ROLE OF DIAGNOSTIC RIGID NASAL ENDOSCOPY IN THE EVALUATION OF BLEEDING POINTS AND MANAGEMENT OF EPISTAXIS

rhinoscopy gives a limited view of the nasal cavity. Diﬃculty in the localiza�on of bleeding points on anterior rhinoscopy is commonly encountered. We o�en face diﬃculty in the localiza�on of bleeding points, especially the hidden areas. Nasal endoscopy helps to iden�fy the hidden bleeding points and speciﬁcally control the bleeding.


INTRODUCTION
Epistaxis is frequently encountered as an otorhinolaryngologic 1 emergency and the prevalence varies from 10-12%. Epistaxis is seen in all age groups and is more common in 2 males. Causes of epistaxis can be idiopathic, local, or 3 associated with systema c condi ons. Local causes include any pathology in the nasal cavity, paranasal sinuses, or nasopharynx. Associa ons of epistaxis have been linked with systemic condi ons such as cirrhosis of the liver, coagulopathies, and also the use of an coagulant 2,3 medica ons for a long me. The nasal cavity is a highly vascular structure, contributed mainly by branches of the external caro d artery 2 anastomosing with branches of the internal caro d artery. Sphenopala ne artery is a major contributor to blood supply in the nasal cavity. Basically, epistaxis is classified into 3 anterior and posterior epistaxis. Most common site of anterior epistaxis is Li le's area, a vascular area formed by anastomosis of branches of the external caro d area with greater contribu on from a branch of the sphenopala ne 1-3 artery. Woodruff's plexus is a venous plexus in the posterior part of the inferior meatus, which is considered to be the site of the posterior epistaxis. 4 We o en face difficulty in the localiza on of bleeding points, especially the hidden areas. Anterior and posterior 3,4 rhinoscopies are not sufficient in visualizing bleeding points. They give a limited view of the nasal cavity, resul ng in poor visualiza on of hidden areas. Difficulty in localiza on of bleeding points on anterior and posterior rhinoscopy is a commonly encountered problem during the management of epistaxis. Furthermore, at the me of ac ve bleeding when pa ents are usually in a state of stress, it becomes almost impossible to visualize the bleeding point completely 5 without the use of endoscopes. Nasal endoscopy helps to iden fy the hidden bleeding points and specifically control the bleeding. Without proper visualiza on, it becomes difficult to control the bleeding. Nasal endoscopy is extremely useful in not just iden fying bleeding points but 2,3 also controlling the bleeding. Hirschman is credited for his first a empt to examine the nasal cavity via nasal endoscopy in 1901. He u lized a modified cystoscope to examine the sinonasal cavity. Reichert is remembered for the first endoscopic procedure. He named the procedure rudimentary maxillary sinus 5 manipula ons. In 1925, Maltz made wide use of nasal endoscopes for diagnos c evalua on of the sinonasal cavity and coined the term 'sinuscopy'. The crea on of the Hopkins rod system in the 1960s is considered the major landmark in the field of nasal endoscopy. However, Messerklinger used a rigid endoscope for the first me in endoscopic nasal and 5,6 sinus surgery. Messerklinger published a book in 1978 on diagnos c nasal endoscopy of the nose and paranasal sinuses which detailed the endoscopic anatomy and p at h o l o g y o f t h i s re g i o n a n d sta r te d to u l i ze polysomnography to improve visualiza on. The use of an endoscope has helped to understand intranasal anatomy and improved visualiza on as well as the management of 7 intranasal pathology.
Epistaxis is mostly controlled without interven on. However, around 6% of the cases need interven on to control bleeding and only 1% require hospitaliza on, with a 6 mortality rate below 0.01%. Epistaxis can usually be controlled by applying local pressure. However, interven on might be required when not controlled spontaneously and by conserva ve management. Management ranges from the applica on of topical vasoconstrictors, nasal packing, chemical or electro cauteriza on, and emboliza on to even liga on of vessels in 7,8 rare cases.

METHODOLOGY
This was a descrip ve cross-sec onal study conducted among pa ents a ending ENT OPD at Kathmandu University School of Medical Sciences from 25th November 2020 ll 25th April 2021. The main objec ve of our study was to demonstrate the efficacy of iden fying the bleeding site by nasal endoscopy and controlling epistaxis without nasal packing. Wri en informed consent was obtained from all the par cipants. Ethical approval was taken from the Ins tu onal Review Commi ee of Kathmandu University School of Medical Sciences. A total of 76 pa ents above 16 years of age presen ng with spontaneous epistaxis were included in the study. The pediatric popula on was wholly excluded from this study considering compliance with nasal endoscopy. Nasal bleeding following nasal surgeries like Septoplasty and Func onal Endoscopic Sinus Surgery were excluded from the study. Similarly, pa ents presen ng with epistaxis secondary to bleeding disorders, facial and nasal trauma, pregnant women along with those not willing to give consent were excluded from the study.
First of all, nasal cavi es were inspected through anterior and posterior rhinoscopies. Then nasal cavi es were packed with co on soaked in 2% Lignocaine and Oxymetazoline for 15 minutes. A er the removal of nasal packs, nasal endoscopy was performed with 0°, 30°, and the 45° Hopkin's Rod, 4mm in diameter. The first, second, and Third passes were performed sequen ally. Bleeding points were visualized, and findings were noted. Bleedings were controlled by 30 % Trichloro Ace c Acid in the OPD, and a few cases were managed with electrocautery in OT. Refractor y cases were managed by endoscopic sphenopala ne artery liga on (ESPAL) in opera on theatre under General Anaesthesia. Data were recorded in MS excel and analysis was done in SPSS version 21.

RESULTS
The total number of pa ents included in the study was 76. Among these 43 (56.5%) were male and 33(43.5%) were female. Pa ents from 18 to 81 years were included in the study. The mean age group was 38±13.4 years. The highest number of cases was seen in the 26-35 years of age group (Table 1). Among these pa ents, 53 (69.7%) pa ents presented with anterior epistaxis, and 22 (28.9%) presented 1 with posterior epistaxis. pa ent presented with bleeding  from the anterior as well as the posterior part of the nasal cavity. Bleeding from the right side of the nasal cavity was seen in 57.9% (n=44) and from the le in 40.8%(n=31). Bleeding from the bilateral nasal cavity was seen in 1.3%(n=1). On rigid nasal endoscopy majority of pa ents, i.e., 57.9 %(n=44) had no obvious abnormality associated with epistaxis( Table  2). This was followed by Deviated Nasal Septum with a septal spur (Figure 1). On localizing the bleeding points, 77.6% (n=59) of bleeding points were seen on the septum (Table 3). 69.7% of pa ents (n=53) presented with bleeding points anterior epistaxis, taking an imaginary line drawn from the anterior nasal process of frontal bone to nasal spine of a maxillary crest (Co le's line) as a demarca on (Table 4). 57.9% (n=44) of pa ents developed epistaxis on the right side (table 5). 58%(n=52) of pa ents were managed with endoscope-assisted chemical cauteriza on followed by endoscope-associated electro-cauteriza on using bipolar cautery. Among those managed endoscopically, the maximum number of pa ents (58.4%) were managed with endoscopic-assisted chemical cauteriza on using 30% Trichloro Ace c acid (TCA), followed by Endoscopic Assisted Electrocauteriza on (15.8%). (Figure 2).     Epistaxis is commonly encountered as an ENT emergency. It is es mated that up to 60% of the popula on experience 8,9 an episode of epistaxis in their life me. There are mul ple treatment op ons available for the management of epistaxis. However, endoscopic management of epistaxis is gaining popularity. The majority of pa ents were seen in the age group of 26-35 years of age group similar to studies 10 performed by Kodia et al. Male preponderance is seen in our study similar to different studies performed [10][11][12] worldwide. Although the exact reason for this could not be found, it is postulated that estrogen in females in a premenopausal state has a protec ve effect on the nasal mucosa against epistaxis. More exposure of males to outdoor environmental factors could be another reason for the difference. Anterior epistaxis is seen in 69.7% of pa ents in our study like pa erns seen worldwide as men oned in [13][14][15][16] different literature. Highly vascular anterior nasal septum is prone to bleeding in most cases. Unilateral bleeding with right-sided predominance is seen in our study like the study performed by 16 17 Varshney et al as well as by Cassano et al. Although extensive inves ga on op ons are available nowadays, similar to most of the studies performed worldwide, no obvious cause was found in 57.9% cases. This 18 finding is similar to studies performed by . When Ando et al no obvious causes are iden fied then they are labeled as idiopathic or primary epistaxis. This was followed by deviated nasal septum. Stretching of blood vessels seems to be the prominent reason for the bleeding. There are varie es of op ons available for controlling epistaxis ranging from conven onal methods of anterior and posterior nasal packing to liga on of arteries supplying 19 the nasal cavity. Method of treatment depends upon types, severity, causes, and availability of resources. The use of nasal endoscopes has revolu onized the management of epistaxis. It has not just replaced the use of uncomfortable 19,20 nasal packing but also minimized hospital stays. Posterior nasal packing may lead to hypoxia, infec on, columellar 21 necrosis, and prolonged hospital stay. In our study, not a single pa ent required nasal packing as all pa ents included in the study could be managed endoscopically. 58% of cases were managed by chemical cauteriza on using 30% Trichloroace c acid in OPD under visualiza on of the endoscope. Similarly, 16% of cases were managed with the use of endoscopic electrocauteriza on of bleeding points. 22 The study performed by Ahmed et al. reported an 89% success rate with endoscopic electrocautery in pa ents with epistaxis. 10% of the cases were managed with Endoscopic Sphenopala ne Artery Liga on (ESPAL) in our study. This is a reliable procedure in managing refractory epistaxis as it ligates a major artery supplying the nasal cavity and therefore minimizes the risk of refractory epistaxis from 20 collateral circula on. Success rate of ESPAL is found to be [22][23][24] between 92% to 100% as men oned in different literature. In our study, none of the pa ents presented again with epistaxis on monthly follow-ups a er ESPAL, during the study period. Nasal endoscopy helps to detect the pathologies inside the nasal cavity that can be easily missed 25 by clinical examina ons alone. In our study, hemangioma was localized in 5.3% of cases. Similarly, a bleeding nasal mass was localized on the lateral wall of the nasal cavity by nasal endoscopy, which was later diagnosed histologically as an inverted papilloma a er an excisional biopsy.

CONCLUSION
We found that the endoscope helped us to clearly visualize the hidden areas of the nasal cavity like the posterior part of the nasal septum, the posterior end of the nasal turbinate, the middle meatus, and the area where bleeding from the sphenopala ne artery occurs. Nasal endoscopy has not just helped in finding the cause and sites of nasal bleeding, but also immediately managing the cases with endoscopicassisted chemicals and electrocautery. Shortcomings of conven onal methods are being replaced by endoscopic management. Surgical interven on with ESPAL is one of the preferred interven ons nowadays for refractory cases due to its high success rate, comfort, and reduced hospital stay compared to other treatment modali es such as anterior and posterior nasal packing. Even severe instances can now be managed without nasal packing. Nasal endoscopy, on the other hand, is s ll not a replacement for nasal packing. However, because preserving the integrity of the nasal mucosa is given utmost importance, a nasal endoscope is gaining popularity as it avoids trauma to the normal mucosa caused by these packing.

RECOMMENDATIONS
Since this study was conducted on a limited number of pa ents for a dura on of five months the outcome of this study could have been more effec ve if the mul centric study was conducted in a large popula on for a longer dura on. However, the outcome of this study will help in poin ng out the need for rigid endoscopy in localizing the bleeding points and effec vely managing epistaxis. The use of nasal endoscopy should be promoted in clinical prac ces and further research should be carried out on a large scale.

LIMITATIONS OF THE STUDY
The main limita on of the study is the small number of par cipants and short me dura on. Moreover, this is a descrip ve cross-sec onal study.