergency in a period of 365 days. Out of these, 204 patients presented with chief complaints of nasal bleeding. Epistaxis constituted 32.85 % of total emergency cases. Out of these 66.66 (%) were male and 33.33 (%) were female patients in a ratio of 2:1. The age of patients ranged from 2 years to 90 years with a mean age 42.52 years. Maximum incidence was observed in age group of 51-60 years. Table 1 gives the age distribution pattern of patients presenting with epistaxis.
Monthly variation of nasal bleeding was noted and tabulated in month wise categories ( Table 2). Maximum incidence of epistaxis was observed in winter months. 57.35 % of cases were observed in winter months of the year ( Table 2). Most of the cases 168 cases (82.35%) were anterior nasal bleed whereas 36 cases 17.65 % presented with posterior nasal bleeding. The discrimination between anterior and posterior was in relation to the pyriform aperture of the nose [1]. Cardiovascular complaints 27.94%, mainly hypertension were the leading cause of nasal bleeding in our study.
Hypertensive epistaxis was primarily seen in aged individual most of who were already on antihypertensive medication.    as idiopathic epistaxis. This category comprised of 7.84% [16] cases in our study. Table 3 depicts the various etiologies of epistaxis seen during the course of our study.

NOV-DEC
The management of epistaxis was done according to the presentation and generally preceded from conservative to more invasive procedures ( emergency. Geriatric epistaxis is assumed to be prone to more severe nosebleed than young population due to loss of elastic and contractile property in their arteries [8]. Most studies including ours show a male preponderance of nasal bleeding cases [9]. Seasonal variation of epistaxis has been underlined in numerous studies most of which have shown an increased incidence in winter months [10]. Similar results were observed in this study as winter months had a greater part of nasal bleeding cases. High wind velocity and dryness causing crust formation in the nostrils may predispose to bleeding during winters.
The list of etiologies for epistaxis is a comprehensive one with several broad categories and subcategories and the frequency varies in diff erent series around the world.
Hypertensive epistaxis was the commonest cause of nasal bleeding encountered at our centre. It refl ects poor blood pressure control among the individuals [11]. Epistaxis as the presenting complaints for previously undiagnosed hypertensive cases were also seen during the period of study. Neto et al suggested enlargement of blood vessels in nasal mucosa due to degeneration of vessel wall in hypertension makes them prone for bleeding [8]. Recurrence was frequent in hypertensive nasal bleed particularly in geriatric population. We recommended reevaluation of hypertensive status, regular check up and monitoring of co morbidities in these patients. A casual relationship between hypertension and epistaxis however has been denied by multiple large studies [12]. Traumatic nasal bleed, more often than not is seen in adult male patients [13].
The prominence of nose makes it vulnerable for injury. Road

Discussion
Nasal bleeding is a common condition encountered in the emergency which causes grave anxiety to the patients.
Troublesome nasal bleeding however is a demanding scenario and can have grievous consequences. Multiple etiologies and absence of fi xed management protocols leads to dissimilar strategies adopted by rhinologists around the world. The management of epistaxis comprises a wide range of planning and treatment alternatives so it is imperative to understand when to correctly employ each individual intervention.
The age distribution pattern of epistaxis has shown variability across diff erent studies. The concept of bimodal age distribution of epistaxis is available where epistaxis is commoner in young adults and in geriatric population [5].
Western literature however has multiple studies categorizing epistaxis as a disease of the old with signifi cant occurrence in over 60 years of age [6,7]. Our study observed a considerable occurrence of young male patients most of which were incidence of traumatic epistaxis apart from an increased incidence in The management of epistaxis includes a variety of approaches and management options. It becomes the onus of the rhinologist to appreciate when and how to utilize the option available. Reassuring the patient, monitoring the vital parameters, quick initial overall assessment and swift enquiry about relevant history should be done by primary caregiver. As a signifi cant number of cases are self limiting, conservative management is often suffi cient fi rst line of therapy. Topical nasal decongestants like oxymetazoline have been shown to be successful in treating epistaxis [16]. Role of tranexemic acid used topically or orally has been contentious and opinions show a discrepancy for diff erent researchers [17]. Cauterisation by silver nitrate or electrocautery of the nasal mucosa; by anterior rhinoscopy or by using endoscope, in a non acute situation is an eff ective, cheap and easy to perform technique of epistaxis control [18,19]. Ligation of Sphenopalatine Artery) has been a revolutionary method for epistaxis control since its introduction over two decades ago [24]. It conforms to the idea to controlling the bleed as close as possible to the source and yet maintain a suffi ciently distal area to the bleed. Maxilliary artery ligation described way back in 1965 [25], has recently lost its popularity due to its invasive approach and potential complications.
Ligation of external carotid and the ethmoid arteries are not very routinely performed these days in ENT emergencies.
Recent studies have shown earlier intervention with endoscopic surgical techniques is better suited to manage epistaxis than conventional approaches due to its high success rate, low risks and cost eff ectiveness. There has also been a recent focus on embolisation procedures as better initial option in patients

Limitations
Our study, being a single centre study suff ers from being limited by institutional protocols regarding treatment modality and diagnostic interventions. Epistaxis being a common entity all over the globe has variations in ethnicity, cultural practices and availability of diagnostic and treatment modality. Thus, a multicentre study with sharing of information and knowledge would be more suitable to attain the purpose of such a study.

Conclusion
The management of nasal bleeding with a standardized approach is vital for favorable outcome in emergency situations.
Ascertaining the etiology of epistaxis and locating the source of bleeding must be done meticulously. Nasal packing is a reliable and adequate treatment option for majority of cases.
Endoscopic surgical technique for epistaxis control requires good knowledge of vascular supply of the nose. Every centre should have a management protocol for epistaxis for proper standardization and evidence based treatment.