الفهرس | Only 14 pages are availabe for public view |
Abstract Epistaxis is a common problem in the pediatric population in particular, with the majority of cases being self limited and managed with simple first aid measures (Siddiq and Grainger, 2015). Almost all types of bleeding disorders may present with epistaxis including coagulation factor deficiencies, von Willbrand disease, and inherited platelet function disorders (Israels et al., 2010 and Nurden et al., 2012). In the light of the above mentioned facts we designed a cross sectional study that was conducted in the out-patient clinic of the Pediatric Hospital of Ain Shams University to measure the frequency of epistaxis as the presenting symptoms among children who attended pediatric outpatient clinic, and to estimate the severity of epistaxis using severity score as an assessment tool, and to determine possible underlying etiology of epistaxis and estimate frequency of secondary epistaxis due to bleeding disorder, and by using a pediatric bleeding questionnaire as a screening tool for detecting bleeding tendency in children with epistaxis; trying to reach the underlying etiology of epistaxis to diagnose underlying bleeding tendency that may spare those patients the risk of a life threatening bleeding one day. The study was conducted throughout a period of one year between the 22nd of December 2015and 22nd of December 2016, all recruited subjects were older than two and younger than 18 years with a mean of 7.89±3.8 years and included 53 females and 47 males. 57 patients were presented by other bleeding manifestations; the highest associated bleeding manifestation was cutaneous bleeding. The least association was bleeding after teeth extraction. Seventeen patients out of 100 patients had comorbidities. Five of them had local comorbidities; three of them had allergic rhinitis and one had paranasal sinusitis. The other twelve had systemic co-morbidities mainly in the form of diabetes mellitus and gastrointestinal disease. Basic screening by complete hemogram as well as PT, INR and PTT were performed for all recruited patients. Patients with normal bleeding profile in the form of normal hemogram as well as normal PT, INR and PTT yet a bleeding score exceeding or equal 2 which signifies an underlying bleeding had von Willebrand antigen assay as well as von Willbrand cofactor activity together with platelet function tests with ADP and ristocitein The total number of patients visiting the out- patient clinic was 30043 we recruited 100 patients of them who presented by epistaxis, showing a frequency of one in three hundred cases presented by epistaxis. 100 patients presented with epistaxis were recruited in our study. 43 presented with epistaxis only; 37 patients had normal ENT assessment and normal initial hematological assessment (CBC, PT, and PTT), they were diagnosed as idiopathic epistaxis, 6 patients had local ENT causes. Our results revealed no significant difference while comparing the underlying cause of epistaxis in relation to age, sex of recruited patients, consanguinity of their parents or recurrence of attacks. While there was a statistically significant difference for a positive family history for epistaxis, in the favor of the systemic cause. As our out-patients clinic is a tertiary center, we address the effect of referral on the prediction of cause of epistaxis. There was high statistically significant difference between patients as regard referral from a primary care physician in the favor of having a systemic underlying cause of epistaxis. There was a statistically significant difference as regard the seasonal variation in patients with systemic or local underlying cause of epistaxis in favor of the local cause of epistaxis. There were a statistically significant higher number of patients presented with epistaxis in the months of June, July, August and September and lower number in February and March. As for the site of bleeding most of the patients with epistaxis (90%) were presented by anterior bleeding, ten had undetermined site of bleeding and none had posterior bleeding. Out of 100 patients presented with epistaxis; the majority (96%) had only nasal compression while only 4 had anterior pack and 2 performed cautery. 57 patients were presented with bleeding manifestations beside the epistaxis and were expected to have bleeding disordres; out of them 10 patients had undiagnosed bleeding tendency. The number of cases definitely diagnosed as bleeding disorder were 47 patients; 16 had immune mediated defect (14 patients had ITP and 2 patients had autoimmune diseases (antiphospholipid antibody syndrome and systemic lupus)), 25 inherited defect (12 patients had platelet function defect, 10 patients had VWD, one patient had factor 7 deficiency, one patient had hemophilia A and another had hemophilia B) and 6 had other diseases ( 4 patients had bone marrow disease, One patient had DIC, one patient had post streptococcal glomerulonephritis and hypertension). 43 patients are now regularly following up at pediatric hematology clinic. In our study a bleeding score of 2 or more was of high statistical significance in detecting an underlying systemic cause of bleeding, it gave sensitivity of 85.9% and specificity of 95.35. While epistaxis severity score had statistically significant value in detecting an underlying systemic cause of epistaxis and it gave sensitivity of 66.67% and specificity of 58.14%. |