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Current Approaches to Epistaxis Treatment in Primary and Secondary Care

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Current Approaches to Epistaxis Treatment in Primary and Secondary Care

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Background: The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment.

: This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience.

: There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retrospective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk.

Conclusion: The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.

Mild episodes of epistaxis stop spontaneously or are treated, often successfully, by the primary care physician or by the emergency physician. Only when nosebleeds are recurrent or severe are patients referred to an otorhinolaryngologist or to an accident and emergency department for further diagnostic assessment and treatment. No guideline exists in Germany today on the treatment of epistaxis. The aim of the present article is to provide an up-to-date overview of knowledge regarding its epidemiology, anatomy, and risk factors. Specific recommendations will be given for the treatment of epistaxis at the primary and secondary levels of care.

Learning goals

After reading this article, the reader should:

Have acquired a general understanding of the epidemiology, anatomy, and causes of epistaxis.

Know the most important basic elements of the treatment of epistaxis.

Be familiar with the diagnostic and therapeutic procedures performed by, respectively, general practitioners and emergency physicians, otorhinolaryngologists, and ear, nose, and throat (ENT) hospital departments.

Method

This article is based on a selective literature search of the PubMed database, searching for the terms "epistaxis," "epistaxis anticoagulation," "epistaxis therapy," "epistaxis packing," and "epistaxis embolization" in the title of articles published between 1 January 2000 and 1 February 2017. Some older standard publications, textbooks, and our own clinical experience were also included.

Epidemiology

Anatomy

The arterial supply of the nasal cavity is shown in Figure 1. In 90% to 95% of cases, the bleed occurs anteriorly in the area of the anterior part of the nasal septum, the Kiesselbach area (or Little's area) ( 7- 10), and in 5% to 10% of cases it occurs posteriorly in the posterior region of the nasal cavity ( 7, 10, 11).

Causes/Etiology

Ingestion of anticoagulant drugs increases the risk of epistaxis ( 19). About 24% to 33% of all patients hospitalized for epistaxis take anticoagulants and/or antiplatelet drugs ( 20, 21). Ingestion of acetylsalicylic acid increases the severity and number of recurrences of epistaxis and the need for surgical intervention ( 22, 23). A retrospective cohort study in Zurich, Switzerland, showed ingestion of vitamin K antagonists to be an independent and significant risk factor for recurrent epistaxis with an odds ratio (OR) of 11.6 ( 23). Prescription of direct oral anticoagulants for patients is increasing ( 24). There is currently a paucity of data concerning this group of drugs in relation to epistaxis.

One prospective observational study showed a reduction in the number of cases of severe epistaxis in patients taking dabigatran versus vitamin K antagonists. Hospital stay was longer for dabigatran patients, however, because the lack of an easily available coagulation test and persistent oozing after removal of packing made it necessary to keep the patients under continued observation ( 25). One retrospective study of epistaxis in patients taking rivaroxaban showed a lower percentage of inpatient admissions (10.4% versus 18.0%, p = 0.033) and shorter hospital stay (0.7 ± 2.2 versus 1.5 ± 3.7 days, p = 0.011) in comparison to patients taking vitamin K antagonists ( 26). Another risk factor identified was alcohol ( 14- 16). One randomized, controlled, double-blind study showed that steroid nasal sprays increase the risk of epistaxis within 12 months in comparison to placebo from 8% to 20%. The nosebleeds that occurred were slight to moderate; only 1 of 605 patients suffered a severe nosebleed within 12 months ( 27). In a meta-analysis of randomized, controlled studies, epistaxis was reported to be the most frequent undesired effect of PDE-5 inhibitors, with a relative risk of 4.701 (95% confidence interval [95% CI]: [1.314; 16.812], p = 0.017) ( 28).

Treatment of epistaxis

No uniform guidelines exist for diagnostic and therapeutic procedures in patients with epistaxis. However, clinically tried and tested treatment paths do emerge in hospitals and doctors' offices, based largely on retrospective analyses, case series, and expert opinion. Only few prospective or randomized controlled studies are available for some discrete areas of epistaxis treatment.

Epistaxis ranges from light nosebleeds that are easy to manage using simple methods to life-threatening bleedings that require hospital admission and may even need surgical treatment.

For a structured overview of the interdisciplinary management of epistaxis, in this article treatment recommendations are given separately for level 1 (primary care physician/emergency physician), level 2 (otorhinolaryngologist), and level 3 care (hospital ENT department). Figure 2 shows the treatment algorithm developed by ourselves, which includes treatment recommendations from the international literature as well as our department's own in-house standard operating procedures. Some steps are relevant at all three levels of care.

Contamination control

Measures to prevent contamination must always be observed. It is recommended that all who have close contact with patients, e.g., in the course of rhinoscopy or endoscopy, should wear protective eye gear, lab coat, gloves, and a face mask ( 12).

Initial assessment of breathing and hemodynamics

Especially in cases of severe bleeding, following the ABC approach, security of the airway, breathing, and cardiovascular stability should be assessed ( 29- 31). If symptoms of hypovolemia are found, a peripheral venous access should be placed and volume replacement therapy started. Early blood pressure measurement is an essential part of the diagnostic process.

History taking

Blood tests

In many cases of uncomplicated epistaxis, no blood tests are required. If the patient is on anticoagulation therapy, however, coagulation testing with International Normalized Ratio (INR) measurement should be carried out.

Imaging

Imaging is not usually necessary. However, in patients with recurrent epistaxis of unknown cause, imaging should be carried out to investigate the possibility of neoplastic disease such as juvenile nasopharyngeal angiofibroma ( 32).

Management of patients on anticoagulants

In France, guidelines on the management of epistaxis in patients taking anticoagulants have existed since 2016 ( 33). In acute epistaxis, these recommend screening for overdose and assessment of the risk of thrombosis. Anticoagulation therapy should always be continued so long as the bleeding can be stopped or controlled. Only if bleeding is massive and unstoppable, or if an anticoagulation overdose is found, should adjustment of the anticoagulation therapy be considered in consultation with a hematologist and cardiologist.

Antiplatelet drugs

Because it takes up to 10 days for hemostasis to be restored after cessation of antiplatelet therapy, stopping antiplatelet drugs in a patient with acute epistaxis is not useful. If the bleeding cannot be halted, stopping antiplatelet therapy while at the same time giving platelet transfusions is an option ( 33).

Vitamin K antagonists

For a patients taking a vitamin K antagonist, the drug should be stopped and an antidote given only if the bleeding is uncontrollable. If the vitamin K antagonist has been overdosed and the bleeding can be controlled, the dosage should be altered ( 33).

Direct oral anticoagulants

Stopping medication with direct oral anticoagulants is recommended only after consultation with a cardiologist. If bleeding is uncontrolled, dabigatran is the only drug for which an antidote (idarucizumab 5 mg in two consecutive 5- to 10-min intravenous infusions) is currently available ( 33).

Anticoagulation treatment should not be altered in a patient about to undergo endovascular embolization (expert opinion) ( 33).

Preventing recurrence

To prevent recurrences, intensive care of the nasal mucosa using an antiseptic nasal cream is recommended. A prospective, randomized, controlled study in the United Kingdom in children with recurrent epistaxis compared treatment with an antiseptic cream for 4 weeks versus a wait-and-see policy. A significantly lower recurrence rate was seen in the treatment group (45% versus 71% recurrence rate, relative risk reduction 47% with 95% CI [9%; 69%]) ( 34). In addition, energetic nose blowing should be avoided for 7 to 10 days ( 29). Bed rest is not necessary. According to a Danish prospective, randomized study, mobilizing the patient does not increase recurrence in comparison to bed rest ( 35).

Treatment by the primary care physician and/or emergency physician

The first step is to compress both sides of the nose continuously for 15 to 20 min, using two fingers or a nose clip ( 29, 36, 37). The patient should sit upright and lean slightly forward to prevent the blood from running down the pharynx ( 12). Local application of ice, e.g., at the back of the neck, is intended to encourage vasoconstriction of the blood vessels of the nose. Its therapeutic value is a matter of debate and has been challenged in the literature ( 19, 38). No final conclusion can be drawn on the basis of existing publications. In patients with raised blood pressure that is not causing symptoms (>180/120 mmHg, measured several times), the European Society of Hypertension and the European Society of Cardiology recommend oral medication to reduce the blood pressure. The aim is to slowly reduce the blood pressure over a period of 24 to 48 hours ( 39, 40). In around 65% to 75% of cases, these steps combined with application of a decongestant, oxymetazoline-based nasal spray will succeed in stopping the bleeding ( e1, e2). If bleeding does not restart during a 30-min observation period and the patient is hemodynamically stable, emergency specialist ENT treatment is not required.

In the presence of any of the following, we recommend consultation with an otorhinolaryngologist:

Epistaxis uncontrollable by the measures described above

Recurrent epistaxis

Suspected neoplasm as the source of the bleed

Treatment by an otorhinolaryngologist

Anterior rhinoscopy

Endoscopy

Cauterization

Most cases of epistaxis from an easily visible anterior source can be effectively treated by cauterization with silver nitrate or electrocoagulation. Before starting the procedure, a vasoconstrictor and local anesthetic should be applied ( 30). Figure 3 shows a bleeding from the Kiesselbach area before and after bipolar coagulation. A Swiss retrospective study showed that in terms of therapeutic success, electrocoagulation was superior to chemical coagulation (88% versus 78%) (failure rate 12% with 95% CI [0.09; 0.16] versus 22% with 95% CI [0.14; 0.33]) (evidence level 2b) ( e4). A US study of children treated intraoperatively by these same two methods for recurrent anterior epistaxis also found a lower recurrence rate for electrocoagulation than for chemical cauterization during the 2-year period after the procedure (recurrence events 2% versus 18%) ( e5). Chemical cautery is described as simpler to use, cheaper, and more widely available ( e6). Complications of cauterization include septal perforation, infection, rhinorrhea, and increased bleeding ( 12). Bilateral cautery in the area of the nasal septum should be avoided if possible, as this risks septal perforation ( e7). There are no published studies on the incidence of septal perforation after cautery ( e8, e9).

Hemostatic gauze

As a supplement to cautery, local application of gauze made of oxidized regenerated cellulose can be used. As a resorbable hemostyptic, it supports physiological hemostasis. Diffuse mucosal bleedings in particular can often be adequately managed by the application of a thin layer of this gauze ( e10).

Nasal packing

If cauterization is unsuccessful, the next step in managing epistaxis is nasal packing. Packing takes different forms for anterior and posterior bleeding. Bilateral nasal packing produces a higher intranasal pressure than unilateral packing and its practice is therefore widespread, although there is little evidence to support this ( e11)

Comprehensive overviews of the features and mechanism of action of the most common forms of nasal packing are presented by Beule et al. in their 2004 publication ( e12) and by Weber in his 2009 review article (e 10). The eFigure shows a selection of items in common use for nasal packing. The main nasal packing products used in Germany are rubber-coated sponge packs or tampons (Gummifingerlingstamponaden), expandable sponge packs, and ribbon gauze impregnated with a medical cream ( e12) (for more details see eBox 1).

Complications of nasal packing-The most serious complication of nasal packing is posterior dislocation. Reports have been published of fatal aspiration of nasal packs ( e13). Rubber-coated sponge tampons and cotton ribbon gauze packs are liable to dislocate ( e10). To prevent this, all nasal packs must be strongly fixed to the patient's face, e.g., with sticking plaster on the bridge of the nose or the cheek ( e7, e12). Additionally, the threads attached to some packs should be tied together in front of the columella. Other reported complications include allergic reaction, mucosal necrosis, foreign body reaction, tube dysfunction, paraffinoma, and decompensation of pre-existing sleep apnea ( e7, e10, e12). Nasal packing can also cause discomfort for the patient in the form of pain, obstructed breathing, and a reduced sense of smell ( e10). In addition, bilateral nasal packing can result in impaired pressure equalization via the auditory (Eustachian) tube, leading to the patient's discomfort due to negative pressure in the middle ear ( e10). There have been case reports of staphylococcal toxic shock syndrome as a serious complication ( e14- e16). The release of toxic shock syndrome toxin 1 (TSST1) causes symptoms such as vomiting, diarrhea, fever, myalgia, diffuse erythema, and even septic shock. Treatment consists of immediate removal of the packing, intravenous antibiotics, and transfer of the patient to an intensive care ward ( e10).

Removal of packing-When to remove the packing is variously defined in the literature, ranging from 12 or 24 hours to 3 to 5 days after placement ( 12, 29, 30). For anterior packing alone, we recommend removal after 48 hours. Where a nasopharyngeal balloon has also been placed, this should be at least partially deflated after 24 hours at the latest. If clinically significant bleeding starts again after packing removal, we advise surgical treatment where possible.

Treatment in the ENT department

From the point of view of the ENT department, for both unilateral and bilateral packing, inpatient admission for observation and packing removal are recommended because of the risk of posterior dislocation.

Other indications for inpatient admission are shown in Figure 2.

Surgical treatment

When conservative treatment fails, surgical hemostasis is generally required. A Swiss retrospective cohort study showed surgical intervention to be markedly superior to packing in the management of posterior epistaxis (treatment failure rate 3% [0.00; 0.14] versus 38% [0.30; 0.67]) ( e4).

The method of choice is endoscopic clipping or coagulation of the sphenopalatine artery ( e19). A British study reviewed the evidence for endoscopic sphenopalatine artery ligation and compared it to alternate methods. The former proved to be superior to the other treatment methods (monopolar cautery, embolization, etc.), controlling the bleeding in 98% of cases ( e20). In retrospective cohort studies, recurrence of bleeding, intranasal dryness with crust formation, sinusitis, impaired nasal and palatal sensitivity, formation of intranasal synechiae, unilateral chronic epiphora, and septal perforation have all been reported as complications. One Brazilian retrospective longitudinal study reported a case of amaurosis after the intervention ( e21). Taken together, these studies show endoscopic sphenopalatine artery ligation to have few complications ( e21- e25). Clinically significant hypoxia of the territory supplied by this artery has not been described and is not anticipated, given the multiplicity of anastomoses between the sphenopalatine and ethmoidal arteries ( 9). For this reason, the criteria for surgical treatment can be quite wide: recurrence of bleeding after one attempt at packing and where the source of the bleeding is not evident ( e19). Surgical hemostasis (eBox 2) should also be considered early on in patients with persistent bleeding despite packing. Endoscopic ligation of the anterior ethmoidal artery is indicated mostly in the context of revision surgery. In four retrospective studies, approximately 2.9% to 8.6% of all patients undergoing surgery for severe epistaxis had anterior ethmoidal artery ligation ( e21- e23, e26).

Embolization

Another possible method in patients with epistaxis that is difficult to control is percutaneous embolization. This technique has a reported success rate of 87% to 93% ( e27- e29). The target vessel is imaged angiographically and then an occluding agent is injected via a percutaneous transarterial catheter ( e30). The embolization should be carried out by an experienced interventional neuroradiologist ( e31). Because of the potential for complications such as cerebrovascular ischemia, facial nerve paralysis, and soft tissue necrosis, some authors recommend using this technique only in patients who have an increased anesthetic risk because of other comorbidities, or in whom attempted surgical treatment has failed ( 30). One retrospective cross-sectional study in the US compared embolization with surgical vascular occlusion in terms of morbidity, hospital mortality, and duration of hospital stay. No significant differences were found in relation to blood transfusions (22.8% versus 24.3%), stroke (0.5% versus 0.3%), amaurosis (0.4% versus 0.5%), and hospital mortality. However, surgery is associated with lower hospital costs and a shorter hospital stay ( e32).

Treatment of epistaxis in children

An overview of recommended treatment strategies in epistaxis in children is given in a French systematic review by Béquignon et al. ( e33). In addition to removal of clots, bidigital compression, and (permissible from the age of 6 onwards) application of a local anesthetic and decongestant, the use of an antiseptic cream is recommended ( e33). If bleeding persists, chemical cautery (silver nitrate stick) should be preferred to electrical cautery, as electrical cautery is more painful and would therefore require a general anesthetic ( e33).

Conclusions for clinical practice

In 65% to 70% of cases of epistaxis, simple first aid measures provided by the primary care physician or emergency physician stop the bleeding. If bleeding -persists, specialist ENT expertise should be urgently consulted. So long as the source of the bleeding is visible, most cases of epistaxis can be successfully treated using electrical or chemical cautery. In cases where the bleeding source is posterior, or where the bleeding remains refractory to packing, surgery should be considered early on and liberally. Because of its high success rate and comparatively low complication rate, endoscopic ligation or coagulation of the sphenopalatine artery is the method of choice. In cases of severe epistaxis, where surgical treatment fails or the patient has a high anesthetic risk, percutaneous embolization is a reasonable alternative.

Epidemiology
The lifetime prevalence of epistaxis is 60%. Only about 6% to 10% of those affected seek medical help.

Anatomy
In 90% to 95% of cases of epistaxis, the source of the bleed is in the area of the anterior part of the nasal septum, the Kiesselbach area (Little's area).

Causes
The most frequent cause of epistaxis is trauma due to digital manipulation.

Treatment
The treatment of epistaxis requires a structured interdisciplinary approach by the primary care physician, emergency physician, otorhinolaryngologist, and hospital ENT department.

Contamination control
It is recommended that all who have close contact with patients, e.g., in the course of rhinoscopy or endoscopy, should wear protective eye gear, a lab coat, gloves, and a face mask.

Patients on anticoagulants
If the bleeding can be stopped or controlled, anticoagulation therapy should be continued. Only if bleeding is massive and unstoppable, e.g., due to anticoagulation overdose, should adjustment of the anticoagulation therapy be considered.

Direct oral anticoagulants
Stopping medication with these drugs is recommended only after consultation with a cardiologist. If bleeding is uncontrolled, dabigatran is the only drug for which an antidote is currently available.

Treatment by the primary care physician and/or emergency physician
Important basic measures are compression of the nostrils, oral medication to reduce blood pressure if appropriate, and use of an oxymetazoline nasal spray.

Treatment by an otorhinolaryngologist
For anterior epistaxis, the treatment of choice is bipolar coagulation. Where bleeding is persistent or from a posterior source, the first step is nasal packing.

Nasal packing
The main nasal packing products used in Germany are rubber-coated sponge packs, expandable sponge packs, and ribbon gauze impregnated with a medical cream.

Complications of nasal packing
Posterior dislocation, allergic reaction, mucosal necrosis, foreign body reaction, tube dysfunction, paraffinoma, decompensation of pre-existing sleep apnea, and staphylococcal toxic shock syndrome.

Treatment in an ENT department
For posterior epistaxis, surgical intervention is markedly superior to packing. The method of choice is endoscopic clipping or coagulation of the sphenopalatine artery, which controls the bleeding in 98% of cases.

Embolization
Where surgical treatment fails or the patient has a high anesthetic risk, percutaneous embolization is a reasonable alternative.

Treatment of children
In a child with persistent bleeding, chemical cautery (silver nitrate stick) should be preferred to electrical cautery, as electrical cautery is more painful and would therefore require a general anesthetic.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Corresponding author
Prof. Dr. med. Andreas Dietz
Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde
Liebigstr. 10-14,
04103 Leipzig, Germany
andreas.dietz@medizin.uni-leipzig.de

► Supplementary materialFor eReferences please refer to:
www.aerzteblatt-international.de/ref0118

eBoxes, eFigure:
www.aerzteblatt-international.de/18m0012

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6.

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28.

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e7.

e18.

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e34.

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Deutscher Ärzteverlag GmbH, Redaktion Deutsches Ärzteblatt

# data[].attributes.attachment_link.title
Current Approaches to Epistaxis Treatment in Primary and Secondary Care (08.01.2018)

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Background: The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment. : This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience.

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Systematic endoscopic assessment of bleeding sites in severe epistaxis: the role of the S-point and the superior epistaxis

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Systematic endoscopic assessment of bleeding sites in severe epistaxis: the role of the S-point and the superior epistaxis

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Free Download Volume: 58 - Issue: 5 First page: 477 - Last page: 481 C.N. Loures - T.C. Castro - G.R. Luz-Matsumoto - V.S. Siebert - L.S. Lacerda - M.V. Miranda - M.S. Tepedino - L. Balsalobre - A.C. Stamm - E.M. Kosugi
BACKGROUND: Systematic endoscopic assessment (SEA) of bleeding sites is critical for topodiagnosis and treatment of severe epistaxis, which is not limited to the posterior region. A bleeding site originating from the ethmoidal vasculature, the S-point, has recently been described. The aim of this study is to ascertain the prevalence of each bleeding site in severe epistaxis using a SEA protocol that includes the S-point.
METHODOLOGY: Prospective longitudinal study of 51 severe epistaxis patients who underwent 53 SEA under general anesthesia from April 2018 through March 2019. SEA consisted of use of a rigid nasal endoscope; no reduction in blood pressure; no use of topical vasoconstrictor; systematic search of all regions of the nose. Bleeding sites were assigned to either superior or posterior epistaxis.
RESULTS: At least one bleeding site was identified in 37 evaluations (69.8%). The S-point was the most common bleeding site (28.3%), followed by the lateral middle turbinate (9.4%), non-S-point upper septum (7.5%), nasal roof (7.5%), and upper lateral wall (7.5%). Superior epistaxis was identified in the most of cases (27 SEA, 50.9%), whereas only 14 SEA (26.4%) identified posterior epistaxis - fewer than the 16 SEA that did not identify any bleeding sites (30.2%). There were two recurrences (3.8%).
CONCLUSIONS: Systematic endoscopic assessment effectively identified bleeding sites in 69.8% of severe epistaxis. The S-point was the most common bleeding site identified (28.3%). Finally, superior epistaxis corresponded to more than half of the identified bleeding sites, demonstrating the importance of examining this region judiciously in patients with severe epistaxis.
Rhinology 58-5: 477-481, 2020

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Free Download Volume: 58 - Issue: 5 First page: 477 - Last page: 481 C.N. Loures - T.C. Castro - G.R. Luz-Matsumoto - V.S. Siebert - L.S. Lacerda - M.V. Miranda - M.S. Tepedino - L. Balsalobre - A.C. Stamm - E.M.

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Prevalence and characteristics of S-point bleedingcompared to non S-point bleeding in severe epistaxis

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Prevalence and characteristics of S-point bleedingcompared to non S-point bleeding in severe epistaxis

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Endoscopic Sphenopalatine Artery Cauterization in Refractory Hypertensive Epistaxis

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Endoscopic Sphenopalatine Artery Cauterization in Refractory Hypertensive Epistaxis

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Indian Journal of Otolaryngology and Head & Neck Surgery (2021) Cite this article

Abstract

Epistaxis is a commonly occurring phenomenon which is defined as "bleeding from inside the nose" and often presents as an emergency. The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly. Endoscopic sphenopalatine artery cauterization is a safe, simple and effective procedure in the management of refractory epistaxis. Moreover, in view of minimal morbidity, higher success rate, shorter hospital stays and higher patient satisfaction, our current practice is to consider this treatment option in the management of cases not responding to conservative treatment modalities. A total of 11 patients (8 males and 3 females) underwent sphenopalatine artery cauterization during the study period. All patients were hypertensive and were refractory to treatment with general measures, anterior nasal packing and Foley catheter. The mean age of the study population was 58.36 and the range was 39-70 years. The epistaxis was rapidly controlled in all patients without any intraoperative or postoperative complications. The follow up period was 60-90 days. Strict control of hypertension was done throughout the follow up period. None of the patients developed epistaxis in the follow up period. The sphenopalatine artery cauterization technique using nasal endoscope was safe, simple, fast and effective with low rates of morbidity and complications for the management of refractory epistaxis. It was concluded that endoscopic sphenopalatine artery cauterization should be considered as an immediate second line treatment where conservative measures fail and it is proved to be of low morbidity and cost effective.

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Affiliations

Department of Otorhinolaryngology, Dr. Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, 695504, India

Sajilal Manonmony, Sreelakshmi Balakrishnan, Rejee Ebenezer Renjit & Avinash Mohan

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Correspondence to Sreelakshmi Balakrishnan.

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Manonmony, S., Balakrishnan, S., Renjit, R.E. et al. Endoscopic Sphenopalatine Artery Cauterization in Refractory Hypertensive Epistaxis. Indian J Otolaryngol Head Neck Surg (2021). https://doi.org/10.1007/s12070-021-02414-1
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Keyword

Hypertensive epistaxis

Treatment modalities

Endoscopic sphenopalatine artery cauterization

# data[].attributes.attachment_link.title
Endoscopic Sphenopalatine Artery Cauterization in Refractory Hypertensive Epistaxis - Indian Journal of Otolaryngology and Head & Neck Surgery

# data[].attributes.attachment_link.description
Epistaxis is a commonly occurring phenomenon which is defined as "bleeding from inside the nose" and often presents as an emergency. The management of epistaxis involves many factors with regard to the treatment and ultimate control of the condition. Each patient presenting with epistaxis should be well assessed clinically and managed accordingly.

# data[].attributes.headline
Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the emergency department

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Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the emergency department

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Sphenopalatine Artery Surgery for Refractory Idiopathic Epistaxis: Systematic Review and Meta-Analysis

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Sphenopalatine Artery Surgery for Refractory Idiopathic Epistaxis: Systematic Review and Meta-Analysis

# data[].attributes.attachment_link.title
Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta‐analysis

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Objectives
Epistaxis, especially posterior epistaxis, is occasionally refractory to treatment. In these cases, sphenopalatine artery surgeries, including cauterization and ligation, are required. Pr...

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Plain Language Summary: Nosebleed (Epistaxis)

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Plain Language Summary: Nosebleed (Epistaxis)

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doi: 10.1177/0194599819889945.

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

² Emory University Hospital, Atlanta, Georgia, USA.

³ Consumers United for Evidence-based Healthcare (CUE), Baltimore, Maryland, USA.

⁴ American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

doi: 10.1177/0194599819889945.

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

² Emory University Hospital, Atlanta, Georgia, USA.

³ Consumers United for Evidence-based Healthcare (CUE), Baltimore, Maryland, USA.

⁴ American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Abstract

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Keywords: epistaxis; hereditary hemorrhagic; nasal cautery; nasal packing; nosebleed; plain language summary.

Similar articles

Clinical Practice Guideline: Nosebleed (Epistaxis).

Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Tunkel DE, et al. Otolaryngol Head Neck Surg. 2020 Jan;162(1_suppl):S1-S38. doi: 10.1177/0194599819890327. Otolaryngol Head Neck Surg. 2020. PMID: 31910111

Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary.

Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Tunkel DE, et al. Otolaryngol Head Neck Surg. 2020 Jan;162(1):8-25. doi: 10.1177/0194599819889955. Otolaryngol Head Neck Surg. 2020. PMID: 31910122 Review.

Plain Language Summary: Sudden Hearing Loss.

Chandrasekhar SS, Hollingsworth DB, Monjur TM, Satterfield L. Chandrasekhar SS, et al. Otolaryngol Head Neck Surg. 2019 Aug;161(2):211-217. doi: 10.1177/0194599819859884. Otolaryngol Head Neck Surg. 2019. PMID: 31369348

Hypertension and Epistaxis: Why Is There Limited Guidance in the Nosebleed Clinical Practice Guidelines?

Payne SC, Feldstein D, Anne S, Tunkel DE. Payne SC, et al. Otolaryngol Head Neck Surg. 2020 Jan;162(1):33-34. doi: 10.1177/0194599819889972. Otolaryngol Head Neck Surg. 2020. PMID: 31910123

Review of Clinical Practice Guideline: Nosebleed (Epistaxis).

Kasle DA, Fujita K, Manes RP. Kasle DA, et al. JAMA Surg. 2021 Oct 1;156(10):974-975. doi: 10.1001/jamasurg.2021.2873. JAMA Surg. 2021. PMID: 34232284 Review. No abstract available.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Plain Language Summary: Nosebleed (Epistaxis) - PubMed

# data[].attributes.attachment_link.description
This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clini ...

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Systematic endoscopic assessment of bleeding sites insevere epistaxis: the role of the S-point and the superiorepistaxis

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Systematic endoscopic assessment of bleeding sites insevere epistaxis: the role of the S-point and the superiorepistaxis

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Free Download Volume: 58 - Issue: 5 First page: 477 - Last page: 481 C.N. Loures - T.C. Castro - G.R. Luz-Matsumoto - V.S. Siebert - L.S. Lacerda - M.V. Miranda - M.S. Tepedino - L. Balsalobre - A.C. Stamm - E.M. Kosugi
BACKGROUND: Systematic endoscopic assessment (SEA) of bleeding sites is critical for topodiagnosis and treatment of severe epistaxis, which is not limited to the posterior region. A bleeding site originating from the ethmoidal vasculature, the S-point, has recently been described. The aim of this study is to ascertain the prevalence of each bleeding site in severe epistaxis using a SEA protocol that includes the S-point.
METHODOLOGY: Prospective longitudinal study of 51 severe epistaxis patients who underwent 53 SEA under general anesthesia from April 2018 through March 2019. SEA consisted of use of a rigid nasal endoscope; no reduction in blood pressure; no use of topical vasoconstrictor; systematic search of all regions of the nose. Bleeding sites were assigned to either superior or posterior epistaxis.
RESULTS: At least one bleeding site was identified in 37 evaluations (69.8%). The S-point was the most common bleeding site (28.3%), followed by the lateral middle turbinate (9.4%), non-S-point upper septum (7.5%), nasal roof (7.5%), and upper lateral wall (7.5%). Superior epistaxis was identified in the most of cases (27 SEA, 50.9%), whereas only 14 SEA (26.4%) identified posterior epistaxis - fewer than the 16 SEA that did not identify any bleeding sites (30.2%). There were two recurrences (3.8%).
CONCLUSIONS: Systematic endoscopic assessment effectively identified bleeding sites in 69.8% of severe epistaxis. The S-point was the most common bleeding site identified (28.3%). Finally, superior epistaxis corresponded to more than half of the identified bleeding sites, demonstrating the importance of examining this region judiciously in patients with severe epistaxis.
Rhinology 58-5: 477-481, 2020

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Free Download Volume: 58 - Issue: 5 First page: 477 - Last page: 481 C.N. Loures - T.C. Castro - G.R. Luz-Matsumoto - V.S. Siebert - L.S. Lacerda - M.V. Miranda - M.S. Tepedino - L. Balsalobre - A.C. Stamm - E.M.

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Etiology, Management, and Outcome of Pediatric Epistaxis

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Etiology, Management, and Outcome of Pediatric Epistaxis

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Are Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis?

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Are Prophylactic Antibiotics Necessary for Anterior Nasal Packing in Epistaxis?

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Resection of the ethmoidal crest in sphenopalatine artery surgery

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Resection of the ethmoidal crest in sphenopalatine artery surgery

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https://pubmed.ncbi.nlm.nih.gov/27513601/

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Abstract

Background: In severe cases of epistaxis, in spite of several procedures described in the literature for its management, surgical treatment has been recognized by most authors as 1 of the most effective, especially when it includes ligation and/or electrocoagulation of the nasal branches of the sphenopalatine artery. The objective of this study is to determine the importance of ethmoid crest resection during sphenopalatine artery surgery, in the management of severe epistaxis.

Methods: We report a double-blinded randomized clinical trial, in which intervention was the ethmoid crest resection during electrocoagulation of the sphenopalatine artery. The study participants consisted of 42 patients with severe epistaxis and indication for surgical treatment, treated at the Otorhinolaryngology Emergency Room (ORL ER) of Hospital Sao Paulo, the teaching hospital of the Federal University of Sao Paulo.

Results: There was significant greater exposure of the arterial branch after removal of the ethmoidal crest (p = 0.009). The rate of bleeding within 48 hours of the procedure was significantly lower in the crest removal group.

Conclusion: Resection of the ethmoid crest during sphenopalatine surgery proved to be feasible without additional risks, including promoting decrease in the overall surgical time. It provided better exposure of arterial branches of the sphenopalatine foramen, leading to a lower rebleeding rate within 48 hours.

Keywords: endonasal surgery; epistaxis; ethmoidal crest; nasal surgical procedures; sphenopalatine artery.

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[Ethmoid sinus operation for therapy of recurrence severe epistaxis].

Metternich FU, Brusis T. Metternich FU, et al. Laryngorhinootologie. 1998 Oct;77(10):582-6. doi: 10.1055/s-2007-997030. Laryngorhinootologie. 1998. PMID: 9842523 German.

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Cassano M, Longo M, Fiocca-Matthews E, Del Giudice AM. Cassano M, et al. Auris Nasus Larynx. 2010 Apr;37(2):178-84. doi: 10.1016/j.anl.2009.06.008. Epub 2009 Aug 26. Auris Nasus Larynx. 2010. PMID: 19713060

Transcaruncular electrocoagulation of anterior ethmoidal artery for the treatment of severe epistaxis.

Morera E, Artigas C, Ferrán L, Trobat F, Tomás M. Morera E, et al. Laryngoscope. 2011 Feb;121(2):446-50. doi: 10.1002/lary.21372. Laryngoscope. 2011. PMID: 21271604

Endoscopic assisted external approach anterior ethmoidal artery ligation for the management of epistaxis.

Douglas SA, Gupta D. Douglas SA, et al. J Laryngol Otol. 2003 Feb;117(2):132-3. doi: 10.1258/002221503762624594. J Laryngol Otol. 2003. PMID: 12625888 Review.

Endoscopic management of posterior epistaxis: a review.

McClurg SW, Carrau R. McClurg SW, et al. Acta Otorhinolaryngol Ital. 2014 Feb;34(1):1-8. Acta Otorhinolaryngol Ital. 2014. PMID: 24711676 Free PMC article. Review.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Resection of the ethmoidal crest in sphenopalatine artery surgery - PubMed

# data[].attributes.attachment_link.description
Resection of the ethmoid crest during sphenopalatine surgery proved to be feasible without additional risks, including promoting decrease in the overall surgical time. It provided better exposure of arterial branches of the sphenopalatine foramen, leading to a lower rebleeding rate within 48 hours.

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Nasal Packing in the Emergency Department:A Practical Review for Emergency Providers

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Nasal Packing in the Emergency Department:A Practical Review for Emergency Providers

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Nasal Packing in the Emergency Department | OAEM

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We performed a narrative review of epistaxis management in the Emergency Department.

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Changing Trends in the Management of Epistaxis

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Changing Trends in the Management of Epistaxis

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Affiliation

¹ Department of Otolaryngology-Head and Neck Surgery, American University of Beirut Medical Center, Phase I, 6th Floor, Room C-638, Bliss Street, P.O. Box 11-0236, Beirut, Lebanon.

Free PMC article

Free PMC article

Affiliation

¹ Department of Otolaryngology-Head and Neck Surgery, American University of Beirut Medical Center, Phase I, 6th Floor, Room C-638, Bliss Street, P.O. Box 11-0236, Beirut, Lebanon.

Abstract

Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment modalities including cautery, nasal packing, maxillary artery ligation, anterior artery ligation, and sphenopalatine artery ligation. The paper also proposes an algorithm for managing such cases.

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Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary.

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Management of intractable spontaneous epistaxis.

Rudmik L, Smith TL. Rudmik L, et al. Am J Rhinol Allergy. 2012 Jan-Feb;26(1):55-60. doi: 10.2500/ajra.2012.26.3696. Am J Rhinol Allergy. 2012. PMID: 22391084 Free PMC article. Review.

Nasal Packing in the Emergency Department: A Practical Review for Emergency Providers.

Tran QK, Barnett J, O'Connell F, D'Anza B, Pourmand A. Tran QK, et al. Open Access Emerg Med. 2021 Dec 2;13:527-533. doi: 10.2147/OAEM.S247017. eCollection 2021. Open Access Emerg Med. 2021. PMID: 34880690 Free PMC article. Review.

Computed tomography findings in patients with primarily unknown causes of severe or recurrent epistaxis.

van Horn N, Faizy TD, Schoenfeld MH, Kohlmann P, Broocks G, Haag P, Fiehler J, Habermann CR, Karul M. van Horn N, et al. PLoS One. 2019 Aug 1;14(8):e0220380. doi: 10.1371/journal.pone.0220380. eCollection 2019. PLoS One. 2019. PMID: 31369603 Free PMC article.

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References

Rockey J. G., Anand R. A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy. Rhinology. 2002;40(3):147-149. - PubMed

Krempl G. A., Noorily A. D. Use of oxymetazoline in the management of epistaxis. Annals of Otology, Rhinology & Laryngology. 1995;9, part 1:704-706. - PubMed

Doo G., Johnson D. S. Oxymetazoline in the treatment of posterior epistaxis. Hawaii Medical Journal. 1999;58(8):210-212. - PubMed

Zahed R., Moharamzadeh P., AlizadehArasi S., Ghasemi A., Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. The American Journal of Emergency Medicine. 2013;31(9):1389-1392. doi: 10.1016/j.ajem.2013.06.043. - DOI - PubMed

Hilton L. Best evidence topic reports. BET 3: topical intranasal tranexamic acid for spontaneous epistaxis. Emergency Medicine Journal. 2014;(5):436-437. - PubMed

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national center for biotechnology information

# data[].attributes.attachment_link.title
Changing Trends in the Management of Epistaxis - PubMed

# data[].attributes.attachment_link.description
Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment mod ...

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Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

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Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary

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doi: 10.1177/0194599819889955.

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

² Cleveland Clinic, Cleveland, Ohio, USA.

³ University of Virginia School of Medicine, Charlottesville, Virginia, USA.

⁴ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

⁵ SUNY Downstate Medical Center, Brooklyn, New York, USA.

⁶ Ear Nose Throat of Georgia, Atlanta, Georgia, USA.

⁷ Consumers United for Evidence-Based Healthcare (CUE), Baltimore, Maryland, USA.

⁸ University of Rochester, Rochester, New York, USA.

⁹ Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.

¹⁰ Michigan State University, Grand Rapids, Michigan, USA.

¹¹ NYU Langone Health, New York, New York, USA.

¹² University of Wisconsin, Madison, Wisconsin, USA.

¹³ Pomona Pediatrics, a Division of Boston Children's Health Physicians, Pomona, New York, USA.

¹⁴ Massachusetts Eye and Ear, Boston, Massachusetts, USA.

¹⁵ Emory University Hospital Midtown, Atlanta, Georgia, USA.

¹⁶ Georgetown University, Washington, DC, USA.

¹⁷ Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA.

¹⁸ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

¹⁹ Weill Cornell Medical College, New York, New York, USA.

²⁰ Washington University School of Medicine, St Louis, Missouri, USA.

²¹ AdventHealth Medical Group, Celebration, Florida, USA.

²² University of Central Florida, Orlando, Florida, USA.

²³ University of South Florida, Tampa, Florida, USA.

²⁴ Inova Alexandria Hospital, Alexandria, Virginia, USA.

²⁵ Stanford University, Palo Alto, California, USA.

²⁶ American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

doi: 10.1177/0194599819889955.

Affiliations

¹ Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

² Cleveland Clinic, Cleveland, Ohio, USA.

³ University of Virginia School of Medicine, Charlottesville, Virginia, USA.

⁴ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

⁵ SUNY Downstate Medical Center, Brooklyn, New York, USA.

⁶ Ear Nose Throat of Georgia, Atlanta, Georgia, USA.

⁷ Consumers United for Evidence-Based Healthcare (CUE), Baltimore, Maryland, USA.

⁸ University of Rochester, Rochester, New York, USA.

⁹ Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.

¹⁰ Michigan State University, Grand Rapids, Michigan, USA.

¹¹ NYU Langone Health, New York, New York, USA.

¹² University of Wisconsin, Madison, Wisconsin, USA.

¹³ Pomona Pediatrics, a Division of Boston Children's Health Physicians, Pomona, New York, USA.

¹⁴ Massachusetts Eye and Ear, Boston, Massachusetts, USA.

¹⁵ Emory University Hospital Midtown, Atlanta, Georgia, USA.

¹⁶ Georgetown University, Washington, DC, USA.

¹⁷ Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA.

¹⁸ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

¹⁹ Weill Cornell Medical College, New York, New York, USA.

²⁰ Washington University School of Medicine, St Louis, Missouri, USA.

²¹ AdventHealth Medical Group, Celebration, Florida, USA.

²² University of Central Florida, Orlando, Florida, USA.

²³ University of South Florida, Tampa, Florida, USA.

²⁴ Inova Alexandria Hospital, Alexandria, Virginia, USA.

²⁵ Stanford University, Palo Alto, California, USA.

²⁶ American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Abstract

Objective: Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds.

Purpose: The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients.

Action statements: The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

Keywords: epistaxis; hereditary hemorrhagic telangiectasia (HHT); nasal cautery; nasal packing; nosebleed.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary - PubMed

# data[].attributes.attachment_link.description
The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding ...

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Foley catteter (Posterior nasal packing ballon 1) - Copy

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Foley catteter posterior anterior nasal packing - Copy