Frequency of Nontraumatic Epistaxis in Older Male Patients

Introduction: Epistaxis is a common problem which may affect all age groups. It has bimodal presentation.Nontraumatic epistaxis may affect more frequently among older male. Objective: It is important to observe the common factors related with the different etiological types of epistaxis. It is also important to observe the various socio demographic characteristic of the patient with pattern of presentation of the epistaxis. Mehods: Cross-sectional study in tertiary level hospital. From July 2012 to June 2013, 176 participants were selected. Results: Traumatic epistaxis was more frequent (70.51%) among younger age group (age <45yeras), whereas non-traumatic epistaxis was more frequent (72.92%) among older age group (age >45yeras). There was a statistically significant difference between the different age group with their etiology of the epistaxis (P = <0.001). Conclusion: Older males are more prone tonontraumatic epistaxis.


Introduction:
Epistaxis is a Greek word, means nose bleed. 1 Epistaxis is defined as a bleeding of the nasal mucosa. 2 Clinically any bleeding from the nostril, nasal cavity, or nasopharynx considered as epistaxis. 3 Epistaxis may affect all age groups 3 . Study shows it has common bimodal presentation 3,4 . The prevalence is increased for children less than 10 years of age and then rises again after the age of 35 years. 4 It is important to locate the site of bleeding in the nose, which can be classified as anterior or posterior bleeding. 5 Anterior bleeding is common in younger age group while posterior bleeding is common in older age group. 2,5 Children and adolescents are more often afflicted with minor episodes of anterior nasal bleeding, whereas the incidence of severe posterior nasal bleeding is greater in those who are more than 50 years old. 6 Anterior epistaxis is far more common than posterior epistaxis, accounting for more than 80% of cases 7 , Anterior nosebleeds arise from damage to Kiesselbach's plexus on the lower portion of the anterior nasal septum, known as the Little's area 4 , whereas posterior nosebleeds arise from damage to the posterior nasal septal artery or sphenopalatine artery. 5 Trauma is considered to be a major aetiological factor for local cause. Traumatic epistaxis is more common in younger individuals (under age 35 years) and is most often due to digital trauma, facial injury, or a foreign body in the nasal cavity.
Non-traumatic epistaxis is more characteristic of older patients (over age 50 years) and may be due to organ failure, neoplastic conditions, inflammation, or environmental factors (temperature, humidity, altitude). Hypertension may not be the cause for initiation of nasal bleed, but the loss of arterial muscle power to contract may result in persistence of bleeding. Rise in blood pressure may or may not be due to anxiety. 8 This cross sectional study conducted in different major tertiary level hospitals in the Dhaka, Bangladesh, where the attending patients were from all the corners of the country and were more or less representative of all the population of Bangladesh.
During this study ethical implication was thoroughly looked upon. All the data pertinent to the patient will be confidential. The accumulated data will be analyzed by standard statistical method. The result of the study will provide some knowledge about the frequency of epistaxis, pattern of presentation and relation of different demographic and prevailing factors as its etiology that will provide basis for planning of preventive strategies and establishment of treatment guidelines.
To observe the various socio demographic characteristic of the patient with epistaxis.    16.263.). 93(53.45%) patient were more than forty five years of age.
There was bimodal peak age distribution, one in young age (10-20 years) and others in older age (50-70 years). There was no significant difference in the proportions of traumatic and nontraumatic aetiological group among the patient with epistaxis (P = 0.228).  Traumatic epistaxis was more frequent (70.51%) among younger age group (age <45yeras), whereas non-traumatic epistaxis was more frequent (72.92%) among older age group (age >45yeras). There was a statistically significant difference between the different age group with their etiology of the epistaxis (P = <0.001).   11 . In some reports where no significant sex difference exists. 9,11 After 50 (in geriatric age) no significant deference between sex as reported, 12 the ratio is close to 1:1. 13 It is possible that the female pre-menopausal state may provide a significant protection from this disease. The mechanism for this is unknown, but may be secondary to a direct effect of oestrogen on the nasal mucosa or vasculature, or the healing of vessels in this region. Alternatively, this observation may simply be a reflection of protection the pre-menopausal state provides against cardiovascular disease in general. 12 Their age ranged between 4 years and 83 years (mean 43.58 SD±20.74 years). Average age of male patient was 46.47 SD±19.89 and female patient 36.91 SD±19.35.There was a statistically significant difference between the male and female patient regarding their age (P = 0.005).There was a bimodal peak age distribution, One in young age (10-20 years) and other in older age (50-70 years). 93(53.45%) patient were more than forty five years of age.
There was bimodal distribution in the age of onset of epistaxis reported from north American, Europe 13,14 and in subcontinent. 14,15 The higher prevalence in younger males is most probably related to more exposure to trauma on account of active involvement in out-door activities; sports, traveling and interpersonal violence. Whereas, in the older age group vascular pathology and hypertension are responsible in the majority. Some authors portray epistaxis as a disease of the young, whereas others have noted epistaxis to be more common in the elderly. 16 The study shows an increase frequency between the age of 15-25 years 17 and later from 45 to 65 years with no evidence of sex predilection. In Dehradun, India study most of the patients was older than 40years (63.64%) with a mean This may due to the difficulties in transportation in addition to that most patients from rural areas are managed by local health centers and not referred to the hospital especially if one remember that, in general nose bleed in the young person either are easy to treat or stop spontaneously.
Patient with epistaxis were more frequent from the month of September to March (autumn to spring). Peak incidence was in the month of November. 103 (59.19%) patient with epistaxis attended in the autumn and winter season. Among them 58(33.33%) patient were attended in autumn and 45(25.86%) patient in winter.
Higher incidence of admitted cases was seen in winters in other study. 21 Episode of epistaxis was more in autumn and winter months and low during summer and rainy months found in another study. 22,23 The effect of decreased ambient humidity leads to reduced nasal humidification. Dry air facilitates excoriation and cracking of the nasal mucosa. This subsequently reduces local wound healing mechanisms, and any local traumatic or inflammatory event has an increased ability to disrupt the nasal mucosa. Some other report the incidence increases in hot dry climate 22,24 also in rainy season in Nigeria. 25 The etiological profile of epistaxis has been reported to vary with age and anatomical location (Pallian DJ 2005). Among the study patient, 78(44.83%) patient were in traumatic epistaxsis patient group and 96(55.17%) patient were in non-traumatic epistaxis patient group.
The present study shows that the most common cause of epistaxis was trauma (44.83%) followed by idiopathic(19.54%) and hypertension(14.94%), which is consistent with other studies in developing countries. 12,18 This is in discordance with what was found in the Eastern part of Nigeria where it represented the dominant form. 5,11 Findings in most western literature, cites idiopathic causes as the commonest, followed by trauma. 8,12 Among the non-traumatic epistaxis patient group, 21(12.07%) patient had local cause and 75(43.10%) patient had systemic cause. Idiopathic cause was the most common (19.54%) cause followed by hypertension (14.94%) and nasal neoplastic disease (6.90%) in non-traumatic epistaxis patient group.
This trauma varied from minor injury such as digital trauma to varying degrees of nasal injury from road traffic injury. The nose being a prominent feature on the face is highly susceptible in craniofacial injury. Most of our patients with epistaxis from trauma were actually victims of road traffic injury. Trauma being the most common cause of epistaxis can partly explain the frequency of this problem in males. This group is the adventurous group in our community. They are often on the road in search of economic well-being thereby making them prone to such accidents. High incidence of traumatic epistaxis resulting from road traffic crashes in our study calls for urgent preventive measures targeting at reducing the occurrence of RTCs in order to reduce the incidence of epistaxis in this region.
Hypertension being the third commonest cause in this report (14.94%) shows epistaxis as evidence of poor blood pressure control. In Nigeria, some patients of epistaxis occurred when hypertension was not controlled due to cessation of antihypertensive drug therapy. 23 Varsney and Saxena (2005) in India recorded hypertension as the second commonest cause of epistaxis after idiopathic causes while Chaiyasate et al (2005) in Thailand reported hypertension to be the commonest cause of epistaxis followed by idiopathic causes. 12,14 The need for regular blood pressure check and compliance to antihypertensive medications must be emphasized. Epistaxis and arterial hypertension are frequent in the population, more evident in patients with severe epistaxis, with prevalence of 24 to 64% in these cases. 24 Traumatic epistaxis was more frequent (70.51%) among younger age group (age <45yeras) a. whereas non-raumatic epistaxis was more frequent (72.92%) among older age group (age >45 yeras). There was a statistically significant difference between the different age group with their aetiology of the epistaxis (P = <0.001).
The male preponderance in this study may be attributed to high incidence of traumatic epistaxis which tends to affect young males because of their frequent involvement in high risk behaviour. Young males are the most active in the population and so are more vulnerable to trauma from nose picking especially among children, fights, road traffic accident with maxillofacial injuries causing epistaxis.
Non-traumatic cause of epistaxis was significantly common among the older male patient (p=<0.012). Most of the older patients have the history of longstanding hypertension, atherosclerosis, chronic disease (liver and kidney) and neoplastic pathology.
Significantly anterior epistaxis is common among the traumatic epistaxis group (69.23%) and posterior epistaxis in nontraumatic epistaxis group (47.92%). About 25.86% patient the exact site was not detected as there was diffuse bleeding.
Little's area was the most frequent (79.49%) site in anterior epistaxis.
133 (76.44%) patients were presented with unilateral nasal bleeding. Left side was slight predominate to the right side of the nose, left to right side ratio was 1.37:1 with no significant difference in the proportions (z= 0.926; P = 0.355.)

Conclusion:
Epistaxis is a common otolaryngological emergency and is often due to lesions within or around the nose and systemic conditions. Controlling epistaxis presents a challenge in the underdeveloped, resource-poor centers where there are limited facilities. A high incidence in young adults was reported with preponderance of males over females.
Occurrence of different types of epistaxis was strongly related with the certain demographic factors like age, sex, season of the year and habitat of the patient. This study supports the credibility of conservative management procedure in the treatment of epistaxis. Simple nasal packing is the commonly practice conservative method with high success. Hence, this approach should be the preferred option in the management of epistaxis especially in developing countries.