|Year : 2014 | Volume
| Issue : 2 | Page : 81-85
Epistaxis: The experience at Kaduna Nigeria
Grema Umar Sambo, Abubakar Tijjani Sai'du, Abdullahi Musa Kirfi, Muhammad Sani, Musa Thomas Samdi
Department of Clinical Services, National Ear Care Centre, Kaduna, Nigeria
|Date of Web Publication||18-Sep-2014|
Dr. Abdullahi Musa Kirfi
Department of Clinical Services, National Ear Care Centre, Golf Course Road, off Independence Way, PMB 2438 Kaduna
Source of Support: None, Conflict of Interest: None
Background: Epistaxis is one of the commonest otolaryngological emergency. The aim is to evaluate the prevalence of epistaxis, educational status, mode of presentation, and intervention rendered patients with epistaxis at the study centre. Patients and Methods: A retrospective study of all patients presenting with epistaxis at the study centre from January 2002 to December 2012. Results: Hospital prevalence was 0.23%, minimum age at presentation was 1 year and maximum age 75 years, 70 (36.46%) were children and 122 (63.54) were adults, 106 (55.2%) males and 86 (44.8%) females. No formal education in 13% while 32.8% had tertiary education. Sixty seven (34.9%), 56(29.2%), 69(35.9%) had left, right and bilateral nasal bleeding respectively. Etiology in 84 (43.75%) patients being trauma. Sinonasal infection was more prevalent in children while trauma predominates in adults. Bleeding site was identified in 17 (8.9%), 11 (5.7%) had cauterization, 93 (48.43%) had nasal packing while 15 (7.8%) had blood transfusion in addition to other forms of treatment. Conclusion: Epistaxis in Kaduna-Nigeria, has low prevalence and the causative factor is mostly sinonasal infection in children and trauma in adults, bilateral nasal bleeding predominates, anterior nasal bleeding predominates in both children and adults, majority of the patients had tertiary education and nasal packing was found to be an effective management.
Keywords: Epistaxis, Experience, Kaduna
|How to cite this article:|
Sambo GU, Sai'du AT, Kirfi AM, Sani M, Samdi MT. Epistaxis: The experience at Kaduna Nigeria. J Med Soc 2014;28:81-5
| Introduction|| |
Epistaxis (nose bleeds) is one of the commonest otolaryngological emergency warranting prompt attentions. It has been reported that up to 60% of the general population will experience at least one episode of epistaxis in their life time, and 6% will seek medical attention for the epistaxis.  Epistaxis may present as an emergency or as part of symptomatology of a generalized disorder.
Epistaxis occurs in all ages, believed to be commonly seen in the younger age-group, but posterior epistaxis is generally believed to be disease of the older age-groups.  It shows an increase in frequency between the ages of 15 and 25 years, and from 45-65 years, with no evidence of sex predilection.  The incidence of epistaxis is higher during colder winter months when fluctuations in both temperature and humidity are most dramatic. It is also common in hot dry climates with low humidity.  The increased incidence of epistaxis during the hot and cold dry seasons may be due to the increased incidence of upper respiratory infections during such weather.  A United States health examination survey from 1972 of 6672 adults revealed a 7-14% incidence of epistaxis. The general incidence from most reports from Europe and America is about 10-15% of the population.  It also occurs in horses. 
Epistaxis is generally divided into anterior and posterior, depending on the bleeding site. , The nasal mucosa is richly supplied with blood from branches of external and internal carotid arteries. The Kiesselbach's plexus is believed to be involved in anterior epistaxis while posterior epistaxis is adduced mainly to sphenopalatine artery.  Classification of epistaxis into primary or secondary, childhood or adult and anterior or posterior is preferred over the traditional classification based on local and systemic causes.  Epistaxis has been traditionally linked with hypertension, especially in the elderly, but there is paucity of data to that effect. ,,,,,,
The aim of this study is to evaluate the prevalence of epistaxis, educational status of those presenting with epistaxis, mode of presentation, as well as intervention rendered to the patients presenting with epistaxis at the study centre during the period under review.
| Patients and Methods|| |
This is a retrospective study of 192 patients seen with primary complaints of epistaxis, seen between 1 st January, 2002 and 31 st December, 2012. Ethical clearance was obtained from the research ethics committee of the study center. The study center is the only tertiary health facility in Nigeria dedicated to Ear Nose and Throat diseases, which epistaxis is one of them. The health facility is located in the central area of the city of Kaduna, Northwestern Nigeria. All the patients' case notes were reviewed and data generated include demographics (gender, age, marital status, and occupation), educational status, mode of presentation, site of nasal bleeding, examination findings, intervention as well as days on admission for those admitted patients. The generated data was coded and entered into computer, then analyzed descriptively with SPSS version 16.0. Result of the study is as shown below.
| Results|| |
In the period under review, 82,951 patients were seen at the study centre, out of which 192 presented primarily with epistaxis either as emergency or through routine clinics. This consists of 70 (36.46%) children and 122 (63.54%) adults. Hospital prevalence was calculated as 0.25%.
Epistaxis was found to be commonest (21.9%) among those under nine years of age, less common among those above 70 years of age [Table 1].
Epistaxis was found to be higher in males (55.2%) than females (44.8), with a male to female ratio as 1.2:1. This is as shown in [Table 2].
Thirty three percent of the patients reviewed had tertiary education while 13% had no formal education [Table 3].
Epistaxis has the highest prevalence in the months of November and march. [Table 4] showed the detail.
Etiologically, 84 (43.75%) of the patients had epistaxis from traumatic causes (consisting of physical nasal trauma from road traffic accidents, domestic fights and nasal picking), giving it the highest percentage, followed by acute/chronic sinonasal infections and then idiopathic. However, in some patients, more than one etiological factor was identified [Table 5]
Age-wise, the etiologies in children and adults is shown in [Table 5]a and b.
Bilateral nasal bleeding predominates, followed by left and right nasal bleeding respectively. This is depicted in [Table 6]. One hundred and seventy nine had anterior nasal bleeding, 10 patients had posterior nasal bleeding while 3 patients had combination of both. Out of the 70 children, 69 (98.57) had anterior nasal bleeding, while an adolescent male with a diagnosis of nasopharyngeal angiofibroma had posterior nasal bleeding. In the adult population, anterior nasal bleeding was seen in 110 (90.16%), posterior nasal bleeding in 9 (7.38%) while a combination of both was seen 3 (2.46%).
One hundred and nineteen patients had active intervention in the form of nasal packing, cautery or blood transfusion. This is as shown in [Table 7]. Of the 15 patients that had blood transfusion, 4 (26.67%) had anterior nasal packing, 3 (20%) had posterior nasal packing while 7 (46.67%) had both anterior and posterior nasal packing. Only one (6.67%) patient had cautery and later on transfused based on clinical and laboratory evidence of severe anemia. Thirteen (86.67%) of the patients that had blood transfusion were given other drugs including antihemorrhagics, hematinics, and antibiotics.
| Discussion|| |
Epistaxis (nose bleeds) being a fairly common problem in the society, especially among the younger age-group. In our work, the peak age at presentation was in those less than nine years accounting for 21.9% (42 patients). This is contrary to the work put forward by Eziyi  in Ife, southwestern Nigeria where the peak age at presentation was 21-40 years. In a study conducted in Thailand  the peak age was 40-49 years. Our study agrees with the one conducted by Sogebi  where two peaks were noticed; 0-10 and 31-40 years as well as the work of Iseh  in Sokoto northwestern Nigeria where 26.4% of his patients were less than 10 years of age at presentation.
Gilyoma  observed in Northwestern Tanzania that epistaxis was more common among those in their third decade of life, likewise studies carried out in western Africa , epistaxis was more prevalent in the third to fourth decade. However, our study is also in agreement with the findings of Pallin et al.,  where epistaxis had a bimodal age presentation. Possible explanation for the high prevalence in those below 10 years of age could be due to the high incidence of upper respiratory tract infection among children, especially in the dry weather in Northern Nigeria. Importantly, sinonasal infections was identified as the most prevalent etiology in children as opposed to trauma in adults. The high prevalence of sinonasal infections could be attributed to the dry and windy weather in the study region especially that epistaxis was seen more in the harmattan period corresponding to November through to March.
Slight male preponderance was observed as 1.2:1. This agrees with the findings of Kodiya et al.,  in Kaduna Nigeria as well as the finding of Muhammad I K  in Pakistan. Awuah  also found male preponderance in Ghana. Male predominance in epistaxis has been documented in the literature; this could be explained by the aggressive nature of males in the African population especially if we consider the majority of the etiology of epistaxis in our study being trauma (considering nasal picking as a form nasal trauma). Males are considered the breadwinners of their respective families especially in the setting of northern Nigeria where the study was carried out. Trauma was identified as the most common etiologic factor for epistaxis in the works of Awuah,  Gilyoma  and Olatoke  . However, idiopathic causes predominate in the findings of Saisaward,  Sogebi,  Kodiya,  and Iseh. 
Epistaxis was observed in all categories of patients with varied educational status. No documented data relating level of education with the occurrence of epistaxis. In our study, epistaxis was mostly seen among those with higher level of education. This could be explained by the health seeking behavior of those with high level of education. However, no significant statistical evidence to link the increasing prevalence of epistaxis with educational status.
Epistaxis has the highest prevalence in the months of November and March. This has been documented in the literature.  Saisaward  found the prevalence of epistaxis in Thailand to be more in January - April which compares to winter and summer seasons in Thailand.
Fifty-six patients (29.2%) presented with right nasal bleeding, 67 patients (34.9%) presented with left nasal bleeding whereas 69 patients (35.9%) had bilateral nasal bleeding. This finding contrasts the work of Gilyoma  where they reported predominantly right nasal bleeding in Tanzania and also the findings of Awuah  in Ghana.
Ninety patients (46.9%) lost less than 100 mls of blood before presenting to the hospital whereas 95 patients (49.5%) lost 100-200 mls of blood. Seven patients (3.6%) lost more than 200 mls of blood. Considering the work put forward by Nwaorgu,  most of the patients could be categorized in to category 1. Fifteen patients (7.8%) of the patients had at least a pint of blood transfused.
Seventy-four patients (38.5%) presented to the facility within the first hour of commencement of nose bleeds while 118 (61.5%) patients presented after the first hour. It is pertinent to note that the late presentation may be attributed to poor or non-existent ambulance services as well as poor road networks leading to the study centre and most a time awareness of existence of such center in the study area. No documentation concerning the period of presentation in most works from the West African sub-region.
Twenty-eight (14.6%) of the patients were found to be hypertensives. This is lower than the findings of Olatoke  in Ilorin, north-central Nigeria where hypertension was seen in 17.4% of patients presenting with epistaxis. Our findings agree with the work of Awuah  in Ghana where hypertension was seen in 5.2% of the patients presenting with epistaxis, also with the work of Kodiya  where 12.87% of his patients presented with hypertension. However, our findings differ from those of Iseh,  Saisaward,  and Gilyoma  where hypertension was cited as the third most frequent aetiology of epistaxis. Likewise the work of Isezuo  whose finding support an association between epistaxis and hypertension but was not able to establish cause and effect relationship. Poor blood pressure control may worsen epistaxis among hypertensives; this has been documented in the medical literature. More works need to be done on the causal relationship between hypertension and the development of epistaxis.
Sixty-three (32.8%) of the patients presented for the first time while 129 (67.2%) had recurrent nasal bleeding warranting more than one visit to the facility.
Bleeding site was identified in 17 (8.85%) of the patients using endoscope out of which 11 (64.71%) had a form of cautery.
The minimum hospital stay was 24 hours while longest was 6 days. Mean hospital stay was 2.17 ± 1.29 days. Saisaward  reported an average hospital stay of 6.2 ± 3.8 days in Thai patients. The long hospital stay could be attributed to the fact that their hospital is a referral centre, so it is likely to have patients with severe or complicated cases of epistaxis.
Fifteen patients (12.6%) had at least a pint of blood transfused in addition to anterior nasal packing, posterior nasal packing, combination of both, as well as cautery. Olatoke et al.,  transfused 4.6% of their patients, Sogebi et al.,  reported transfusion rate of 8.9%. Considering the two studies above, the percentages of their patients who had blood transfusion was less than our finding. This is likely because their sample size was less than half of our study sample size. However, Eziyi  reported transfusion in 18.8% of patients in their series largely because most of the patients that had blood transfusion developed epistaxis following maxillofacial and head injuries.
Sixty-eight (35.4%) of our patients had anterior nasal packing with either gauze impregnated with paraffin, BIPP or merocele when available. Twenty-five (13%) of the patients had both anterior and posterior nasal packing with a Folley's catheter. Ninety nine (51.6%) of the patients had either cold compression, prophylactic antibiotics or neither. Nasal packing is a safe procedure especially in the hands of a trained Otolaryngologist. Nasal packs were removed within 24-48 hours. No complications were recorded. This finding agrees with the work of Sogebi  in Sagamu, where nasal packing effectively controlled epistaxis in 77.3% of their patients. Our finding is also in agreement with the results of Olatoke,  Kodiya,  Iseh,  Nwaorgu,  Gilyoma,  Awuah,  and Muhammad.  However, more studies should be carried out to compare the efficiency of anterior nasal packing and chemical/electrical cautery. LASER can also be used to cauterize a bleeding vessel, but the availability and expertise is not forthcoming in the developing countries.
| Conclusion|| |
Epistaxis, usually seen in dry weather in Kaduna, north-western Nigeria, has low prevalence and the causative factor is mostly sinonasal infections in children and trauma in adults, majority of the patients had tertiary education, bilateral nasal bleeding predominate generally, anterior epistaxis was predominant in children while a combination of anterior and posterior epistaxis was seen in the adult population, and the most cost effective mode of treatment is nasal packing.
| Acknowledgement|| |
We wish to acknowledge the efforts of the Medical Director of the National Ear Care Centre Kaduna for making the enabling environment for us to conduct this research, also the entire record staff of the centre for their co-operation during the study period.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]