ENT

New Epistaxis (Nosebleed) Management Practice Guidelines

SUMMARY:

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has released new 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 visualized 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