EpistaxisLast revised in August 2010Epistaxis - SummaryEpistaxis
is bleeding from the nose, caused by damage to the blood vessels of
the nasal mucosa.Most epistaxis is self-limiting and harmless, and
often the cause of damage to the blood vessels is not
identified.Local causes of damage to the blood vessels include
trauma, inflammation, topical drugs, surgery, vascular causes (such
as hereditary haemorrhagic telangiectasia, Wegener's
granulomatosis), or tumours (such as squamous cell carcinoma).More
general causes of damage include hypertension; atherosclerosis;
increased venous pressure from mitral stenosis; haematological
disorders such as thrombocytopenia, leukaemia, and haemophilia;
environmental factors such as temperature, humidity, or altitude;
systemic drugs such as anticoagulants and antiplatelets; and
excessive alcohol consumption.Complications of epistaxis are rare,
and include hypovolaemia, anaemia and complications from nasal
packing treatment.If the person is haemodynamically compromised,
epistaxis should be managed as an emergency, and immediate transfer
to hospital arranged.If the person is haemodynamically stable,
epistaxis can usually be managed with first aid measures: the
person should sit with their upper body tilted forward and their
mouth open; the soft part of the nose should be pinched firmly and
held for 1015 minutes.If a posterior bleed is suspected (bleeding
is profuse, from both nostrils, and the bleeding site cannot be
identified on examination), admission to hospital may be
necessary.If bleeding stops with first aid measures, a topical
antiseptic such as Naseptin (chlorhexidine and neomycin) cream may
be applied to prevent re-bleeding.If bleeding does not stop after
1015 minutes of pressure, nasal cautery or nasal packing (if
available) may be used to stop the bleeding, otherwise immediate
admission to Accident and Emergency is recommendedInvestigations
are rarely needed in primary care following acute epistaxis but may
include:A full blood count if bleeding has been heavy or recurrent,
or anaemia is suspected.Coagulation studies, only if a clotting
diathesis is suspected or the person is on warfarin
therapy.Management of a person with recurrent epistaxis
includes:Topical antiseptic treatment such as Naseptin
(chlorhexidine and neomycin) cream to reduce crusting and
vestibulitis, orNasal cautery (if available).Referral to an ear,
nose, and throat specialist if epistaxis is recurrent despite
treatment, or there is a high risk of a serious underlying
cause.DefinitionWhat is it?Epistaxis is bleeding from the
nose.Epistaxis mostly (8090%) originates from Little's area on the
anterior nasal septum, which contains the Kiesselbach plexus of
vessels [Crown and Criner, 2004;Schlosser, 2009].Less commonly,
epistaxis originates from branches of the sphenopalatine artery in
the posterior nasal cavity [Pashen and Stevens, 2002;Wormald,
2002;Schlosser, 2009].CausesWhat causes it?Blood vessels in the
mucosa (particularly in Little's area) are superficial and
therefore easily damaged, causing bleeding [Crown and Criner,
2004;Schlosser, 2009]. Most epistaxis is self-limiting and
harmless, and the cause of damage to the blood vessels is not
identified [Pope and Hobbs, 2005;Schlosser, 2009].Local causes of
damageto the blood vessels include:Trauma injury from nose-picking,
nasal fractures, septal ulcers or perforations, foreign body, blunt
trauma (such as falls in children).Inflammation infection (for
example chronic sinusitis), allergic rhinosinusitis, nasal
polyps.Topical drugs for example cocaine, topical
decongestants.Vascular for example hereditary haemorrhagic
telangiectasia, Wegener's granulomatosis.Post-operative bleeding
for example following: ear, nose, and throat surgery; maxillofacial
surgery; or ophthalmic surgery.Tumours benign (such as
angiofibroma), malignant (such as squamous cell carcinoma). Older
people are more likely to have epistaxis associated with
cancer.Nasal oxygen therapy causes drying of the nasal mucosa.More
general causes of damageinclude:Hypertension (although this is
controversial).Atherosclerosis.Increased venous pressure from
mitral stenosis.Haematological conditions such as thrombocytopenia,
platelet dysfunction, and conditions such as leukaemia and
haemophilia.Environmental factors temperature, humidity,
altitude.Systemic drugs including anticoagulants and antiplatelet
agents (for example aspirin, clopidogrel).Excessive alcohol
consumption.[McGarry et al, 1994;Pashen and Stevens, 2002;Wormald,
2002;Crown and Criner, 2004;Kucik and Clenney, 2005;Pope and Hobbs,
2005]PrevalenceHow common is it?Epistaxis is common.Up to 60% of
the population have experienced an episode of epistaxis, but only
6% have sought medical attention for it [Kucik and Clenney,
2005;Daudia et al, 2008].The incidence of epistaxis changes with
age.Peaks in incidence occur in children younger than 10years of
age, and in adults older than 45years of age [Kucik and Clenney,
2005;Pope and Hobbs, 2005;Schlosser, 2009].Epistaxis in children
younger than 2years of age is unusual and may be associated with
injury or serious illness [McIntosh et al, 2007;Paranjothy et al,
2009].Posterior epistaxis is more common in older people compared
with younger people [Schlosser, 2009].PrognosisWhat is the
prognosis?Most episodes of epistaxis are self-limiting and do not
require medical treatment [Schlosser, 2009].It is unusual for
epistaxis to necessitate a transfusion, although (rarely) massive
nasal bleeding can be fatal [Kucik and Clenney, 2005;Schlosser,
2009].ComplicationsWhat are the complications?Complications of
bleeding(for example hypovolaemia and anaemia).Complications of
nasal packing [Kucik and Clenney, 2005;Schlosser,
2009].Sinusitis.Septal haematoma or abscess (due to traumatic
packing).Pressure necrosis (secondary to excessively tight
packing).Toxic shock syndrome (from prolonged packing).Apnoeic
episodes (associated with bilateral anterior or posterior nasal
packs).OverviewOverview of management for acute epistaxisIf the
person is haemodynamically compromised, telephone 999 for an
emergency ambulance and advisefirst aid measureswhile awaiting its
arrival.If the person is not haemodynamically
compromised:Advisefirst aid measures.Assess:Blood loss.The site of
bleeding (which nostril, and if it is from the anterior or
posterior nasal area).What attempts have been made to stop the
bleeding before seeking medical help.Determine if there is a
likelyunderlying causeor comorbid condition that may influence the
decision to refer the person (for example warfarin therapy).If
bleeding stops with first aid measures, considertopical
treatment.If bleeding does not stop after 1015minutes of pressure
and the appropriate expertise and facilities for cautery or packing
arenotavailable in primary care, send the person to the Accident
and Emergency department immediately.If bleeding does not stop
after 1015minutes of pressure and the appropriate expertise and
facilities are available in primary care, consider:Nasal cautery if
the bleeding point can be seen.Nasal packing if nasal cautery is
ineffective or the bleeding point cannot be seen.Consider
whetheradmissionis warranted.Considerreferralto an ear, nose, and
throat specialist if epistaxis is recurrent despite treatment, or
there is a high risk of a serious underlying cause.Offerself-care
adviceafter the bleeding has stopped.First aid measuresWhat first
aid measures should I advise for acute epistaxis?Advise the person
to:Sit with their upper body tilted forward and their mouth
open.They should avoid lying down, unless they are feeling
faint.Leaning forward decreases blood flow through the nasopharynx,
allows spitting out of blood, and minimizes swallowing blood that
drains into the pharynx.Pinch the cartilaginous (soft) part of the
nose firmlyand hold it for 1015minutes without releasing the
pressure, breathing through their mouth.A common misconception is
that compression of the nasal bones will help stop
bleeding.AssessmentHow should I assess a person with acute
epistaxis?Assess the person's airway, breathing, pulse, and blood
pressure.If any are compromised, telephone 999 for an ambulance and
advisefirst aid measureswhile awaiting its arrival.Usually, the
person's airway, breathing, pulse, and blood pressure are not
compromised.If the person is otherwise well, ask:When the bleeding
started, and from which side.How much blood has been lost. This is
difficult to estimate, but establish whether the bleeding is light
or heavy. If bleeding is heavy, ask the person how many cups (each
equates to approximately 250mL) they think they have lost.
Significant blood loss may necessitate admission to
hospital.Whether a temporary pack (such as cotton wool) has been
used before seeking medical help. These are not always easily
visible, and formal nasal packing can push foreign bodies further
into the nose.About any previous episodes of epistaxis and how they
were treated.Examine both nasal passages(ideally with adequate
lighting and a nasal speculum).If the nose is still bleeding,
advise the person to blow their nose to remove clots (several big
blows may be required). Old blood is usually darker and runs out in
a gush with formed clots, then stops. Fresh bleeding is bright red
and drips steadily when the person leans forward.Look for a
bleeding point. Bleeding points which have stopped look like a
small red dot (less than 1mm).Suspect a posterior bleedif bleeding
is profuse, from both nostrils, and the bleeding site cannot be
identified on speculum examination.Determine if there is
anunderlying cause,particularly in children younger than 2years of
age as epistaxis is unusual in this group.Laboratory investigations
are not usually required unless an underlying cause is suspected.A
full blood countshould be considered if bleeding has been heavy or
recurrent, or anaemia is suspected.Coagulation studiesshould be
requested only if a clotting diathesis is suspected or an INR
(international normalized ratio) is required to determine if
warfarin treatment needs adjusting.Identifying an underlying
causeHow should I identify an underlying cause for acute
epistaxis?Determine whether an underlyingcauseis likely,by asking
about:A history of surgery or recent trauma (consider the
possibility of non-accidental injury).Symptoms suggestive of a
tumour (benign or malignant) including nasal obstruction,
rhinorrhoea, facial pain, or evidence of cranial neuropathy (for
example facial numbness or double vision).Current medications (for
example aspirin and warfarin, nasally-administered drugs).If the
person is taking warfarin, check the INR (international normalized
ratio) or admit to hospital if bleeding is difficult to
control.Conditions predisposing to bleeding (such as haemophilia or
leukaemia).Family history of bleeding disorders.Features of
hereditary haemorrhagic telangiectasia that may be evident on
examination include telangiectasia on the lips, mucous membranes,
and fingers.Environmental factors (such as humidity and
allergens).Have a low threshold forreferralin children younger than
2years of age (underlying cause likely).Topical treatmentWhat
topical treatment should I advise for acute epistaxis?If acute
epistaxis settles withfirst aid measures, consider applying a
topical antiseptic preparation, particularly in children for whom
cautery is not an option.Prescribe Naseptin(chlorhexidine and
neomycin) cream first-line. Advise that the cream should be applied
to the nostrils four times daily for 10days. If compliance is a
problem, experts suggest it can be used twice daily for up to
2weeks.Do not prescribe Naseptinfor people known to be allergic to
peanut as it contains arachis oil (peanut oil).If the person is
allergic to peanut or neomycin, consider prescribing mupirocin
nasal ointment. Advise that it should be applied to the nostrils
two to three times a day for 57days.Nasal cauteryHow should I
perform nasal cautery for acute epistaxis?Consider nasal cautery in
primary care if:First aid measureshave not worked,andThe
appropriate expertise and facilities are available (good lighting,
topical anaesthetic spray, and nasal speculum).Prior to cauteryAsk
the person to blow their nose to clear any clots and allow local
anaesthetic to be applied. This may restart the bleeding.Use
topical local anaesthetic spray, preferably with a vasoconstrictor
(such as lidocaine with phenylephrine Co-phenylcaine) prior to
cauterizing the area. Wait for 34minutes for the full effect. The
vasoconstrictor may stop the bleeding, but once the effects have
worn off the bleeding may start again.To cauterize the bleeding
pointIdentify the bleeding point it looks like a small red dot
(less than 1mm) and may not be actively bleeding.Lightly apply the
silver nitrate stick to the bleeding point for 310seconds, until a
grey-white colour develops.Only cauterize one side of the septum to
avoid nasal septal perforation.Avoid touching areas which do not
need treatment (for example facial skin, nasal alae).After
cauteryDab the cauterized area with a clean cotton bud to remove
excess chemical or blood.Apply antibiotic ointment to the area.Use
Naseptin(chlorhexidine and neomycin) cream first-line, applied to
the nostrils four times daily for 10days. Do not prescribe
Naseptinfor people known to be allergic to peanut as it contains
arachis oil (peanut oil).If the person is allergic to peanut or
neomycin, consider using mupirocin nasal ointment. This should be
applied to the nostrils two to three times a day for 57days.Do not
routinely pack the affected side.Offerself-care advice.Nasal
packingHow should I perform nasal packing for acute
epistaxis?Consider nasal packing in primary care if:Nasal
cauteryhas been ineffectiveorthe bleeding point cannot be
seen,andThe appropriate expertise and facilities are available
(good lighting, topical anaesthetic spray, and nasal
speculum).Anaesthetize the nasal cavitywith topical local
anaesthetic spray, preferably with a vasoconstrictor (such as
lidocaine with phenylephrine Co-phenylcaine), if this has not
already been done. Wait for 34 minutes for the full effect.The
decision concerning which product to use is based on availability,
cost, and preference.The available products include:Nasal tampons
(for example Merocel) effective and easy to use.Inflatable packs
(for example Rapid-Rhino) effective, and may be more comfortable to
insert and remove than nasal tampons. They may also be easier for
the healthcare professional to use than nasal tampons.Ribbon gauze
impregnated with Vaselineor bismuth-iodoform paraffin paste packing
with ribbon gauze is not recommended in primary care without
specific training.Insert the packing according to the manufacturers
instructions.Pack the person's nostril whilst they are sitting with
their head tilted forwards and holding a receptacle allowing them
to spit out blood, and breathing through their mouth.Secure the
pack (for example Merocelpacks have a string attached which can be
taped to the cheek) and ensure there is no pressure on the
cartilage around the nostril as this can cause a cosmetic
defect.Check the oropharynx for signs of bleeding from the back of
the nose. If bleeding is seen, consider packing the other side to
increase pressure on the bleeding vessel.Admit the person to
hospital for observation,preferably to an ear, nose, and throat
ward.ReferralWhen should I refer a person with acute
epistaxis?Admit the person to hospitalif:Epistaxis continues
despite efforts to stop the bleeding.Bleeding from the posterior
area of the nose is suspected.A nasal pack has been inserted in
primary care.Consider admission to hospitalif the person is elderly
or has a comorbid condition (such as coronary artery disease,
severe hypertension, clotting disorder, or significant
anaemia).Consider referral to an ear, nose, and throat specialist
if the person has recurrent episodes and is at high risk of having
a serious underlying cause.Use clinical judgement and consider
referral in the following groups:Males 1220years of age
angiofibroma is possible (but rare).Middle-aged people of Chinese
origin due to the high incidence of nasopharyngeal cancer.People
older than 50years of age as nasal, sinus, and nasopharyngeal
cancers are more common (although they usually present with
associated symptoms).People with any symptoms suggestive of cancer
such as nasal obstruction, facial pain, hearing loss, eye symptoms
(proptosis or double vision), or palpable neck glands.People with a
family history of hereditary haemorrhagic telangiectasia and
suggestive features upon examination telangiectasia on the lips,
mucous membranes, and fingers.People with occupational exposure to
wood dust or chemicals.Consider referral to a paediatrician for
children younger than 2years of age who present with
epistaxis.Secondary care treatmentsWhat secondary care treatments
are available for epistaxis?Secondary care treatments for acute
epistaxis include:Resuscitation this may include transfusion to
replace blood volume and provide coagulation factors.Formal packing
(may be under general anaesthetic).Endoscopic assessment and
electrocautery.Examination under anaesthesia and surgical
intervention (such as diathermy, septal surgery, arterial ligation,
laser treatment).Radiological arterial embolization.Intravenous or
oral tranexamic acid.Self-care adviceWhat self-care advice should I
provide after an episode of epistaxis?For 24hours after bleeding,
where practical, advise the person to avoid activities which may
increase the risk of rebleeding.These include:Blowing or picking
the nose.Heavy lifting.Strenuous exercise.Lying flat.Drinking
alcohol or hot drinks as these can cause the nasal blood vessels to
dilate and increase the risk of bleeding.If the nose has been
cauterized,the person should avoid blowing their nose for a few
hours to prevent staining of the nostril.If bleeding restarts and
does not respond tofirst aid measures,the person should seek
medical advice.Scenario : Recurrent epistaxisOverviewOverview of
management for recurrent epistaxisAssessthe person and, if
possible, identify anyunderlying cause.Offer advice on first aid
measures and self-care advice for when an acute episode occurs.
SeeScenario : Acute epistaxis.Discussmanagement optionsfor
recurrent epistaxis.Referthe person if treatment in primary care is
ineffective, or if a serious underlying cause is
suspected.AssessmentHow should I assess a person with recurrent
epistaxis?Ask the personabout:Which side the bleeding occurs.How
much blood is lost during an episode. This is difficult to
estimate, but establish whether the bleeding is light or heavy. If
bleeding is heavy, ask the person how many cups (each equates to
approximately 250mL) they think they have lost.How previous
episodes of epistaxis have been treated. Mild episodes usually stop
with first aid measures. The need for cautery or packing indicates
a more severe bleed.Examine both nasal passages(ideally with
adequate lighting and a nasal speculum).Look for a bleeding point.
Bleeding points which have stopped look like a small red dot (less
than 1mm).Check for a nasal tumour.Determine if there is
anunderlying cause,particularly in children younger than 2years of
age as epistaxis is unusual in this group.Laboratory investigations
are not usually required unless an underlying cause is suspected.A
full blood countshould be considered if bleeding has been heavy or
recurrent, or anaemia is suspected.Coagulation studiesshould be
requested only if a clotting diathesis is suspected or an INR
(international normalized ratio) is required to determine if
warfarin treatment needs adjusting.Identifying an underlying
causeHow should I identify an underlying cause for recurrent
epistaxis?Determine whether an underlyingcauseis likely,by asking
about:Symptoms suggestive of a tumour (benign or malignant)
including nasal obstruction, rhinorrhoea, facial pain, or evidence
of cranial neuropathy (for example facial numbness or double
vision).Current medications (for example aspirin and warfarin,
nasally-administered drugs).If the person is taking warfarin, check
the INR (international normalized ratio).Conditions predisposing to
bleeding (such as haemophilia or leukaemia).Family history of
bleeding disorders.Environmental factors (such as humidity and
allergens).Have a low threshold forreferralin children younger than
2years of age (underlying cause likelyManagementHow should I manage
recurrent epistaxis?If the person isnotathigh riskof having a
serious cause of epistaxis, discuss treatment options for recurrent
epistaxis.Topical treatment with antiseptic cream to reduce
crusting and vestibulitis.This may be particularly useful in
children, as it is easier to tolerate than nasal cautery.Prescribe
Naseptincream first-line. It should be applied to the nostrils four
times daily for 10days (if compliance is a problem, experts suggest
it can be used twice daily for up to 2weeks). Do not prescribe
Naseptinfor people known to be allergic to peanuts as it contains
arachis oil (peanut oil).If the person is allergic to peanuts or
neomycin, consider prescribing mupirocin nasal ointment. Apply to
the nostrils two to three times a day for 57days.Nasal cauteryis
similarly effective to Naseptinantiseptic cream, but may be more
uncomfortable. Consider it for use in primary care only if:The
appropriate expertise and facilities (good lighting, topical
anaesthetic spray, and nasal speculum) are available.The bleeding
point can be identified.It can be tolerated (for example adults and
older children, but not younger children).If epistaxis does not
improve with antiseptic cream or nasal cautery,
considerreferral.ReferralWhen should I refer a person with
recurrent epistaxis?Refer the person to an ear, nose, and throat
specialistif:Epistaxis episodes do not settle with the treatments
available in primary care further investigation and treatment in
secondary care may be required.The person has recurrent episodes
and is at high risk of having a serious underlying cause. Clinical
judgement is required, for example consider referral for:Males
1220years of age angiofibroma is possible (but rare).Middle-aged
people of chinese origin due to the high incidence of
nasopharyngeal cancer.People older than 50years of age as nasal,
sinus, and nasopharyngeal cancers are more common (although they
usually present with associated symptoms).People with any symptoms
suggestive of cancer such as nasal obstruction, facial pain,
hearing loss, eye symptoms (proptosis or double vision), or
palpable neck glands.People with a family history of hereditary
haemorrhagic telangiectasia and suggestive features upon
examination telangiectasia on the lips, mucous membranes, and
fingers.People with occupational exposure to wood dust or
chemicalshttp://cks.nice.org.uk/epistaxis#!topicsummary
