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Chronic Recurrent Epistaxis' (adults and children)

 

This guideline applies to children and adults. For an acute nosebleed please see guidelines on ‘Acute Epistaxis’

 

Useful resources for patients and HCP

https://www.entuk.org/patients/conditions/42/nosebleeds_epistaxis_update

 

Background

Epistaxis tends to affect the elderly, but is also very common in children. Over 50% aged 6-15yr old have nosebleeds regularly. Children under age of 2yr are likely to have an underlying cause for their nosebleeds.


Conservative management

These measures should be employed whereby the patient is haemodynamically stable and bleeding has ceased, either using first aid measures or nasal cautery:

 

1) Provide advice on first aid management of acute epistaxis


2) Self-care advice

Recommend that for 24 hours the patient should avoid the following activities as they may increase the risk of re-bleeding:

  • Blowing or picking the nose
  • Heavy lifting
  • Strenuous exercise
  • Lying flat
  • Drinking alcohol or hot drinks

3) Manage reversible causes and screen for underlying cause

  • Review medications, and consider short cessation of anticoagulation / anti-platelets if clinically appropriate
  • Ask about ETOH excess
  • Control BP
  • Consider arranging FBC for adult


 

4) If NOT at risk of serious underlying cause

  • Advise application of Vaseline/Sterimar regularly to nostrils to moisturise mucosa
  • Trial of topical antiseptic preparation or nasal cautery (see below)

 

5) Consider ENT referral if underlying cause suspected, or failure to respond to conservative treatment

  • If any symptoms and signs as per Nasal and Sinus Red Flags Guideline, refer urgently to rhinology services via the E-RS “Nose Clinic” pathway

 


Topical antiseptic preparations

  • Naseptin cream
    • Apply to nostrils QDS for 10 days
    • If compliance an issue, can use BD for up to 2 weeks
  • Mupirocin nasal ointment
    • Alternative - if allergic to neomycin, peanut or soya
    • Apply to nostrils BD-TDS for 5-7 days

 

Nasal cautery

Consider if the following apply:

 

Before:

  • Ask patient to blow nose
  • Apply topical local anaesthetic spray, e.g. Co-phenylcaine, and wait 3-4 mins

 

During:

  • Identify the bleeding point (will look like a small red dot)
  • Lightly apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops (only cauterise one side of the septum to avoid perforation)

 

After:

  • Dab cauterised area with clean cotton bud
  • Apply topical antiseptic preparation, e.g. Naseptin / mupirocin
  • Follow conservative management advice below

 

 

References

https://www.entuk.org/patients/conditions/42/nosebleeds_epistaxis_update

https://cks.nice.org.uk/topics/epistaxis-nosebleeds/

 

 

Review Date                April 2022

Next Review Date        April 2023

GP Sifter                      Dr Laura Vines

Contributors                 Ms Aileen Lambert

                                     Mr Neil Tan

Version                         2.0