DISCUSSION
Epistaxis is a common problem in the childhood age group. In 60% of the population, at least one epistaxis is seen until the age of 10. In most of the cases, the bleeding originates from the Kiesselbach plexus and causes anterior bleeding. Since the amount of bleeding is often low and self-limiting, it does not require hospitalization (2,10).
The true prevalence of epistaxis is largely unknown as most cases do not require medical attention and are therefore not reported. It has been reported that 0.46% of pediatric and adult emergency room visits between 1992 and 2001 had epistaxis and 6% of them were hospitalized (11). In our study, the annual incidence was found 1.23%. We think that this higher rate is due to the fact that our number of trauma (68.5%) is much higher than in this study (17%). In other studies, they reported the rate of referrals associated with epistaxis to be between 1% and 8% for both adult and pediatric patients admitted to the emergency department (12-13).
Epistaxis in the pediatric population can vary in age, gender and seasonal variation. The superiority of men (57.1%) in our study was consistent with the literature (1,2,5-7,10-11). Average age of patients with epistaxis; it was found 7.54 years in the studies of Shay et al. (1), 8.8 years in the studies of Davies et al. (10), and 10.1 years in the studies of Send et al. (6). The mean age in our study was 5.25 years and the reason for its lower than the literature was attributed to the higher number of patients under 1 year of age due to trauma. Seasonal differences stand out in each study. It is thought that regional climate and environmental factors also affect this situation (2,5). While it was frequently reported in the spring and summer months in one study (1), it was reported to be more common in the winter months in the other study (14). In our study, epistaxis was observed most frequently in autumn (37.6%).
In patients presenting with epistaxis, the location of the bleeding, the duration of the bleeding and its recurrent nature should be questioned in detail in the history taken. One study in the literature reported that 82.2% of the cases were unilateral (6), another study reported that 68.2% of the cases were unilateral (15). Bleeding times were reported to be shorter than 5 minutes in 60% of the cases in one study (10), and it was reported to last less than 30 minutes in 87.54% of the cases in the other study (16). In a study by Asma et al. (7) evaluating 150 cases, it was found that 39.3% of the epistaxis recurred. In our study, similar to the literature, most of the bleeding was unilateral, the bleeding time was less than 5 minutes, and approximately one fifth of the cases had a history of previous epistaxis.
In a study conducted in 2016 in which 216 cases between the ages of 2 and 18 were investigated, it was reported that the most common cause of epistaxis was trauma, the second most common cause was bleeding diathesis between the ages of 2-5 and idiopathic in other age groups (2). In a study, it was reported that 24.7% of patients without any history of trauma had a history of chronic disease and that the most common cause of epistaxis was due to local factors and among them, the most common infection was (15). In another study, they reported that the most common cause was idiopathic. In addition, 98.88% of these patients had no chronic disease and 96.09% did not have a history of drug use (16). In our study, local factors were determined as the most common cause in accordance with the literature, and systemic causes were found to be rare. In the first 10 age group, the most common cause was trauma, and the second most common cause was idiopathic. After the age of ten, idiopathic causes were the most common causes. There was no spontaneous epistaxis under one year of age and no systemic cause was found. In all age groups, there was no patient who presented with isolated epistaxis and was diagnosed with bleeding disorder. Only two patients who presented with epistaxis and had petechiae on physical examination were diagnosed with ITP. This situation actually reveals the importance of physical examination. In addition, 86.7% of our patients did not have a chronic disease and 88.1% did not have a history of drug use. Since our hospital is a center where trauma is examined, the majority of our number belonged to this group and most of them were different from the literature.
The location, severity and clinical condition of the patient are as important as the etiology of the bleeding in planning the treatment. The majority of epistaxis are controlled by simple methods such as spontaneous or local compression. Few of them require advanced treatment methods such as coagulation with silver nitrate and bipolar electrodes, nasal packing, surgical options, and embolization. The most effective treatment is compression (6,9). Nasal mucosal hydration and nasal care are sufficient to treat most patients. Recovery was reported with nasal mucosal hydration in 77% in the study by Elden et al. (8) and 65.2% in the study by Patel et al. (5). Again, in this study, 14 (10.4%) patients were treated with silver nitrate cautery, and it was reported that the patients who underwent cauterization were at an older age and had longer symptom durations (5). In our study, active bleeding were present in 14 (3.7%) patients at the time of admission to the PED. Similar to the literature, most patients (96%) did not require treatment. Similar to our study, in a study where the most common etiological cause was trauma, observation alone (e.g. nasal mucosal hydration, use of topical decongestants, topical antibiotics and foreign body removal in selected cases) was sufficient in treatment in 61% of traumatic patients, while in 55.8% of the inflammatory group and it was reported that in 66.7% of the blood dyscrasia group, nasal packing was needed to control epistaxis (2).
History, physical examination, if necessary, laboratory examinations and radiological imaging should be performed in the evaluation of epistaxis. Research is not required in the majority of cases. Complete blood count (CBC) and coagulation screening are not routinely required unless there is a history of significant bleeding. When a systemic disease is considered in the etiology, an evaluation selected for diagnosis should be planned. It should be kept in mind that coagulation factors do not provide information about vascular integrity, function of platelets, Von Willebrand factor or fibrinolysis (3,8). They emphasized that although 74.9% of laboratory tests were performed in a study conducted in 2014, clinical judgment is important in the selection of patients for laboratory examination and that it can be considered in selected cases such as patients who continue to bleed despite nasal lubricants (5). In our study, no laboratory examination was performed in most patients (73.9%). In a study, it was reported that 13 (21.6%) of a total of 60 patients, 6 of whom had a history of bleeding disease, had a CBC examination. Similar to the literature, CBC was evaluated in a small number of cases (26.1%). However, due to the uncomfortable personalities of doctors, especially pediatricians, and to avoid any disease, cause at least one CBC test to be performed.