Epistaxis bei Kindern und Jugendlichen

In der vorliegenden Arbeit wurden die Krankenakten von 62 pädiatrischen Epistaxispatienten ausgewertet, um Besonderheiten der kindlichen Epistaxis und deren Therapie herauszuarbeiten. Bei 45/62 Patienten war zunächst keine direkte Ursache für die Blutung aus der Nase aufgefallen. In 13/62 Fällen war...

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Bibliographische Detailangaben
1. Verfasser: Harlfinger, Martin
Beteiligte: Folz, Benedikt (Prof. Dr.) (BetreuerIn (Doktorarbeit))
Format: Dissertation
Veröffentlicht: Philipps-Universität Marburg 2009
Hals- Nasen- und Ohrenheilkunde
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Inhaltsangabe: In this thesis, the medical records of 62 paediatric patients with epistaxis were analysed to identify the specifics of epistaxis in childhood and its therapy. In 45/62 cases no direct cause of the bleeding was evident. In 13/62 cases a trauma caused the haemorrhage. In most of those cases it was due to an accident and more rarely due to digital manipulation. In 3/62 cases the epistaxis occurred in combination with a syndrome, i.e. in two cases it was due to Morbus-Rendu-Osler and in one case due to Ectrodactyly-Ectodermal-Dysplasia-Clefting-Syndrome. One patient bled from a vascular malformation on the right side of her columella. In 60/62 cases, so called anterior epistaxis occurred, and only in 2/62 cases posterior bleedings occurred, which were both secondary to surgery within the nose or the nasopharynx. Out of the 45 patients without direct cause of the bleeding, 6 were diagnosed with increased or decreased blood pressure. No essential influence of the blood pressure on frequency or duration of epistaxis could be determined in the paediatric group. In 5/45 patients Willebrand’s disease was diagnosed, and 3/45 patients were under the influence of acetylsalicylic acid. In both groups, a longer than average bleeding duration could be shown. In 34/45 cases, the epistaxis did not appear in combination with a systemic disease. However, in 27/34 cases a conspicuous finding of the nasal mucosa was identified. Nineteen of 34 patients suffered from a dry nasal mucosa. A correlation to the climate could be shown because there was an increase of epistaxis on days with low humidity and during the winter months with dry interior climate produced by heating systems. More than one third of the patients (12/34 patients) had a prominent vessel shining through the mucosa at the anterior or lower edge of the nasal septum, and teleangiectic vessels appeared in 4/34 cases. The result of the analysis shows that long lasting haemorrhages of more than one hour duration mainly occur in connection with prominent vessels, while teleangiectatic vessels mainly correlate with frequently recurrent epistaxis. During the rhinoscopic examination of the anterior nasal septum, a vessel leading from the floor of the nose to Little’s area could be identified in several cases. In contrast to literature, anastomoses with vessels coming from the cranial portion of the septal mucosa deriving from the anterior ethmoidal artery could not be found. According to the findings of the present analysis, Little’s area is mainly supplied by the inferior branch of the sphenopalatine artery. Therefore, it should be the aim of therapy of recurrent epistaxis to obliterate this vessel. In 21/45 cases without direct cause of the bleeding, the first line of treatment was bipolar cautery. All acute bleedings could be stopped by this therapy. Six out of these 21 cases, required another treatment because of epistaxis in the following months. Only patients with prominent vessels, teleangiectatic vessels or Willebrand’s disease needed further treatment. Chemical coagulation with silver nitrate was applied in 2/45 cases. It was successful in one case. In 18/45 cases, Nd:YAG laser therapy was used. All patients suffered from long lasting or frequently recurring epistaxis, 2/3 of them had bipolar cautery before laser therapy, all without enduring success. All cases showed definite improvement of the epistaxis after laser therapy, which means that no noteworthy bleedings occurred under continuous moisturizing treatment of the nose with lubricants. For patients with long lasting or frequently recurring epistaxis, Nd:YAG-laser therapy seems to be more successful than bipolar cautery. Thus, this therapy should be recommended especially for patients with predisposing factors for epistaxis, such as prominent or teleangiectatic vessels on the nasal septum or for patients with notably long bleedings, for example patients with Willebrand’s disease. In addition, the laser therapy is appropriate for patients who were treated with bipolar cautery earlier without success. Therapy of the two patients with Morbus-Rendu-Osler was similar in both cases. It included a pre-treatment with lubricants and Nd:YAG laser therapy in the region of Little’s area. After an 8-weeks healing period, the other side of the nose was treated. Afterwards a continuous moisturizing therapy with lubricants was prescribed. During the two years following this treatment, neither patient reported significant complaints regarding epistaxis. The patient with the Ectrodactyly-Ectodermal-Dysplasia-Clefting-Syndrome could also be treated successfully with a time-shifted bilateral laser therapy and followed by the use of nasal ointments. However, no permanent improvement of epistaxis could be achieved in a patient with a large malformation of the nasal vessels in the region of the columella of one patient.