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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 93-98

Comparison of endoscopic-guided silver nitrate cauterization and nasal packing in the treatment of epistaxis


1 Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission02-Apr-2020
Date of Acceptance05-Jun-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Abdulrazak Ajiya
Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University Kano/Aminu Kano Teaching Hospital
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_16_20

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  Abstract 


Background: Epistaxis is a common disorder and often presents as an emergency. The management is challenging and various modalities of the treatment of epistaxis have been described. Nasal packing and silver nitrate chemical cautery are the commonest methods of treatment. However, there is no sufficient literature regarding the comparison of these two methods in the study area. The objective of this study is to compare endoscopic-guided silver nitrate cauterization with nasal packing in the treatment of epistaxis in our institution. Objective: To compare the endoscopic-guided silver nitrate cauterization with nasal packing in the treatment of epistaxis in our environment.
Patients and Methods: This was a retrospective review of patients who presented with epistaxis at our clinic. The case notes of all patients with epistaxis who were managed with anterior packing (AP), posterior packing (PP), or endoscopic cauterization (EC) were selected. Patients with incomplete records were excluded. The information obtained included sociodemographic variables, clinical details, method of treatment, complications, and treatment outcome. The data were analyzed using SPSS version 20.
Results: One hundred and twenty six patients were reviewed of which 70 (55.6%) were males and 56 (44.4%) females, within the age range of 5–80 years (mean age ± SD = 33.5 ± 17.9). The success rate of EC (93.5%) was higher compared to that of AP (68.3%) and PP (74.3%). The patients treated with EC had a statistically significant lower rate of recurrence (6.5%) compared with AP (31.1%) and PP (25.7%), respectively (P = 0.037). The mean hospital stay for patients treated with EC was significantly shorter (0.8 ± 0.6 days) compared to the group treated with AP (3.2 ± 0.9 days) and PP (6.2 ± 2.7 days), respectively (P = 0.000).
Conclusion: Patients with epistaxis that underwent endoscopic-guided silver nitrate cauterization had better success rate, less complication, and shorter hospital stay than the group treated with nasal packing.

Keywords: Cauterization, epistaxis, nasal endoscopy, nasal packing, treatment


How to cite this article:
Adamu A, Ajiya A, Hamisu A, Hasheem MG. Comparison of endoscopic-guided silver nitrate cauterization and nasal packing in the treatment of epistaxis. Arch Int Surg 2019;9:93-8

How to cite this URL:
Adamu A, Ajiya A, Hamisu A, Hasheem MG. Comparison of endoscopic-guided silver nitrate cauterization and nasal packing in the treatment of epistaxis. Arch Int Surg [serial online] 2019 [cited 2020 Dec 3];9:93-8. Available from: https://www.archintsurg.org/text.asp?2019/9/4/93/300557




  Introduction Top


Epistaxis is bleeding from the nose or nasopharynx. It is a common disorder and often presents as an emergency to otolaryngologists. It is one of the commonest emergency seen in otorhinolaryngology practice worldwide.[1] Epistaxis can be seen in all age group but it was found to be more prevalent in children below the age 10 years, and then in adults after the age of 35 years as a bimodal age distribution pattern.[2] In Nigeria, epistaxis was reported to be commonest among patients 1–20 with years and 31–40 years of age,[3] and a slight male preponderance was also reported by several authors.[3],[4],[5],[6],[7] The majority of cases of epistaxis reported in Nigeria were secondary to trauma and infections, other causes include sinonasal tumors, bleeding disorders, uremia, hypertension, and chronic liver disease.[3],[4],[5],[6],[7]

Patient may present with mild or severe bleeding associated with life-threatening complications that may pose a challenge to even well-trained otolaryngologist. The complications and outcome of uncontrolled severe epistaxis can be serious and may include shock, myocardial infarction, stroke, and airway compromise from blood clot retention.[8] Uncontrolled severe epistaxis is more common from a posterior bleeding. Fortunately, most cases of epistaxis originate in the anterior portion of the nasal septum at the Kiesselbach's plexus.[9]

Various modalities of the treatment of epistaxis have been described, which include anterior nasal packing, posterior nasal packing, diathermy electro-cautery, chemical cauterization, and surgical arterial ligation. There is no consensus on the best modality of treatment for epistaxis, each method has its advantages and complications.[10] Endoscopic-assisted cauterization is an established technique for the treatment of epistaxis, it was found to be an effective method of control for nasal bleeding.[11],[12] Endoscopic-assisted silver nitrate cauterization was reported to be superior to conventional nasal packing in terms of reduction in hospital admission, recurrence, and complication rate.[11] However, other authors reported that conventional nasal packing had high success rate compared to chemical cauterization.[13] Before selecting endoscopic silver nitrate cauterization or nasal packing as a modality of treating epistaxis, some factors need to be considered such as site of bleeding (anterior or posterior), identification of bleeding point and severity of bleeding.[14],[15] If the epistaxis is anterior type, and the bleeding point can be identified, silver nitrate cauterization is favored over nasal packing.[15],[16]

Nasal packing and silver nitrate chemical cautery are the most common treatment modalities used in our environment.[3],[5],[6],[7] However, there is no sufficient clinical data regarding the comparison of the two methods. Therefore, the aim of the study was to retrospectively compare the endoscopic-guided silver nitrate cauterization and nasal packing in the treatment of epistaxis in our environment, vis-à-vis the success rate, length of hospital stay, recurrence, and occurrence of complications.


  Patients and Methods Top


This was a retrospective study of patients who presented with epistaxis at the ENT clinic and emergency unit of our institution between January 2014 and December 2018. Ethical approval was obtained from the Institutional ethical review committee on 11th March, 2019. The case notes of all patients who presented with epistaxis within the study period were reviewed and the patients managed with nasal packing or endoscopic-guided (Rigid endoscope: 0.4 mm, Karl Storz, Germany) silver nitrate cauterization was selected. Though some patients had more than one treatment modality, the initial treatment adopted was chosen as the main treatment. All the patients underwent routine investigations such as full blood count, platelets count, urea and electrolytes, grouping and cross-matching, hemoglobin electrophoresis, and clothing profile. Radiological and other additional investigations were ordered for based on history and physical examination. Intravenous line was established where indicated. Endoscopic-guided silver nitrate cauterization was done for patients with anterior epistaxis, localized bleeding point, mild to moderate epistaxis, and mostly done as outpatient. On the other hand, nasal packing was done for patients with unidentified bleeding point, severe diffuse bleeding and posterior bleeding. Most patients with nasal packing were admitted and placed on antibiotics. Patients with incomplete records or missing folder were excluded from the study. The information obtained from the folders included sociodemographic variables, clinical details (duration, number of episodes, site and side of bleeding, hemodynamic status, and the cause of bleeding), method of treatment, complications, and treatment outcome. The data collected were analyzed using Statistical Product and Service Solution (SPSS) version 20.0 (IBM Corp. USA). The data were summarized and presented as qualitative and quantitative variables. Quantitative variables were presented using mean and standard deviation and compared using t-test, while qualitative data were presented using frequencies and percentages and compared using Chi-squares. Level of statistical significance was set at P ≤ 0.05 at 95% confidence interval.


  Results Top


One hundred and twenty six (126) patients, case notes were selected, there were 70 (55.6%) males and 56 (44.4%) females with male: female ratio of 1:0.8. The age of the patients ranged between 5 and 80 years, with mean and standard deviation (SD) of 33.5 ± 17.9 years. The peak age of occurrence was between the ages of 21–30 years. The details of sociodemographic distribution is shown in [Table 1].
Table 1: Socio demographic distribution of the patients

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Most of the patients (94 [72.2%]) presented to the hospital 24 h after the onset of the epistaxis, and majority of them (78 [61.9%]) had previous episode (s). Bilateral nasal bleeding was seen in 22 (17.5%) of the cases. Left nasal cavity was identified as the side of the bleeding in 55 (43.7%) of the cases while bleeding from the right nasal cavity was seen in 49 (38.9%) of the cases. In majority of the cases, the anatomical site of bleeding point was identified, 79 (62.7%) had anterior bleeding point while 29 (23%) had posterior bleeding point. The bleeding point was not identified only in 18 (14.3%) of the cases. Most of the patients (93 (73.8)) presented with unstable hemodynamic status, and up to 18 (14.5%) had blood transfusion [Table 2].
Table 2: Clinical features of the patients with epistaxis

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Infections 37 (29.4%) and trauma 29 (23.0%) are the commonest etiology, followed by hypertension 28 (22.2%), tumors 12 (9.5%), chronic kidney disease 4 (3.2%), and bleeding disorders 3 (2.4%). Other causes constituted about eight (6.3%) of the cases and they include: chronic liver disease, disseminated intravascular coagulation, and drug induced epistaxis. In five (4%) of the cases no etiology was identified [Figure 1].
Figure 1: Causes of epistaxis among the patients

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Majority of the patients (60 [47.6%]) had anterior nasal packing. Posterior nasal packing was done in 35 (27.8%) patients, while 31 (24.6%) of the participants had endoscopic silver nitrate cauterization [Figure 2]. Most of the patients (112 [88.8%]) had no complication during the treatment, the few complications recorded included facial edema 4 (3.2%), otalgia 2 (1.6%), nasal pack dislodgement 3 (2.4%), nasal vestibular burns 2 (1.6%), and shock 3 (2.4%). [Figure 3] Complications based on type of treatment are presented in [Table 3]. Among the patients who were treated with anterior nasal packing, sevenhad complications, for which four patients had facial edema, one patient had otalgia, nasal pack dislodgement, and shock respectively. Complications of posterior nasal packing were recorded in five, for which one patient had otalgia, two patients had nasal pack dislodgement and shock, respectively. Two patients had nasal vestibular burns as a complication of silver nitrate cauterization.
Figure 2: Modality of treatment of epistaxis

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Figure 3: Complications of treatment of epistaxis

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Table 3: Comparison of outcome between treatment modalities

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[Table 3] compared the outcome of treatment between the three different modalities. Thirty one patients were treated with endoscopic cauterization (EC) with success rate of 93.5%, only two patients had recurrence and complication was recorded in 6.5% of the cases. Anterior nasal packing (AP) was done in 60 patients with 68.3% success rate, 19 patients had recurrence and complication rate was 11.7%. Out of 19 patients who had recurrence after anterior nasal packing; posterior nasal packing was done in 12 patients, cauterization in 5 patients, and excision of nasal mass in 2 patients eventually controlled the bleeding. Thirty-five patients were treated with posterior nasal packing (PP) with success rate of 74.3%, recurrence was recorded in nine patients and complication occurred in 14.3% of the patients. Out of nine who had recurrence after posterior nasal packing, bleeding was controlled by repeat posterior nasal packing in four patients, surgical excision of nasopharyngeal mass in three patients, and two patients were referred for radiotherapy.

The group of patients treated with EC had a statistically significant lower rate of recurrence (6.5%) compared with AP (31.1%) and PP (25.7%) (Chi-square χ2– 6.596, P = 0.037). The mean hospital stay for patients treated with EC was 0.8 ± 0.6 days, while that of AP and PP were 3.2 ± 0.9 and 6.2 ± 2.7 days, respectively. The EC group had a statistically significant lower mean hospital stay compared to AP group (t = 11.353, P = 0.000) and PP group (t = 10.737, P = 0.000).


  Discussion Top


The treatment of epistaxis dates back many centuries ago, when nasal packing was first practiced by Hippocrates in the 5th century BC.[17] Since then nasal packing has been in practice worldwide by both otolaryngologist and general practitioners. Nasal packing was reported as the commonest method of controlling epistaxis.[3],[4],[5],[6],[7] Traboulsi et al.[18] also described nasal packing as simple and effective method of control of nose bleeding. However, it is associated with complications such as sinusitis, otitis media, toxic shock syndrome, facial edema, epiphora, and even cardiopulmonary problems.[19],[20] The increased rate of complications of nasal packing lead to the development of newer treatment methods for control of epistaxis. Rigid nasal endoscopy is a new technology adapted for the management of epistaxis, it gives excellent and magnified view of the nasal cavity, thereby improving identification of bleeding point and precise application of chemical or electrical cautery, and these improve the overall success rate.[21]

In this study, thepeak age of occurrence of epistaxis was similar to the findings of studies done in Nigeria.[6],[22] However, some other authors[3],[23] reported bimodal age distribution. A slight male predominance was noted in this study, which is similar to other studies.[3],[4],[5],[6],[7] Males preponderance may be attributed to the fact that male engage in outdoor activities and they are subjected more to trauma and/or adverse effect of dry Harmattan weather associated with the Sahara desert.

Majority of the patients in our series presented to the hospital after 24 h of the onset of the epistaxis, and most of them had previous episode in the past. This is similar to the findings of Gabriel et al. in Ekiti,[23] where 63.2% of the participants reported to the hospital after 24 h and about 68.4% of the patients had previous history of epistaxis. Similarly, most of the patients in this study presented with unstable hemodynamic status, of which 14.5% required blood transfusion. Two other studies in Nigeria also reported blood transfusion in 12.61%[7] and 8.8%[23] of the patients with epistaxis, respectively

In this series, the bleeding was predominantly left sided, which is contrary to the findings of Gabriel et al.[23] where the bleeding was common on the right side. However, Sambo et al.[7] reported bilateral nasal bleeding as the commonest presentation. This variation might be due to difference in the sample size. Additionally, majority (62.7%) of the patients had anterior bleeding. This is similar to the findings of Sogebi et al.[24] where anterior nasal bleeding was found in 60.8% of the patients. Gabriel et al.[23] in Ekiti also reported that anterior epistaxis occurred more (75.4%) than posterior epistaxis. Similar study in Kaduna also reported that anterior nasal bleeding was more common in both adult and children than posterior bleeding.[7] Anterior epistaxis was the commonest because most of the etiology of epistaxis in our environment are mostly from trauma or infections which tent to affect Little's area more than the posterior aspect of the nose.[3],[4],[5],[6],[7] Conversely, Liu et al.[25] in China reported that the commonest site of epistaxis was the superior part of nasal septum. This variation may be attributed to racial differences.

Endoscopic silver nitrate cauterization (EC) had a very high success rate (93.5%) among our patients which is in agreement with findings by Shamas[26] in India where 90% success rate of endoscopic cauterization was recorded. This is also similar to findings by Ha et al.[11] where they reported 100% success rate of endoscopic assisted cauterization for the treatment of epistaxis. The high success rate of this method may be attributed to excellent visualization of the nasal cavity, accurate identification of bleeding point and adequate cauterization. This study also found that the success rate of EC (93.5%) was higher compared to that of AP (68.3%) and PP (74.3%), respectively. This is contrary to the findings of Razdan et al.[13] where the posterior nasal packing had the highest success rate (95.6%) compared to anterior nasal packing (84.5%) and chemical cauterization (72.07%). The chemical cauterization in their study had lower success rate likely because nasal endoscopy was not used, and that may hinder visualization and identification of the bleeding site, thus reducing the success rate.

The group of patients treated with EC in this study had a statistically significant lower rate of recurrence (6.5%) compared with AP (31.1%) and PP (25.7%), respectively (Chi-square χ2– 6.596, P = 0.037). This is similar to the findings of Shamas[26] where 10% of the patients treated with endoscopic cauterization had recurrence. However, another author reported no re-bleeding for endoscopic-assisted silver nitrate cauterization method, but 16% recurrence rate for conventional nasal packing.[11] In this review, the complication rate in patients treated with EC was found to be lower (3.2%) than that of the patients treated with AP (11.7%) and PP (14.3%), respectively. However, Ha et al.[11] recorded no complication in patients treated with endoscopic assisted cauterization, but 44% complication rate in patients that had conventional nasal packing.

The mean hospital stay for patients treated with EC in this study was shorter (0.8 ± 0.6 days) compared to the group treated with AP (3.2 ± 0.9 days) and PP (6.2 ± 2.7 days). The EC group had a statistically significant lower mean hospital stay compared to AP group (t = 11.353, P = 0.000) and PP group (t = 10.737, P = 0.000). This is in agreement with the findings of a research conducted in Australia where the patients treated with endoscopic cauterization had a significantly lower length of hospital stay (mean = 0.84 days, range <1–1 days) compared to patients treated with conventional nasal packing (mean = 1.55 days, range <1–6 days) [t = 2.05, P = 0.049].[11] The shorter hospital stay associated with endoscopic-assisted cauterization might be of advantage to both the patients and his employer, where the cost of hospital stay and loss of working hour is reduced.


  Conclusion Top


The endoscopic-guided silver nitrate cauterization is a safe procedure for the treatment of epistaxis, it has better success rate compared to nasal packing. The recurrence and complication rates were significantly lower in the group of patients treated with endoscopic cauterization, and the length of hospital stay was shorter than the group treated with nasal packing. Therefore, we strongly advocate the use of endoscopic-guided silver nitrate cauterization in the treatment of epistaxis, which will translate to lower complication, decrease hospital stay, and overall improvement in the management of epistaxis in our environment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Dawar SA, Ullah H, Inam A, Afridi S, Saeedullah S, Khan A, et al. Outcome of silver nitrate cauterization in adults with anterior epistaxis at a tertiary care hospital in Peshawar, Khyber Pakhtunkhwa. J Rehman Med Inst 2017;3:39-42.  Back to cited text no. 14
    
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Shukla PA, Chan N, Duffis EJ, Eloy JA, Prestigiacomo CJ, Gandhi CD. Current treatment strategies for epistaxis: A multidisciplinary approach. J Neuro Intervent Surg 2013;5:151-6.  Back to cited text no. 15
    
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    Figures

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