SUMMARY:

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has released evidence-based guidelines on the management of epistaxis. Usually spontaneous and without obvious cause, it is estimated that nosebleeds will occur in ≥ 60% of individuals in the US and approximately 6% require care. Usual source is the nasal septum, although lateral walls are also vascular and may be a source.

• Possible secondary causes that require specific management: Systemic diseases and head and neck disorders including
  • Tumors of the nose or nasopharynx
  • Vascular malformations of the head and neck
  • History of recent facial trauma
  • History of nasal and/or sinus surgery within the previous 30 days
  • Hemorrhagic telangiectasia syndrome (HHT)
  • Leukemia
  • Liver disease
  • Coagulopathy
• Medications: e.g., anticoagulant or antiplatelet drugs
• Location
  • Anterior epistaxis is often manageable in the outpatient setting with the treatment plan described below | Can be visualizes with anterior rhinoscopy (nasal speculum) | 90% of epistaxis arises from anterior part of nasal septum
  • Posterior epistaxis is usually associated with brisk bleeding, may require acute hospital care | usually requires referral to specialist for endoscopy for visualization and treatment | Consider if bleeding not controlled with cautery or packing
• Treatment Goals
  • Control acute bleeding
  • Prevent recurrence
  • Prevent complications due to treatments
• First line treatments
  • Nasal compression
  • Topical vasoconstrictors
  • Moisturizing or lubricating agents
  • Nasal packing (resorbable and nonresorbable)
  • Nasal cautery (chemicals or electrocautery)
• More complex management for minority of patients with refractory nosebleeds
  • Endoscopic arterial ligation
  • Interventional radiology

KEY POINTS:

Treatment of Active Bleeding

• Apply firm, sustained compression to the lower third of the nose for ≥5 minutes (minimum)
  • Topical vasoconstrictors can aid in decreasing the bleeding
    • 0.05% oxymetazoline: Direct spray or soaked cotton
    • Epinephrine 1:1,000: soaked cotton (risk of systemic absorption and consequent tachycardia or elevated BP)
• Perform anterior rhinoscopy to identify a source of bleeding after removing any blood clots (do not cauterize blindly)
  • Nasal cautery
    • Usually done using silver nitrate
    • Electrocautery is used for more severe cases
    • Cauterize first in a circular pattern around active site first before cauterizing active site
  • Moisturizing or lubricating agents may be helpful
• If patient continues to have bleeding and source cannot be identified, apply nasal packing
  • Long duration for packing not advised | Time not specifically stated in the guidelines due to limited evidence | 48 hours reasonable and then reassess
  • Nasal packing (cotton stripping) impregnated with petrolatum (may come prepackaged) | Layer starting at floor of anterior nasal cavity (see AFP overview for more details in ‘Learn More – Primary Sources’ below)
    • Nasal tampons and nasal balloons also available
  • Some providers use antibiotics (oral or topical) but evidence is limited as to benefit
  • Patients at increased risk for bleeding due to medications
    • Use resorbable (i.e., absorbable, dissolvable) packing to avoid risk of bleeding that may occur upon removal of nonresorbable packing
    • Not necessary for patients taking low dose aspirin
• Use the opportunity to identify risk factors for epistaxis including
  • Personal or family history that may indicate familial bleeding disorder
  • Intranasal drug use
  • Medications (anticoagulants, antiplatelet)
• Recurrent bleeding (front line approaches not working)
  • Refer to specialist for nasal endoscopy to identify site and treat
  • May require surgical arterial ligation or endovascular embolization

Learn More – Primary Sources:

American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

AFP: Epistaxis – Outpatient Management