Importance of nasal endoscopy for the evaluation of epistaxis

Objective : To evaluate the effectiveness of nasal endoscopy in cases of epistaxis. Study design: Prospective study Setting: Department of ENT, Burdwan Medical College & Hospital, Burdwan, India. Method: 118 patients with epistaxis presented in the Department of ENT, Burdwan Medical College & Hospital, Burdwan were evaluated with the help of nasal endoscope to find out the hidden cause of epistaxis. Conclusion: Significant pathology was detected in 88 cases (69%) out of 118 cases of epistaxis. Moreover, endoscope guided biopsy was taken in suspected cases and managed according to histopathology report.


Introduction:
Epistaxis is a common ENT Problem.Although most patients can be treated from emergency as well as from ENT outpatient department.
Thorough clinical history and careful examination was done in all the patients after admission.Emergency management was done and patients were stabilized.Local examination like anterior and posterior rhinoscopy was done in cases with no active bleeding at presentation.Only 64 cases (54.2 %) presented with active epistaxis.Out of these, nasal pack was required in 40 patients only.Merocele pack was given in 24 cases, conventional anterior nasal packing with ointment socked roller gauge pack was given in14 cases.Only 2 cases with torrential bleeding required both anterior and posterior nasal pack.After removal of nasal pack, diagnostic nasal endoscopy was done between 5 th to 10 th days depending upon the condition of nasal mucosa.
Patients with no active bleeding per nose at presentation were 54 in number.The cases , where clinical examination did not reveal any pathology, were selected for nasal endoscopy.Epistaxis due to bleeding diathesis and other general medical causes were excluded from this study.
Proper kits were made ready to combat any emergency, that may arise during and following endoscopy procedure.0.05% Oxymetazoline nasal drop instilled in each nostril and waited for 10 minutes.Superior meatus was anaesthetized with 4% lignocaine solution by Moffett's technique.Nasal cavity was packed with cotton strips soaked in 4% lignocaine solution with adrenaline ( 1 in 30000) and kept for 10 minutes.Straight( 0 degree) and 30 degree angled 4 mm diameter Hopkins rod telescopes were used for diagnostic nasal endoscopy.

Results:
In our study, 118 patients were included among which 80 patients (67.8%) were male and 38 patients (32.2%) were female.Male to female ratio was 2.1: 1.
Most of the patients were within 6 th decade of life (38.5%)followed by 2 nd decade (26.27%).So, it was seen that there is a bimodal distribution of patients of epistaxis regarding their age group.By nasal endoscopic examination, abnormalities were detected in 82 (69.5%) cases.In 36 cases (30.5%) no abnormality was found even after nasal endoscopy.
Group-1: DNS with septal spur [figure1] and unhealthy mucosa was found in 26 cases (22.03%).Most of the cases had pus in the middle meatus.Group-5: Septal ulcer in posterior part was observed in 6 cases (5.08%).
Group-6: Spar with small polyp behind it was found in 4 cases (3.38%).The polyps were so hidden behind the spur that it could not be visualised by anterior rhinoscopy.
54.2 % patients presented with active epistaxis.Rest of the patients had no active bleeding per nose at presentation.77 patients had unilateral and rest of the patients had bilateral nasal bleeding.

Discussion:
Epistaxis is one of the commonest ENT emergencies.It affects all age groups 1 and it has a bimodal age distribution 2 .Prevalence of the disease can be up to 60% of the general population 3,4 .Male patients are more prone to be affected 5,6 .
Usually epistaxis is spontaneous, mild and stops spontaneously following pinching of external nose (Hippocratis method), but it may occur following nose blowing and Epistaxis can be divided into two types, anterior and posterior, depending upon the source of bleeding anterior or posterior to pyriform aperture.Usually, anterior epistaxis is commonly seen in young population and posterior epistaxis is seen in old population.Anterior epistaxis is generally visualised by anterior rhinoscopy in this study all the sources of bleeding were detected posterior to the pyriform aperture.
Between 70 -80% of all cases of epistaxis are idiopathic, spontaneous bleeds without any proven precipitant or casual factor 7 .This type is called primary epistaxis.Whereas, when a clear and defined cause of epistaxis is found, then it is called secondary epistaxis.We have found only 30.5% idiopathic cases.This is due to use of nasal endoscope for examination of epistaxis.

Figure- 1 :
Figure-1: A septal spur protrudes to the lateral nasal wall with congested bleeding contact area.

Figure 3 :
Figure 3: Polypoid changes in right middle meatus

Figure 4 :
Figure 4: Polyp seen between middle turbinate and uncinate process with infective changes in left nasal cavity.

Table - I
Abnormalities found in nasal endoscopy.
Group-2: Mass lesion inside nasal cavity [figure2] was found in 26 cases.It was angiomatous in 10 cases, benign polypoidal in 8 cases and malignant suspicious looking in 8 cases.