Epistaxis


Flowchart

*RAC = Rapid access clinic / Emergency ENT clinic

*RAC = Rapid access clinic / Emergency ENT clinic

Red flags/common pitfalls

  • Epistaxis associated with unilateral nasal blockage, facial pain, neurological or visual symptoms, orbital symptoms, or serosanguinous nasal discharge should prompt a cancer-wait referral.

  • Epistaxis in isolation is rarely a symptom of malignancy, even when unilateral.

  • Epistaxis in children is very rarely indicative of underlying pathology.  Juvenile nasopharyngeal angiofibroma can present with severe epistaxis (usually associated with unilateral nasal blockage) in adolescent boys.

 

History

  • How often do you have a bleed?  

    • Some patients can be very concerned by small monthly nosebleeds; others may be bleeding several times a day.

  • How long do the bleeds last?

    • This can help gauge severity.  A normal FBC is better reassurance in frequent bleeders.

  • How long has this been a problem?

  • Is it always one side?

  • Any other nasal symptoms?

  • Does anything bring your nosebleeds on?

    • Ask specifically about nose-picking, as this is a very frequent cause of ongoing bleeding.

  • What are you doing to try to stop the bleeding when it occurs?

    • Many patients present with insignificant nosebleeds that could simply be managed with better first aid technique.

    • Demonstrate correct first-aid technique to all patients with epistaxis.

  • What medications do you take?

    • Antiplatelet and anticoagulant medications significantly increase frequency and severity.

    • Nasal steroid sprays can cause minor epistaxis from physical irritation, not from “thinning the lining”. Ask the patient to nozzle backwards, not upwards, and slightly away from the septum in the midline.

 

Examination

Nasal examination

  • Examine the patient’s anterior nasal septum using a Thudichum speculum and a headlight (if available), or an otoscope.  Most examinations will be unremarkable.

  • It is often possible to visualise blood vessels in this area, but bear in mind that this does not necessarily mean this is the source of the epistaxis.

Look for:

  • A septal perforation

  • Ulceration or excoriation (usually related to digital trauma)

  • Rarely, a lesion on the nasal septum (usually a pyogenic granuloma)

 

Management in primary care/when to refer

  • Bear in mind that there is no permanent solution for epistaxis, even cautery or surgery.

  • Educate all patients to lean slightly forward and pinch the soft, lower half of the nose, clamping the nostrils closed for >15 mins.

  • Strongly discourage the patient from touching their nose/removing crusts.

  • In very frequent bleeders consider checking FBC.  Clotting screens usually do not influence the management of epistaxis; request only if you feel there is a high risk of derangement (EtOH intake etc).

  • A 10-day course of nasal cream (e.g. Naseptin QDS) has a similar effect size to nasal cautery.  Prescribe a course to all patients with frequent epistaxis.  The effect can last for several months and the course can simply be repeated if needed. If this is effective, onward referral is usually avoided.

  • If a patient does not respond to a course of Naseptin (or similar), refer to ENT.  Most departments have an emergency clinic with a defined referral pathway (call the on-call SHO if in doubt).  This is more suitable than general ENT clinic for patients who are having frequent self-limiting epistaxis.

  • Second-line treatment for epistaxis is silver nitrate cautery (more useful in unilateral epistaxis).  Resistant, severe cases can be treated with endoscopic sphenopalatine artery ligation.

Further reading

  • Lau A, Jacques T, Tandon S, Lesser T (2015). Evidence-Based ENT Emergency Care, 2nd ed. ISBN: 978-1-5076-4597-0.

 

Authors

Mr Elliot Heward, ENT Registrar, North West Deanery

Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London