Pathogenese und Therapie der Epistaxis – Eine prospektive Analyse von 108 konsekutiven Fällen an der HNO-Klinik der Philipps-Universität Marburg

Epistaxis is a frequent symptom in otorhinolaringology which often requires emergency treatment. A frequent appearance of epistaxis is observed under the influence of certain meteorological conditions. The intensity of the epistaxis can be very different and can requiere different treatment measures according to the localization of the bleeding. The different stepts in the management of epistaxis are influenced by certain accompanying diseases, that favor the emerging and the recurrent course of the epistaxis. This investigation examines 108 consecutive cases of epistaxis that were treated in the period by January to May 2003 in the clinic for otorhinolaringology, part of the university clinic of Marburg. The analyzed factors were among others the localization of the hemorrhage source, the treatment methods used, the accompanying diseases and the local nasal factors shown by the patients. The results showed the following data: The general average age of all 108 patients was 61.6 years. The average hospitalisation time was 4.4 days. The sexes ratio was balanced with 51.9% man to 48.9% woman. The meteorological influences on the increased appearance of patients with epistaxis were low temperatures, high air pressure values and small amounts of rainfall during the observed time. The most frequent localization of the epistaxis was the anteriore epistaxis, containing the Locus Kiesselbachii area (48 cases). In 24 patients the bleeding was a posteriore, usually diffuse epistaxis raising from the ethmoidal cells area. The other hemorrhage sources were caused by special local factors like traumatic injuries, local tumors or vascular malformations. The treatment of the anterior epistaxis was carried out primary with a focused coagulation of the hemorrhage sources (successful hemostasis in 82.5%) and could be performed in 24 cases without hospitalisation. Five patients hospilalised in other clinics of the Marburger university clinic were treated consultantly in this manner. Nineteen patients had to receive stationary treatment. The hospitalisation of 4 patients with initialy intense anterior epistaxis was due to observation and the exclusion of recurrent bleeding after the primary treatment. The hospitalisation of 15 older patient (average age: 70.5 years) was due to accompanying diseases that needed additional special treatment and that demonstrably favor the recurrent course of epistaxis: Eleven of the 15 patients showed an episode of elevated blood pressure during the episode of epistaxis and 10 patients received permanent anticoagulative medication. The 24 patients with posterior epistaxis showed an average age of 68.1 years and were all admited to a stationary treatment. The earlier mentioned accompanying diseases were more frequent in this group, than in the total patient collective. For example: 75% of the patients suffered form elevated blood pressure (in comparison with 48.1% in the total patient collective) and permanent anticoagulant medication was found in 70.8% of these patients (in comparison with 41.7% in the total patient collective). The treatment of the posterior epistaxis was performed in 18 of the 24 cases with nasal packings (successful hemostasis in 77.8%). In 6 cases of heavy posterior epistaxis it was necessary to use a posterior Bellocq-packing. In one patient an additional arterial embolisation of the maxillary arterie was performed. The 11 patients with bleeding from endonasal vascular malformations, like they can be found in the Osler-Weber-Rendu Syndrome, were admitted to a treatment with the Nd: YAG-laser under constant treatment with nose-unguents before and after the treatment. In one case a modified septal dermoplastic surgery was additionaly performed. These treatment methodes led to a significant improvement of frequency and intensity of the recurrent bleedings for the 11 patients for a period of 6 to 12 months. In the overall patient collective refractory bleedings were found in 6 patients after the initial treatment. Nine patients showed recurrent episodes of epistaxis that required additional treatment during the observed time of this study after the primary treatment was concluded. Of these 15 patients 12 showed episodes of elevated blood pressure during their first admition to the clinic and 9 patients received permanent anticoagulative medication. In this investigation it was found that the epistaxis events in more than 50% of the patients were caused by various factors, because all of these patients suffered from at least one of these factors that favor the appearance and the recurrent course of epistaxis (elevated blood pressure: 48,1%, anticoagulative medication: 41,7%,). These circumstances were even more significant in patients with posterior epistaxis. In the patients with anterior epistaxis, an additional treatment of accompanying diseases was necessary in 31.3% of the cases and led to a stationary admition of the patients during the management of the epistaxis.