Epistaxis

Principles of Management

See CKS guidelines for advice on management of acute and recurrent epistaxis.

Determine if there is an underlying cause for epistaxis such as:

• Tumour – See ‘Red flags’ below
• Consider Juvenile Nasopharngeal Angiofibroma if recurrent epistaxis in males aged between 12–20 years of age — this is a rare benign tumour.
• Consider hereditary haemorrhagic telangiectasia (HHT) in people with telangiectasia and a family history of HHT.
• Be aware that an underlying cause is likely in children younger than 2 years of age. A history of surgery or recent trauma (consider the possibility of non-accidental injury (NAI)/asphyxia).
• Also consider allergic rhinitis or bacterial rhinosinusitis, nasal polyps, or nasal foreign body. 

Investigations are rarely needed in primary care following acute epistaxis but may include: A full blood count if bleeding has been heavy or recurrent, coagulation studies if recurrent bleeding, a clotting disorder is suspected, or the person is on warfarin therapy.

Red flags

• Nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy (for example facial numbness or double vision, proptosis).

• Be aware that nasal, sinus, and nasopharyngeal cancers are most common in people older than 50 years of age, in those with occupational exposure to wood dust or chemicals, and (for nasopharyngeal cancer) in people of South Chinese or North African family origin.

• Children younger than 2 years of age with suspected trauma or Non-accidental injury. If safeguarding concerns please see the Safeguarding Children - Referrals & Procedures (Remedy BNSSG ICB) page

Treatment in Primary Care

Treatment of acute epistaxis:

1. Use first aid measures to control the bleeding. (Leaning forward and pinching the cartilaginous (soft) part of the nose firmly. Hold it for 15- 30 minutes without releasing the pressure.)
2. Check for haemodynamic compromise and transfer to A&E If compromised
3. If bleeding stops with first aid measures: Consider applying a topical antiseptic such as Naseptin/mupirocin. Refer to secondary care if red flags.
4. If bleeding does not stop with first aid measures transfer to A&E.
5. If bleeding does not stop with first aid measures and appropriate expertise and facilities are available in primary care, then consider nasal cautery if the bleeding point can be seen or nasal packing if cautery is ineffective.
   
   

Treatment for patients presenting to primary care not bleeding acutely but with a history of recurrent epistaxis

If patient is not a high risk of a serious underlying cause consider the following:

1. Topical treatment with an antiseptic preparation to reduce crusting and vestibulitis. The options for topical treatment are one of the following:
   • Naseptin® (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days. If compliance is a problem, advise that it can be used twice daily for up to 2 weeks. This is Contraindicated if allergic to neomycin, peanut, or soya.
   • Mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.
2. Nasal cautery can be used if expertise and facilities are available in primary care if evidence of recent bleeding point visible. Do not cauterise both sides of septum simultaneously as this increases the risk of septal perforation.

Referral Guidance

If nasal cancer is suspected (see Red Flags) then refer via Head & Neck Urgent Suspected Cancer pathway (if there is no tick box on form for some of these indications then free text you concerns and patient should be seen).

Consider referral to ENT HOT clinic  if recurrent bleeding which cannot wait for a routine appointment.

Contact paediatric on call team for children aged <2.

Contact on call team if acute bleeding not responding to first aid measures/ any haemodynamic compromise.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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