Epistaxis: The demographics, etiology, management, and predictors of outcome in Jos, North-Central Nigeria.

Background: Epistaxis, though a mere nuisance can have life-threatening consequences. This first study from Jos on epistaxis aims to determine its sociodemographic characteristics, causes, the treatment modalities and the predictors of patient outcome. Study Design: A retrospective chart review.
Methods: Health records of patients that met the inclusion criteria for epistaxis at the Jos University Teaching Hospital, Jos, Nigeria, between February 2011 and December 2015 were retrieved manually using standardized codes in the International Classification of Diseases 10th revision and studied for age, gender, associated comorbidities, treatment modalities offered, and outcome of treatment.
Results: We managed 154 patients. Records of 92 patients were retrievable aged between 1 and 85 years (Mean = 37.7; standard deviation ± 16.2) with male to female ratio of 2.3:1. Patients in the third decade were the largest group. The most common cause was idiopathic. Anterior nasal bleeding occurred in 51.1%, posterior nasal bleeding in 34.8%. Conservative management was effective in 84.8%. Etiological factors other than chronic liver disease and otolaryngological malignancies showed statistically significant association with good patient outcomes (P = 0.013, P = 0.044, and P = 0.026, respectively). A mortality rate of 5.4% was recorded.
Conclusion: Epistaxis of idiopathic origin occurring mostly in young males is the most common with most resolving on conservative management. Early hospital presentation, normal blood pressure at presentation and all management modalities were positive predictors of outcome in our patients.

INTRODUCTION

Literature, both from Nigeria and international sources are flooded with studies on epistaxis,[123] a condition defined as hemorrhage from the nostril, nasal cavity, and/or the nasopharynx.

It is a common worldwide otorhinolaryngological emergency presenting as a life-threatening condition especially in resource-constrained hospitals with limited health-care facilities for adequate management.[2] It occurs in an estimated 60% of the global population from which approximately 6% will seek treatment as a result of the failure of remedies which erstwhile will control nasal bleeding.[2]

Both genders and all the age groups commonly affected but young males usually are more affected as a result of a greater exposure to trauma.[12]

The etiological factors in epistaxis are varied and are classified as either local, i.e., resulting from damage to the nasal epithelial mucosal lining or systemic with some studies reporting another group referred to as idiopathic in which a cause cannot be ascribed.[45] This is the most common type reported in most available literature while trauma is more common in the younger age group mostly males.[34] The non-traumatic variant is more common in the elderly as a result of organ failure, malignancies, and commonly in association with hypertension.[3]

Presenting usually as a life-threatening emergency or a chronic recurrent bleed, it can also be a pointer to a generalized disease some of which are unusual presentations and have been reported in the literature.[26]

Literature reveals some authors reporting a bimodal age presentation with peaks below 10 years and above 70 years of age, respectively.[5]

The management of epistaxis requires adequate resuscitative measures, a thorough history taking, and treatment of the underlying causes which are usually preventable.[2]

Effective treatment, therefore, depends on the etiology, site of bleed, severity of bleed, and the presence or absence of comorbidities[5] with the use of conservative and surgical modalities to effect control.

The epidemiological and clinical characteristics of epistaxis in our center are unknown because no study on epistaxis from Jos exists in the literature; hence, our study is to determine the sociodemographic characteristics, etiological factors, the treatment and predictors of outcome of this disease in our region to provide baseline information for future studies, prevention, and effective management guidelines.

METHODS

Study design and setting

This is a retrospective review of patients with epistaxis managed at the Jos University Teaching Hospital, Jos, Nigeria, from February 2011 to December 2015. Jos University Teaching Hospital is a 600-bed space hospital providing tertiary health-care services to patients in Plateau state and six neighboring states including the Federal Capital city of Abuja.

Data collection

A predesigned structured format was used to input collected data. Patients with complaints of epistaxis who were managed within the study period had their medical records retrieved and analyzed for age, gender, associated comorbidities, treatment modalities offered, and outcome of treatment. These were patients seen and admitted through the accident and emergency unit of the hospital, those presenting through the outpatient clinic and those on admission referred by other clinicians in the hospital.

Ethical considerations

Approval for this study was provided by the Institutional Health Resource Ethics Committee of the hospital.

Statistical analysis

Data obtained were analyzed using Epi Info database version 3.5.3 (Epi Info, Center for Disease Control, Atlanta, Georgia, USA, 2011) and statistical software version 3.3.5. Descriptive analysis of mean and standard deviation was used to summarize the data collected. Linear regression analysis was used to calculate the statistical significance of categorical variables as predictors of outcome of patients. A statistical significance of P < 0.05 was used. The results are presented in simple descriptive forms.

Limitations of the study

Our inability to retrieve all patients' case notes for review because of poor patient record keeping in our center

The unreliability of the time of onset of epistaxis and presentation of patients given by the patients/informants.

RESULTS

A total of 2843 otorhinolaryngological cases were managed in the study period of which 154 patients presented with epistaxis giving a prevalence rate of 5.4%. The records of only 92 patients were retrievable and analyzed comprising 64 (69.6%) males and 28 (30.4%) females with a male to female ratio of 2.3:1.

Patients were aged between 1 and 85 years (Mean = 37.7; standard devation [SD] = ±16.2). Patients in the third decade constituted the largest group followed closely by those in the fourth and fifth decades [Table 1].

Table 1

Age and gender characteristics of patients with epistaxis

Age range	Gender		Total (%)
	Male	Female
0-9	2	2	4 (4.3)
10-19	3	3	6 (6.5)
20-29	16	5	21 (22.8)
30-39	14	6	20 (21.7)
40-49	16	3	19 (20.7)
50-59	9	6	15 (16.3)
60-69	1	2	3 (3.3)
70-79	3	0	3 (3.3)
80-89	0	1	1 (1.1)
Total	64	28	92 (100)

Sixty-five (70.6%) patients presented through the accident and emergency, 25 (27.2%) were reviewed on admission following referrals from other clinicians and 2 (2.2%) presented through the outpatient clinic. Eighty-six (93.5%) patients were admitted and managed on the ward while 6 (6.5%) were managed as outpatients.

The time of onset of symptoms and presentation of the patients to the hospital was 1 h to 2 weeks (Mean = 58.5 h; SD = ±24.2).

The recorded etiological factors are listed in Table 2 with idiopathic causes being the commonest. Trauma is next, and road traffic accidents are the most recorded followed by hypertension. Twenty-one (22.8%) patients were hypertensive with 20 (21.7%) presenting with high blood pressure at the time of admission.

Table 2

Etiology of epistaxis in presenting patients

Etiological factor	Frequency (%)
Idiopathic	38.0 (41.3)
Trauma
Domestic accident	1.0 (1.1)
Fall from height	1.0 (1.1)
Nose picking	1.0 (1.1)
Religious/terror attacks	8.0 (8.7)
Road traffic accidents	12.0 (13.0)
Hypertension	21.0 (22.8)
Tumors
Maxillary cancer	1.0 (1.1)
Nasopharyngeal cancer	5.0 (5.4)
Primary liver cell cancer	3.0 (3.3)
Sinonasal medullary plasmacytoma	1.0 (1.1)
Total	92 (100)

Forty-seven (51.1%) patients presented with anterior nasal bleeding, 32 (34.8%) with posterior nasal bleeding and in 13 (14.1), there was no recorded site of bleeding.

The most common comorbid condition among patients managed was the human immunodeficiency virus disease.

The management of the patients was varied and included but not limited to nasal packing, chemical cautery, and medical management by the physicians and hematologists with 44 (47.8%) patients having multimodal treatment [Table 3]. Conservative management was recorded in 78 (84.8%) patients with the majority of the patients having anterior and/or posterior nasal packing (n = 89; 96.7%) with ribbon gauze, merocel, and Foley catheters inserted into the postnasal space and the balloon inflated with air. Surgical management was recorded in 14 (15.2%), two patients having intractable epistaxis and managed by maxillary artery ligation [Table 3]. All the patients who had nasal packing were placed on antibiotics.

Table 3

Type of treatment rendered to patients

Treatment	Frequency (%)
Antihypertensives	15.0 (16.3)
Antimalarials	1.0 (1.1)
Cold saline lavage	1.0 (1.1)
Etamsylate injection	10.0 (10.9)
Hematological treatment	3.0 (3.7)
Maxillary artery ligation	2.0 (2.2)
Nasal packing
Anterior	33.0 (35.9)
Anterior and posterior	24.0 (26.1)
Posterior	32.0 (34.8)
Vitamin K injection	2.0 (2.2)

The duration of hospital stays ranged between 2 and 22 days (Mean = 10.8 days; SD = ±5.1).

Linear regression analyses showed that presenting within the 1st h of epistaxis and all management modalities showed statistically significant positive correlations with patient outcomes (P = 0.017, P = 0.021, P = 0.026, P = 0.008, and P = 0.036, respectively) while age, gender, hypertension, and malignancies showed statistical inverse correlation with patient outcomes (P = 0.27, P = 0.39, P = 0.18, P = 0.35, and P = 0.06, respectively) [Table 4].

Table 4

Factors associated with outcome on linear regression analysis of patients with epistaxis

Variable	Coefficient	SE	F	P
Age	0.042	0.037	1.2309	0.0270
Anterior nasal pack	8.678	4.934	3.0929	0.008
Ant and postnasal pack	11.678	4.934	5.6010	0.021
Blood transfusion	4.322	0.969	19.8952	0.000
Cold saline lavage	11.000	4.838	5.1691	0.026
Gender	−2.260	1.078	4.3939	0.391
Nasomaxillary cancer	13.377	6.257	4.5708	0.357
Presentation in 1 h	7.289	2.969	6.0275	0.017
Presentation >h	1.120	1.496	0.5607	0.458
Primary liver cell cancer	11.914	6.286	3.5927	0.061
Postnasal pack	7.599	3.558	4.5615	0.036
Constant	6.974	4.930	2.0008	0.1613

Correlation coefficient r2=0.37. SE=Standard error

Thirty-two (34.8%) patients had blood transfusions. Five patients died in this study giving a mortality rate of 5.4%, three patients from primary liver cell carcinoma and two from associated severe head injuries sustained in road traffic accidents. Eighty-seven (94.6%) patients were discharged to home while 8 (8.7%) patients were referred for radiation and/or chemotherapy.

DISCUSSION

The prevalence rate of 5.4% recorded in our study surpasses the rate of 0.25% and 0.5% from two previous studies from Nigeria.[78] This can be explained by the larger number of patients studied over a longer duration in these studies compared to ours.

A male preponderance is noted in our study, which conforms to findings from other studies in Nigeria and internationally.[129] However, the male to female ratio recorded in our study averages these other studies.

Unlike other studies that reported a bimodal age presentation,[59] our study shows an increased prevalence from the 3rd to 5th decades of life with individuals in the 3rd decades mostly affected. The peak age incidence of 20–49 years (Mean = 37.7) recorded in this study is similar to findings by Eziyi et al. in southwestern Nigeria and that of Gilyoma and Chalya in northwestern Tanzania who recorded 21–40 years and 31–40 years, respectively.[210] This male preponderance is because of the increased activity in young males who are in their productive and reproductive ages with increased exposure to injuries especially in our environment where they use motorcycles for commercial transportation providing a means of livelihood.[11] This is buttressed by the high rate of epistaxis recorded from road traffic accidents in our study. Another factor noted to be responsible for an increased incidence of epistaxis from trauma in this study was head injuries and other maxillofacial injuries sustained during ethnoreligious and terrorist attacks that occurred in Jos, Nigeria, within the study period.[11] Reducing the incidence of trauma, ethnoreligious crises and terror attacks will reduce the case of emergency epistaxis.

The etiological factors of epistaxis vary from one study to the other but the most prominent three being idiopathic, trauma and hypertension[1259] which is in concordance with the findings in this study with idiopathic being the most common etiological factor in our study.

We recorded hypertension as the third-most common etiological factor. The relationship between hypertension and epistaxis though misunderstood has been documented in some studies in which patients presenting with epistaxis demonstrated significantly higher blood pressures especially following stoppage of antihypertensive use.[121314] Our study showed a significant number of patients with epistaxis presenting with uncontrolled hypertension for which control was required with antihypertensives.

Epistaxis occurs more commonly in hypertensives, and some authors have ascribed this to the increased fragility of the blood vessel walls due to long-standing hypertensive disease.[15] Further research is required to establish the causal relationship between epistaxis and hypertension.

Sinonasal and nasopharyngeal malignancies as recorded in our study are noted tumor types presenting with epistaxis.

Most patients in this study had more than modality of treatment. We were able to achieve anterior and/or posterior nasal packing in 89 (96.7%) patients with 4 (4.5%) of these recurring and requiring silver nitrate cautery, which proved to be safe and efficient. Posterior nasal packing was required in our patients with posterior nasal bleeds mostly from uncontrolled hypertension at presentation. This was done with Foley catheters passed into the post-nasal space with the balloon inflated with air instead of water as is used in certain centers[2] in other to prevent the patients from aspiration in the eventuality of the balloon bursting and this practice has proven to be effective.

The use of prophylactic antibiotic cover for patients who have nasal packing is a controversial topic but is recommended by proponents to prevent rhinosinusitis and toxic shock syndrome.[1617] This is the practice in our center and the reason all patients in this study whose nostrils were packed being administered antibiotics.

Surgical intervention required in 14 (15.2%) of our patients is more than the reports from other studies.[210]

The blood transfusion rate of 34.8% recorded in our study is higher than the reports from many other studies.[27910] This is due to the severe blood losses recorded in this study from maxillofacial injuries suffered by our patients from road traffic accidents and terrorist/ethnic-religious crises during the study period.

This study reports a mean hospital stay of 10.8 days, which is higher than findings from other studies.[210] Some of the patients in this study were those referred by other clinicians, especially those with hypertension and other comorbid conditions requiring their peculiar management modalities and this could explain their lengthy hospital stay.

Hospital presentation within 1 h of onset of epistaxis, normal blood pressure at presentation, and all types of management modalities were found to be favorable predictors of outcome for patients in our study.

Early hospital presentation would mean a prompt attention to the nosebleed resulting in a better patient outcome. The relationship between epistaxis and hypertension as postulated by some authors has been stated above. Therefore, a normal blood pressure in a patient presenting with epistaxis should result in a better outcome for the patient. Coagulation abnormalities occur in patients with primary liver cell cancer, and this could explain the poor outcome in our patients presenting in this form with resultant death witnessed in all three.

The mortality rate recorded from previous studies is lower than the rate of 5.4% obtained in our study.[210] This is because of the increased incidence of severe head injuries and primary liver cell cancer obtained in this study.

CONCLUSION

The most common cause of epistaxis in Jos, Nigeria, is idiopathic occurring mostly in young males with trauma and hypertension being close to etiological factors. The prevention of road traffic accidents, ethnoreligious, and terror attacks and adherence to antihypertensive treatment will reduce the incidence of epistaxis in our region.

Nonsurgical management was effective in most of our patients, and surgical treatment was safe and effective in a few of our patients requiring this treatment modality.

Early hospital presentation, normal blood pressure at presentation, and all management modalities were positive predictors of outcome in our patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.