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    Epistaxis – Treatment

    Cardinal Presentations / Presenting Problems, Ears, Eyes, Nose, and Throat, Hematological / Oncological

    Last Updated Aug 05, 2020
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    • 60% of adults experience epistaxis, and 10% seek medical attention.
    • 90% anterior, 40% of which are treated conservatively.
    • Posterior epistaxis is usually more severe and may require:
      • Admission.
      • Posterior nasal packing with risk of:
        • Nasal trauma or pressure necrosis.
        • Hypoxia, dysrhythmias.
        • Infection.
      • Embolization or arterial ligation.

    Recommended Treatment

    See “Dundee protocol” for general approach to epistaxis.

    Anterior Epistaxis:

    1. Topical vasoconstrictor and analgesic:
    • Options:
      • 0.05% oxymetazoline and lidocaine 4% or 2% spray or drops.
        • 65% of patients with epistaxis controlled with oxymetazoline alone.
        • Can also apply oxymetazoline to packing after insertion for additional vasoconstriction with expansion.
      • LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%).
      • 4% cocaine hydrochloride (both anesthetic and vasoconstrictive).
    • Apply with gauze or cotton balls in nares for 10 – 15 mins.
    1. Apply pressure:
    • Patient to apply pressure to nose ala onto septum for 10 – 15 mins OR use tongue blades to apply pressure.
    • Attempt twice before proceeding to chemical cauterization or packing.
    1. Chemical cautery (silver nitrate):
    • Indications:
      • If topical vasoconstrictors and pressure don’t control bleeding.
      • If source has been localized, bleeding has stopped or is mild (works best on relatively bloodless surface as coagulates blood which limits contact with bleeding vessel).
    • Clinical pitfalls:
      • Inadequate analgesia.
      • Using on both sides of the nasal septum (risk of ulceration/perforation).
      • Not waiting 4-6 weeks to try again (risk of ulceration/perforation).
    • Start on surrounding area and then on source itself. Roll over area 5-10 seconds.
    1. Sealants, nasal packing and/or topical tranexamic acid (TXA):
    • If conservative measures (steps 1-3) ineffective: Aliem.com

    Posterior Epistaxis:

    • Consult ENT.
    • Posterior packing:
      • Temporizing measure due to higher complication rates.
      • Options:
        • Foam packing (10 cm length).
        • Foley catheter (12 or 14F):
          • Some cut tip beyond balloon (may stimulate gag reflex).
          • Lubricate distal third of catheter with lidocaine gel.
          • Advance Foley tip along nasal floor until end is seen in posterior oropharynx.
          • Inflate with air (< 10 cc to prevent pressure necrosis), then retract against posterior nasal choana.
          • Secure at nasal ala, with padding to prevent pressure injury.
        • Dual balloon epistaxis catheter (e.g. Epistat, Storz T-3100):
          • May cause significant pressure and discomfort.
          • Not always successful.
        • Bilateral anterior nasal packing can help tamponade the septum.

    Other Treatments: 

    • Warm water irrigation for refractory epistaxis:
    • If patient anticoagulated:
      • Resorbable packing (e.g. Surgicel) preferred, to avoid rebleeding during removal.
      • TXA may be beneficial as alternative or adjunct to packing.
      • Comprehensive risk assessment if considering holding medications (see figure 1).
      • Consider reversal if supratherapeutic coagulation studies and moderate to severe uncontrolled bleeding. Consult hematology if uncertain.

    Clinical Controversies:

    • Hypertension and epistaxis.
    • The relationship between hypertension and epistaxis is uncertain.
      • There may be an increased risk of epistaxis secondary to the vasculopathic effects of hypertension, or hypertension may not increase the risk of epistaxis but simply prolong it.
      • Do not treat hypertension, focus on hemorrhage control, analgesia, mild sedation as needed.
    • Benefit of prophylactic antibiotics:
      • Toxic Shock Syndrome is a very rare complication of nasal packing.
      • Available evidence does not support routine use of topical or oral antibiotics, but may be considered if:
        • Increased risk of infection (diabetic, immunocompromised, elderly, prosthetic valve).
        • Posterior packing (some reports of severe infections).
      • Options: amoxicillin-clavulanate, 1st generation cephalosporin, or clarithromycin if penicillin allergy, for 5 days after unpacking.

    Criteria For Safe Discharge Home

    • General patient instructions:
      • Continue vs. hold antiplatelets or anticoagulants (consider risk benefit).
      • Instructions on how to control bleeding if re-hemorrhage occurs.
      • Analgesics for comfort.
    • For resolved anterior epistaxis or chemical cautery:
      • Observe for 1 hour after control. Encourage ambulation prior to discharge.
      • Antibiotic ointment and/or vaseline to coat mucosa TID for 7-10 days.
      • Consider intranasal vasoconstrictors such as oxymetazoline for rebleeding.
    • If anterior nasal packing:
      • Follow up in 24-72 hours for removal of packing.
      • ENT follow up if criteria met (see below).
    • If biodegradable hemosealant:
      • Nasal saline spray for mucosal healing and biodegrading of product.

    Criteria For Hospital Admission

    • Airway compromise.
    • Hemodynamic instability.
    • Complications associated with blood loss.
    • Recommended for posterior packing (for cardiac monitoring).

    Criteria for ENT Consult

    • Posterior packing.
    • Bilateral anterior packing.
    • Uncontrolled anterior epistaxis.
    • Recurrent unilateral epistaxis warrants investigation for nasopharyngeal neoplasm.

    Quality Of Evidence?


    • No benefit of prophylactic antibiotics to prevent TTS.
    • Benefit of TXA as alternative to anterior packing.
    • Use of FloSeal as alternative to anterior packing.

    Additional Resources

    Related Information

    Reference List

    1. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States. JAMA Otolaryngol Neck Surg [Internet]. 2013 Dec 1 [cited 2019 Dec 19];139(12):1279.

    2. Schlosser RJ. Epistaxis. N Engl J Med [Internet]. 2009 Feb 19 [cited 2019 Dec 17];360(8):784–9.

    3. American College of Emergency Physicians. Treatment of epistaxis [Internet]. ACEP Now. 2009 [cited 2019 Dec 18].

    4. Barnes ML, Spielmann PM, White PS. Epistaxis: A Contemporary Evidence Based Approach. Otolaryngol Clin North Am [Internet]. 2012 Oct [cited 2019 Dec 18];45(5):1005–17.

    5. Gallegos M. Epistaxis Management in the Emergency Department: A Helpful Mnemonic [Internet]. ALiEM: Academic Life in Emergency Medicine. 2017 [cited 2019 Dec 17].

    6. McGinnis HD. Chapter 244: Nose and Sinuses. In:  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e [Internet]. New York, NY; [cited 2019 Dec 17].

    7. Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systematic review. Clin Otolaryngol [Internet]. 2016 Dec [cited 2019 Dec 17];41(6):771–6.

    8. Zahed R, Moharamzadeh P, AlizadehArasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med [Internet]. 2013 Sep [cited 2019 Dec 4];31(9):1389–92.

    9. Approach to the adult with epistaxis – UpToDate [Internet]. Uptodate. 2019 [cited 2019 Dec 18].

    10. Movin’ Meat: Drip Drip Drip [Internet]. 2010 [cited 2019 Dec 17].

    11. Bequignon E, Vérillaud B, Robard L, Michel J, Prulière Escabasse V, Crampette L, et al. Guidelines of the French Society of Otorhinolaryngology (SFORL). First-line treatment of epistaxis in adults. Eur Ann Otorhinolaryngol Head Neck Dis [Internet]. 2017 May 1 [cited 2019 Dec 19];134(3):185–9.

    12. Spielmann, P. M., Barnes, M. L., & White, P. S. (2012). Controversies in the specialist management of adult epistaxis: an evidence‐based review. Clinical Otolaryngology37(5), 382-389.

    13. Musgrave, K. M., & Powell, J. (2016). A systematic review of anti-thrombotic therapy in epistaxis. Rhinology54(4), 292-391.

    14. Biggs, T. C., Baruah, P., Mainwaring, J., Harries, P. G., & Salib, R. J. (2013). Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients. The Journal of Laryngology & Otology127(5), 483-488.

    15. Tran, Q. K., Rehan, M. A., Matta, A., & Pourmand, A. (2019). Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections. The American Journal of Emergency Medicine.

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