|Year : 2015 | Volume
| Issue : 2 | Page : 234-238
A retrospective study on etiology and management of epistaxis in elderly patients
Kalpana Sharma1, Siva Kumar1, Tafiqul Islam1, Manigreeva Krishnatreya2
1 Department of Otorhinolaryngology, Guwahati Medical College and Hospital, Guwahati, Assam, India
2 Department of Epidemiology and Biostatistics, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
|Date of Web Publication||16-Dec-2015|
Department of Otorhinolaryngology, Guwahati Medical College and Hospital, Guwahati - 781 028, Assam
Source of Support: None, Conflict of Interest: None
Background: Epistaxis is a symptom which is often benign and nonspecific, but it may be a life threatening in elderly patients. Aim and Objective: The aim was to diagnose the underlying etiology of epistaxis in the elderly patients and identify definite management protocol to reduce the morbidity. Materials and Methods: A retrospective study of admitted elderly patients with epistaxis was carried out for the period of January 2005 to January 2014 in the Department of ENT at a tertiary care referral center in North East India. All the patients with epistaxis were retrospectively analyzed for gender distribution, etiology, and their initial and consequent management. Results: M:F = 2.6:1, hypertension was seen as the most common etiology (59.2%), followed by local cause like trauma (16.4%). Initial management with merocele application (50%) and anterior nasal packing (36.2%) were done in most of the cases and anemia was an important associated sign in 73% of patients. Conclusion: Hypertension on irregular treatment is an important underlying etiology of epistaxis in the elderly patients and comprehensive systemic management with medications should be done, including initial local control measures by nasal packing. Coexisting anemia in epistaxis should be treated to reduce any future complications.
Keywords: Elderly patients, epistaxis, etiology, hypertension, nasal packing
|How to cite this article:|
Sharma K, Kumar S, Islam T, Krishnatreya M. A retrospective study on etiology and management of epistaxis in elderly patients. Arch Med Health Sci 2015;3:234-8
|How to cite this URL:|
Sharma K, Kumar S, Islam T, Krishnatreya M. A retrospective study on etiology and management of epistaxis in elderly patients. Arch Med Health Sci [serial online] 2015 [cited 2019 Sep 16];3:234-8. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/234/171911
| Introduction|| |
Epistaxis is a common symptom in otorhinolaryngology practice, with most people suffering one or more episodes in their lifetime. According to some studies, as many as 60% of the population suffer from epistaxis in their lifetime. , In elderly patients, epistaxis should not be regarded as a harmless event either from the diagnostic or therapeutic point of view. Epistaxis may occur due to various underlying causes with a significant morbidity and even mortality in rare cases. It occurs more frequently in the dry environment, when low humidity dries the mucosa of the anterior nasal septum. Commonly epistaxis occurs from the Kiesselbach's plexus or the retro-columellar vein, which results in anterior epistaxis. These nosebleeds are relatively easy to manage with the pressure and most often it stops spontaneously on its own. Posterior epistaxis have various sites of bleeding that includes Woodruff's plexus, which is situated on the posterior aspect of the lateral wall of inferior meatus, posterior end of the inferior turbinate, posterior part of lateral nasal wall near the sphenopalatine foramen, the middle turbinate and its medial surface, middle and posterior part of the septum, floor of the nose beneath the inferior turbinate.  The traditional methods of anterior or posterior nasal packing, nasal tampons and arterial ligation are advocated to control posterior bleeding. Nasal packing is most commonly used. Apart from the high failure rate of 26-50%,  marked discomfort, pain and swallowing difficulty may be associated with traditional nasal packing. Local complications such as sinusitis, nasal synaechia, otitis media, collumelar or alar necrosis, septal perforation, facial edema, epiphora, and orbital cellulitis may also develop with nasal packing. General complications such as toxic shock syndrome, hypoxia, angina, cardiac arrhythmia, and sepsis may rarely occur after applying anterior, posterior pack. As much as 68% complication rate has been reported by Wang and Vogel.  Small and Maran advocated early arterial ligation in posterior epistaxis which has its own demerits.  External carotid artery ligation can be done easily under local anesthesia, but this ligation is far from the bleeding site and drop in local blood flow may not be substantial. High failure rate is noted due to flow from anastomotic connections with the ipsilateral internal carotid artery or the opposite carotid system. A failure rate of 45% described by Spafford and Durham.  Internal maxillary ligation is a popular method with a reported success rate of 75-100%. , Complications such as persistent pain in upper teeth, infraorbital neuralgia, sinusitis, oroantral fistula, potential damage to sphenopalatine ganglion and vidian nerve, and rarely blindness are reported.  Arterial embolization of internal maxillary artery was used by Sokoloff et al. for intractable epistaxis.  It is contraindicated in patients with atherosclerosis and allergy to contrast material. Posterior epistaxis is more common in elderly patients who usually cannot tolerate the hemodynamic changes of hypertension, diabetes and chronic obstructive pulmonary disease. If associated with hypertension, bleeding disorder like hemophilia or occurring in patients on a blood thinner as aspirin, epistaxis becomes more difficult to manage. In view of these factors, elderly patients with epistaxis need hospitalization and constant monitoring. Epistaxis occurs at any age group, and there are quite a number of published literatures on epistaxis, but with few available reports on the elderly population. The World Health Organization has classified elderly population into three groups, namely, elderly: 60-75 years, old: 76-90 years, and very old: >91 years of age. This report is an institutional based experience with epistaxis in elderly patients (patients of 60 years of age and above). The aims and objectives of this study are to diagnose the underlying cause of epistaxis in elderly and identify definite management protocol to reduce the morbidity.
| Materials and Methods|| |
A retrospective study of admitted elderly patients with epistaxis was carried out for the period of January 2005 to January 2014 in the Department of ENT at a tertiary care referral hospital in the North East India. All the elderly patients admitted in the Department of ENT with the symptom of acute epistaxis were included in this study. In this study, elderly patients with epistaxis were retrospectively analyzed for gender distribution, etiology, and their initial and consequent management. The information on age, gender, symptoms, and management was obtained from the case records. In all the cases, initial brief history followed by detailed history after the management of acute symptom were taken followed by physical examination by diagnostic nasal endoscopy, hematological and biochemical profile examination, and blood cross matching were also done in all the cases [Figure 1]. The following were done as initial management for the bleeding depending on the severity of bleeding:
|Figure 1: The schematic of management in elderly patients with epistaxis|
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Records of consultation and opinion of the cardiologist, endocrinologist, and nephrologists which were noted was obtained from the case records for identifying consequent management in these patients. The results of this study were shown by descriptive statistics and presented as percentages.
- Minimal bleeding with visible bleeding point: Cauterization and/or gel foam application or merocele application.
- Moderate bleeding: Merocele application.
- Profuse bleeding: Anterior nasal packing, if necessary posterior nasal packing.
| Results|| |
A total number of 539 (n) elderly patients were admitted in ENT ward of our institution during the study period. Epistaxis was present in 243 (n) (45%) patients. There were 176 male patients and 67 female patients. Maximum numbers of patients were in the age group of 60-70 years with a peak incidence at the age of 65 years. The hospital stay was from 1 to 3 weeks depending on the severity of the disease. The different etiologic bases both local and systemic are shown in [Table 1]. On analyzing the cause of epistaxis in decreasing order; hypertension on irregular treatment with antihypertensive drugs was recorded in 144/243 (59.25%) patients, local trauma was the cause of epistaxis in 40/243 (16.46%) patients, malignancy of the nose and para nasal sinuses (PNSs) was diagnosed in 12/243 (4.93%) patients, septal abscess with diabetes was seen in 10/243 (4.11%) cases, chronic sinusitis was the cause of epistaxis in 10/243 (4.11%) cases, epistaxis from a deviated nasal septum (DNS) with spur was seen in 9/243 (3.7%) cases, idiopathic epistaxis was recorded in 8/243 (3.28%) patients. Chronic renal failure with electrolyte imbalance was the cause of epistaxis in 6/243 (2.46%) patients. In 4/243 (1.64%) cases of epistaxis benign nasal condition like, infected polyp in 3/243 (1.23%) and inverted papilloma in 1/243 (0.42%) patient. Anemia was noted as an associated sign in 178/243 (73.25%) patients.
|Table 1: Both local and systemic etiology of epistaxis in elderly patients|
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Initial control of bleeding was done by cauterization (chemical and/or electro-cautery) in 12 (4.9%) patients, merocele application in 122 (50%) patients, anterior nasal packing in 88 (36.2%) patients, and posterior nasal packing in 21 (8.6%) of patients [Table 2].
|Table 2: The first line of management that was done for the control of epistaxis|
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Antihypertensive drugs, sedative, and insulin therapies were subsequently added according to the patients further need. Four patients had undergone peritoneal dialysis after nephrological consultation.
Surgical intervention was done for the drainage of septal abscess, correction of DNS with spur removal, reduction fracture nasal bone, lateral rhinotomy and endoscopic tumor resection (for inverted papilloma and nasal polyp) in respective patients. The 12 patients with malignant nose and PNS tumor reported at a very advanced stage where, surgical resection could not be performed as a definitive measure. Hence, they were referred for radiation therapy and chemotherapy.
| Discussion|| |
The aging change of people is progressive. There are individual variations influenced by genetic factors, environment, occupation, habits, sedentary lifestyle, smoking, high blood pressure, and diabetes to attenuate the normal ageing process. In India, ageing is faster than in many European and developed countries. The increasing numbers of elderly have a direct impact or a demand for health services exclusively prepared for this population. As India prepares to address the challenge of its ageing population, the need for geriatric disease analysis has also increased. In our analysis prevalence of epistaxis was seen in 45% of patients, who required hospital stay for various otorhinolaryngologic diseases. The male to female ratio was 2.6:1 in our study. Epistaxis in elderly have a diverse etiology with hypertension as the common etiological factor. ,, We recorded that 59.25% case of epistaxis had hypertension, and these patients were on irregular treatment as the most common underlying etiology. This underscores the importance of intake of antihypertensive drugs on a regular basis. Chaiyasate et al. had reported in general, hypertension to be the commonest cause of epistaxis.  While Varshney and Saxena recorded hypertension as the second common cause of epistaxis after idiopathic in patients of all ages.  At the age of 70 years, 70% people suffer from hypertension which is the major stress factor for strokes, heart failure, and coronary disease. Epistaxis associated with hypertension in elderly becomes difficult to control at times. It requires nasal packing and gradual reduction of blood pressure to prevent cardiac ischemia. As per available literature, posterior nasal packing are commonly used in the management of epistaxis with hypertension. , In our series use of either anterior nasal packing or merocele application was done in the majority (87%) of the cases for the initial control of the bleeding and few required posterior nasal packing.
Trauma (16.46%) was the second most common cause of epistaxis in our study. However, Nash and Field recorded trauma (30.89%) as the commonest cause of epistaxis in a study on the epidemiology of epistaxis.  In traumatic cases, application of merocele under endoscopic visualization to control the bleeding was sufficient in our series. Direct visualization helps in avoiding further damage to the nasal mucosa.  About 40% elderly patients need hospitalization for trauma following fall, and about 5% of fall resulted in fracture. 
Early biopsy and histopathological examination with targeted treatment are necessary in cases of epistaxis with carcinoma nose and PNS. Nasal packing, and use of gel foam gives temporary control of epistaxis in such cases. 
Chronic rhinosinusitis also gives rise to epistaxis in the elderly, as recorded (4%) in this study. Initial control of bleeding with merocele application or nasal packing followed by control of infection was the protocol followed in the management of our cases as per the records in this retrospective study.
Epistaxis with a DNS was found in nine cases in this retrospective study. Cauterization of the bleeding point controlled epistaxis at the initial stage. One patient had recurrent epistaxis within a short period of time. In our series, septoplasty procedure with correction of spur was needed in three (1.2%) cases. As per literature anemia is a frequent disease in elderly. , In our study, anemia (73.25%) was commonly associated with epistaxis in the elderly. Iron deficiency by itself or in combination with the lack of folic acid, vitamin B12 is responsible for almost 20% of all anemia in elderly patients. , Other factors like poor renal function, alteration of stem cell sensitivity to erythropoietin, polymedication, comorbidities like hypothyroidism, may contribute to the etiological factor of anemia. , All these factors need to be excluded while treating a case of epistaxis with anemia in elderly patients. Our study has shown that in addition to local measures and conservative medications, consequent dialysis was required in 1.6% of all patients as part of comprehensive management of elderly patients presenting with epistaxis.
Epistaxis poses a greater risk in elderly in whom clinical deterioration progresses rapidly with significant blood loss. Elderly population with their associated morbidity requires more intense treatment.  In our study, all the elderly patients were admitted for the management of epistaxis. Lifestyle factors, like previous disease and medication, are to be considered while treating any elderly patient. Medications like alpha and beta blockers, centrally acting antihypertensive drugs, angiotensin converting enzymes inhibitors may reduce sympathetic tone leading to vasodilation and symptoms of nasal congestion. Significant difference in control of epistaxis was found in patients with warfarin, dipyridamole, and nonsteroidal antiinflammatory drugs (NSAID) by Watson and Shenoi.  It is thought that the link between the use of NSAID and epistaxis may be due to alteration of platelet function. The effect of ageing on the nose includes structural, mucosal, olfactory, hormonal, and neural changes. Thus, various factors come into account while treating a case of epistaxis in an elderly patient.
| Conclusion|| |
Epistaxis is a leading cause of hospitalization in elderly patients with otolaryngologic diseases, and elderly males are almost three times affected than females. Local measure for the initial control of nasal bleeding like nasal packing or merocele application is required in most cases. The detection of the underlying chronic disease should form a part of every epistaxis case evaluation in the elderly patients. A comprehensive management of the underlying cause, is necessary to reduce the morbidity associated with epistaxis in the elderly. The coexistence of anemia with epistaxis is very high in the elderly, which always should be considered as pathological, as it is associated with multiple negative clinical effects in the future management.
| Acknowledgment|| |
The authors would like to thank Dr. K. C. Saikia, Principal of Guwahati Medical College and Hospital for his encouragement and support in carrying out the study.
| References|| |
Petruson B. Epistaxis. A clinical study with special reference to fibrinolysis. Acta Otolaryngol Suppl 1974;317:1-73.
Lunedo SM, Sass SM, Gomes AB, Kanashiro K, Bortolon L. The prevalence of the major ENT symptoms in an ambulatorial geriatric population. Int Arch Otorhinolaryngol 2008;12:95-8.
Kaluskar SK. Endoscopic Sinus Surgery, A Practical Approach. London: Springer-Verlag; 1971. p. 107-10.
Pritikin JB, Caldarelli DD, Panje WR. Endoscopic ligation of the internal maxillary artery for treatment of intractable posterior epistaxis. Ann Otol Rhinol Laryngol 1998;107:85-91.
Wang L, Vogel DH. Posterior epistaxis: Comparison of treatment. Otolaryngol Head Neck Surg 1981;89:1001-6.
Small M, Maran AG. Epistaxis and arterial ligation. J Laryngol Otol 1984;98:281-4.
Spafford P, Durham JS. Epistaxis: Efficacy of arterial ligation and long-term outcome. J Otolaryngol 1992;21:252-6.
Metson R, Lane R. Internal maxillary artery ligation for epistaxis: An analysis of failures. Laryngoscope 1988;98:760-4.
Shaw CB, Wax MK, Wetmore SJ. Epistaxis: A comparison of treatment. Otolaryngol Head Neck Surg 1993;109:60-5.
Pearson BW, MacKenzie RG, Goodman WS. The anatomical basis of transantral ligation of the maxillary artery in severe epistaxis. Laryngoscope 1969;79:969-84.
Sokoloff J, Wickbom I, McDonald D, Brahme F, Goergen TC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974;111:285-7.
Juselius H. Epistaxis. A clinical study of 1,724 patients. J Laryngol Otol 1974;88:317-27.
Small M, Murray JA, Maran AG. A study of patients with epistaxis requiring admission to hospital. Health Bull (Edinb) 1982;40:20-9.
Chaiyasate S, Roongrotwattanasiri K, Fooanan S, Sumitsawan Y. Epistaxis in Chiang Mai University Hospital. J Med Assoc Thai 2005;88:1282-6.
Varshney S, Saxena RK. Epistaxis: A retrospective clinical study. Indian J Otolaryngol Head Neck Surg 2005;57:125-9.
Cannon CR. Effective treatment protocol for posterior epistaxis: A 10-year experience. Otolaryngol Head Neck Surg 1993;109:722-5.
Nash CM, Field S. Epidemiology of epistaxis in a Canadian Emergency Department. Isr J Emerg Med 2008;8:23-8.
Gupta AK, Jain S, Singh DP, Jindal A, Singh K. Epistaxis: Management protocol as per etiology. Clin Rhinol Int J 2009;2:43-6.
Bora H, Bandyopadhyay SN, Basu SK, Majhi PK. Geriatric problems in otolaryngology. J Indian Med Assoc 2004;102:366, 368, 370.
Carmel R. Nutritional anemias and the elderly. Semin Hematol 2008;45:225-34.
Andrès E, Federici L, Serraj K, Kaltenbach G. Update of nutrient-deficiency anemia in elderly patients. Eur J Intern Med 2008;19:488-93.
Makipour S, Kanapuru B, Ershler WB. Unexplained anemia in the elderly. Semin Hematol 2008;45:250-4.
Ferrucci L, Guralnik JM, Bandinelli S, Semba RD, Lauretani F, Corsi A, et al.
Unexplained anaemia in older persons is characterised by low erythropoietin and low levels of pro-inflammatory markers. Br J Haematol 2007;136:849-55.
Pope LE, Hobbs CG. Epistaxis: An update on current management. Postgrad Med J 2005;81:309-14.
Watson MG, Shenoi PM. Drug-induced epistaxis? J R Soc Med 1990;83:162-4.
Sahin Yilmaz AA, Corey JP. Rhinitis in the elderly. Curr Allergy Asthma Rep 2006;6:125-31.
[Table 1], [Table 2]