Approach to the adult with epistaxis

INTRODUCTION — Epistaxis is a common problem, occurring in up to 60 percent of the general population [1]. While most episodes are uncomplicated, epistaxis can occasionally be difficult to control. Knowledge of the basic anatomy of the nasopharynx and a few hemostatic strategies are reassuring in the face of acute hemorrhage.

This topic discusses epistaxis in adults. Epistaxis in children is reviewed separately. (See "Evaluation of epistaxis in children" and "Management of epistaxis in children".)

EPIDEMIOLOGY — Survey data suggest that although 60 percent of adults experience an epistaxis episode, only 10 percent or fewer seek medical attention [2,3]. Epistaxis is a common otolaryngologic cause for hospital admission, although surgical intervention is rarely needed [4].

Epistaxis appears to have a bimodal age distribution, with most cases occurring before age 10 or between 45 and 65 years of age [1,5]. Hospital admission for epistaxis increases progressively with age, but these data often do not control for aspirin or anticoagulant use [6]. Among hospitalized patients, there is male predominance prior to age 49, after which the sex distribution equalizes. This phenomenon has been attributed to a protective effect of estrogen in women, whether in fostering a healthy nasal mucosa or in preventing vascular disease more generally [6-8].

Seasonal variation, with predominance in winter months, has been found in most [9-13] but not all [14], studies. Seasonal factors affecting epistaxis include the incidence of upper respiratory infections, allergic rhinitis, and mucosal changes associated with fluctuations in temperature and humidity.

ANATOMY — Epistaxis may be classified as anterior or posterior, depending upon the source of bleeding.

Anterior bleeds — Anterior nosebleeds are by far the most common [15]. A large proportion is self-limited and can be managed definitively in the primary care setting.

Up to 90 percent of nosebleeds occur within the vascular watershed area of the nasal septum (figure 1 and figure 2) known as Kiesselbach's plexus (figure 3 and figure 4) [16]. Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery. The sphenopalatine artery also gives off branches supplying the posterolateral wall and posterior choana; these vessels are the most likely source of posterior nosebleeds.

Posterior bleeds — Posterior epistaxis arises most commonly from the posterolateral branches of the sphenopalatine artery (figure 3) but may also arise from branches of the carotid artery (figure 5).

Posterior nosebleeds can result in significant hemorrhage. The skilled clinician may temporize with nasal packing, but most patients require prompt referral to an emergency department, possible consultation with an otolaryngologist, and sometimes hospital admission.

ETIOLOGY — Anterior nosebleeds often result from mucosal trauma or irritation.

●Nose picking is a common cause. The source is usually just proximal to the mucocutaneous junction where there is little subcutaneous tissue into which an excoriated vessel can retract.

●Low moisture content in the ambient air can result in mucosal dryness and irritation. This factor is common in centrally-heated rooms that are not humidified.

●The mucosal hyperemia that accompanies allergic or viral rhinitis makes bleeding from local trauma especially profuse, which may prompt patients to seek medical care.

●The presence of a foreign body should be considered when bleeding is accompanied by purulent discharge; sinusitis is also in the differential diagnosis in these circumstances.

●Chronic excoriation can lead to small septal perforations that may bleed from surrounding friable granulation tissue; chronic intranasal drug use (eg, cocaine) may present similarly.

●Patients who suffer facial trauma from a motor vehicle crash or other blunt facial impact often bleed from the nose, usually from an anterior source.

Anterior and posterior bleeds may be caused by or associated with a number of conditions, as outlined below. In some cases, evidence supporting these associations is limited:

●Anticoagulation ‒ Anticoagulated patients are at higher risk for nosebleeds and for more severe bleeding from nosebleeds [17,18]. The role of warfarin cessation and reversal of anticoagulation are controversial in the setting of epistaxis. Patients who are in the therapeutic international normalized ratio (INR) range for their specific indication and in whom hemostasis is achieved may be safely maintained on their warfarin regimen. (See "Management of warfarin-associated bleeding or supratherapeutic INR".)

One large retrospective study in an anticoagulation clinic noted that reversal was required for epistaxis at a rate of only 1.5 per 1000 patient-years [19], despite patient recall data in the same hospital suggesting an annual incidence of epistaxis of 25 percent among anticoagulated patients [20].

●Bleeding disorders ‒ Epistaxis is the most common presenting symptom among patients with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) [21]. The bleeding can be quite difficult to control in these individuals. The friable lesions may appear to bleed more with treatment than without. Nevertheless, the treating clinician should initiate hemostatic measures and obtain appropriate consultation [21-23]. (See "Clinical manifestations and diagnosis of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)".)

Patients with familial blood dyscrasias, particularly platelet disorders, von Willebrand disease, and hemophilia, are prone to epistaxis. A bleeding diathesis should be considered in the patient with recurrent spontaneous epistaxis. (See "Approach to the adult with a suspected bleeding disorder".)

●Vascular conditions, including aneurysm ‒ Recurrent posterior bleeds or massive hemorrhage may be due to aneurysm of the carotid artery [24]. This is of particular concern in a patient with a prior history of head and neck surgery, or following trauma (pseudoaneurysm) [25], but most often posterior bleeds arise spontaneously.

There are case reports associating vasculitis, including small vessel vasculitides, with epistaxis [26].

●Neoplasm ‒ Epistaxis may be a symptom of a nasal neoplasm. The most common tumors associated with epistaxis are squamous cell carcinoma, adenoid cystic carcinoma, melanoma, and inverted papilloma [16]. Nasopharyngeal cancers are more common in patients of Chinese or southeast Asian heritage. Patients who have had significant epistaxis (posterior bleed) should receive a thorough ear, nose, and throat (ENT) evaluation after the bleeding has been controlled.

●Aspirin ‒ The data on the importance of aspirin as a risk factor for epistaxis are not definitive [27]. In one study of habitual nose bleeders, the recalled rate of aspirin use did not differ from that of controls [28]. In contrast, another case control study found a positive correlation between aspirin use and epistaxis (relative risk [RR] 2.17 or 2.75, depending upon whether a community or hospital control group was used) [29]. There is no reported increase in risk associated with other nonsteroidal antiinflammatory drugs (eg, ibuprofen).

●Hypertension ‒ Hypertension is associated with an increased risk for epistaxis. In a nested cohort study involving over 70,000 patients using data from the National Health Insurance database of the Republic of Korea, the incidence rate for epistaxis among adults being treated for hypertension was 32.97 per 10,000 persons (95% CI 30.57-35.51) compared with a rate among matched controls of 22.76 per 10,000 persons (95% CI 20.78-24.89) [30]. In this study, hypertensive patients who developed epistaxis were more likely to seek treatment in the emergency department and receive posterior nasal packing. Multiple prior studies have related hypertension to nosebleeds [4,10,30-35], although studies specifically exploring this relationship were unable to confirm the association [7,20,36-38]. In aggregate, the data from Korea and others suggest that longstanding hypertension contributes to an elevated risk of epistaxis, most likely due to its vasculopathic effects [37]. Some specialists suggest that hypertension does not cause epistaxis but does prolong episodes of bleeding [39]; this view at present lacks substantive data to support it.

●Alcohol use may increase the risk for epistaxis [40].

●Intranasal preparations for seasonal allergies may increase the risk for epistaxis [41]. Nasal steroids are used with increasing frequency, and their contribution to the incidence of anterior nosebleeds is likely to increase. A meta-analysis of 72 studies suggests a persistent elevation of risk for epistaxis of about 50 percent (odds ratio [OR] 1.48, 95% CI 1.32-1.67) among users of nasal steroids; beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate had the highest incidence, whereas beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were less likely to be associated with bleeding [42].

●Heart failure ‒ One large case-control study explored factors associated with recurrent epistaxis [34]. In addition to known risks for first-time bleeding, patients with decompensated heart failure were noted to be at somewhat higher risk for repeated episodes of epistaxis.

EVALUATION

Initial assessment — The initial evaluation of epistaxis should focus on airway assessment and cardiovascular stability. Airway intervention, fluid resuscitation, and emergent otolaryngologic consultation can be necessary in severe epistaxis. Normal appearance, vital signs, and respiratory function are evidence that the examiner can safely attend to the presenting complaint. (See "Basic airway management in adults" and "The decision to intubate".)

History — The history should address the following issues [43-45]:

●Conditions that predispose to bleeding, possibly including tumors, coagulation disorders (personal and family history), recent trauma or surgery, medications (eg, aspirin, warfarin, clopidogrel, intranasal glucocorticoids), and other conditions (eg, cirrhosis, human immunodeficiency virus [HIV], intranasal cocaine use).

●The timing, frequency, and severity of epistaxis should be assessed (eg, is this an isolated episode or one of many?).

●The possible presence of chronic medical problems that can be exacerbated by blood loss, such as coronary artery disease and chronic obstructive pulmonary disease, and symptoms that may be related (eg, chest discomfort, dyspnea, lightheadedness).

Coagulation studies and other tests — A prothrombin time (PT) with international normalized ratio (INR) is not indicated as a routine test but should be ordered for the anticoagulated patient [46,47]. A hematocrit and type and crossmatch should be obtained in the setting of massive or prolonged hemorrhage, and two large bore IV lines placed in such cases.

Initial tamponade — Properly instructed patients may achieve hemostasis unassisted while the evaluation gets underway. The following approach may be helpful:

●Patient blows their nose to remove blood and clots.

●Clinician sprays the nares with oxymetazoline.

●Patient pinches the alae tightly against the septum and holds continuously for 10 minutes (picture 1 and picture 2).

Many otolaryngologists recommend initial treatment with two sprays of oxymetazoline (Afrin) to hasten hemostasis, although little published data exist to support the practice. One small retrospective study found that oxymetazoline spray stopped bleeding in 65 percent of patients presenting to an emergency department with epistaxis [48]. The application of oxymetazoline for the purpose of reducing bleeding through vasoconstriction is unlikely to cause an elevation in blood pressure.

To achieve tamponade, the patient must exert pressure properly by grasping the alae distally and pinching them tightly against the septum such that the mucosal surfaces are tightly apposed (picture 1 and picture 2). The patient should maintain this position continuously for 10 to 15 minutes without releasing pressure to see if the bleeding has stopped.

Other maneuvers include having the patient bend forward at the waist while sitting up (to avoid swallowing blood), placing a plug of cotton wool or a pledget into the bleeding nostril (sometimes coated with antibiotic ointment), expectorating blood that accumulates in the pharynx, and applying a cold compress to the bridge of the nose. These maneuvers should be taught to patients for use at home [20]. The anxious patient may be given a small parenteral dose of an anxiolytic medication, such as lorazepam.

Another initial measure commonly practiced by otolaryngologists is the acute reduction of elevated blood pressures in the setting of epistaxis, with the idea that bleeding will not be controlled while systemic pressures remain high [49]. This practice has not been studied in prospective trials and its validity remains unclear. Furthermore, some patients do not tolerate acute reductions in blood pressure. For these reasons, we believe that, in the absence of a hypertensive emergency, antihypertensive medications should not be part of initial therapy for epistaxis [50]. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)

Physical examination

General examination — It is important to assess the vital signs, mental status, and airway of any patient with significant bleeding, looking for signs of airway compromise or hypovolemic shock. This assessment is particularly important in the elderly and those with severe systemic disease. In patients with recurrent nosebleeds, the patient should be evaluated for signs of coagulopathy (eg, ecchymoses, petechiae, telangiectatic lesions) [44,45].

Pretreatment — The nasal cavity should be anesthetized prior to performing a detailed examination, which otherwise is uncomfortable. Adequate anesthesia can often be achieved with cotton swabs soaked in an anesthetic and vasoconstrictive agent. Drugs commonly used for this purpose include 2 percent lidocaine, lidocaine with epinephrine, and 4 percent cocaine. These agents have not been studied in primary epistaxis, but a small literature on the prevention of epistaxis in nasotracheal intubation suggests that they are roughly equivalent [51].

The selected medication may be applied using two saturated cotton swabs, one placed directly posteriorly and another posterosuperiorly, or with saturated cotton pledgets hand rolled from cotton wool and placed in the nose with bayonet forceps.

Oxymetazoline nasal preparation, although it has no anesthetic properties, can provide vasoconstriction. It is administered as two sprays. Oxymetazoline is readily available, convenient, and inexpensive. Topical phenylephrine is not recommended following reports of several deaths associated with its use intraoperatively [52].

Examination of the nose — It is important to obtain as clear and complete a view of the nares as possible. Ideally, the patient should be examined in a dental chair or its equivalent. If this is unavailable, bring the head of an examination table to upright so the patient can sit comfortably while head movement is restricted. Good lighting is essential, preferably with a headlamp or mirror. Use an emesis basin to catch blood and expectorated clots. Encourage the patient to spit posterior pharyngeal blood into the basin as this will reduce the risk of emesis and aspiration.

An adequate examination for the source of bleeding requires use of a nasal speculum (picture 3); an otoscope speculum is significantly less effective [43,53]. When inserted, the nasal speculum is oriented so one blade moves superiorly and the other moves inferiorly (figure 2).

Further techniques to optimize use of the nasal speculum are based upon anecdote. The clinician can stabilize the speculum's position by placing his or her index finger on the bridge of the patient's nose. Alternatively, the clinician can use the index finger to press the nasal alae against the superior blade of the speculum, once it is inserted. This allows only the lower blade to move and may reduce patient discomfort.

Ask the patient to look directly ahead and attempt the sniffing position. Patients often try to tilt the head back to facilitate a nasal examination, but the nasopharynx lies in the anteroposterior plane and extension of the neck will obscure most of the cavity from view [43].

Clots may be cleared either with suction or by asking the patient to gently blow his or her nose. The most common suction setup, the Yankauer tip, is poorly suited to the nares, and the surgeon's Zoellner sucker is often too small. Some clinicians have found a disposable tube connector or a Frazier suction catheter to be helpful [54].

Inspect the area of Kiesselbach's plexus first since the majority of bleeds originate here (picture 4 and figure 3). Look closely for bleeding, ulceration, or erosion. It is sometimes helpful to displace coagulum gently with a cotton swab to identify a bleeding source. Also inspect the nasal vestibule, septum, and turbinates for sources of bleeding.

Not uncommonly, a primary bleeding site cannot be identified. In such cases, bleeding may stem from a posterior source, including a mass that is difficult to identify, or a trivial insult to the nasal mucosa that has resolved spontaneously or following noninvasive treatment.

Distinguishing anterior and posterior bleeds — It can sometimes be difficult to determine the source of epistaxis. Neither the volume nor the rate of bleeding is helpful; anterior bleeding can be brisk. However, minor bleeding is unlikely to originate posteriorly. While pinching the alae stops many but not all anterior bleeds, many posterior bleeds stop spontaneously making interpretation difficult. Perhaps the best way to determine the bleeding source in difficult cases is to place bilateral anterior nasal packing and examine the patient. Brisk bleeding despite proper packing strongly suggests a posterior source.

TREATMENT OF ANTERIOR BLEEDING — The treatment of anterior epistaxis proceeds in a stepwise fashion until hemostasis is achieved [45]. The attached flowchart presents a general approach to adult patients with epistaxis (algorithm 1). A list of the equipment that may be needed for epistaxis management is provided (table 1).

Bleeding stops with conservative measures — Sometimes minor anterior nosebleeds resolve without intervention prior to clinical evaluation or with the initial attempt at tamponade described above. If no anterior source is evident and bleeding has stopped, the nose should be packed only if bleeding recurs rapidly [43]. (See 'Initial tamponade' above.)

It is reasonable to observe the patient for approximately 30 minutes for recurrent bleeding. Such patients should be discharged with antibiotic ointment to coat the mucosa, applied with a fingertip or cotton swab three times daily for three days.

The natural history of nosebleeds that resolve spontaneously is not well-described. Among younger patients, it appears that rebleeding rates are relatively low (approximately one in three or four cases) [55]. Given the discomfort of packing and the effectiveness of conservative measures in most cases, it is reasonable for patients without recurrence to forego packing.

Cautery — If an anterior bleeding source is visualized, first-line treatment consists of chemical or electrical cautery [44,56]. Chemical cautery is usually performed with silver nitrate sticks, which are used in the following manner. After determining that topical anesthesia is adequate, apply the applicator tip to a small area surrounding the bleeding site. Begin at the periphery of this small area and move towards the center, starting proximally. Avoid cauterizing large areas and remove excess silver nitrate with a cotton swab [43,53]. A video demonstrating cautery using a silver nitrate stick can be found in the following reference [57].

Cautery is applied for a few seconds (no longer than 10 seconds), until a white precipitate forms (picture 5). Both types of cautery may cause rhinorrhea and crusting. Avoid overzealous cautery of the septum, which can lead to ulceration and perforation. Rarely, if ever, should both sides of the septum be cauterized in the same session in order to avoid tissue necrosis [1].

Though silver nitrate requires moisture to act, it will work only on a relatively bloodless surface; the bleeding point itself cannot be cauterized until hemostasis is achieved either through proximal cautery, vasoconstrictive agents such as oxymetazoline drops, or tamponade from manual pressure. (See 'Initial tamponade' above.)

Suction may be used to dry areas with minor bleeding. Electrical cautery works equally well [58] but is also not effective on bloody surfaces. Cautery can be extremely painful if the patient is inadequately anesthetized. Assuming hemostasis is achieved with cautery, these patients should apply antibiotic ointment with a fingertip or cotton swab three times daily for three days.

Nasal packing — If cautery is unsuccessful, the next step in the management of suspected anterior epistaxis is nasal packing to tamponade local bleeding [44,56]. Several packing options are available (picture 6). Before nasal packing is placed, the anxious patient may be given a small parenteral dose of an anxiolytic medication, such as lorazepam.

Nasal tampons — Nasal packing is most easily accomplished with a nasal tampon. These are usually made of Merocel (picture 6 and picture 3), a synthetic open-cell foam polymer that appears to provide a less hospitable medium for Staphylococcus aureus (S. aureus) than traditional gauze packing [59]. (See 'Antibiotics and toxic shock syndrome' below.)

The Merocel tampon is easy to use and effective. It is inserted as follows:

●Position the patient properly and pretreat with a topical anesthetic (eg, 2 percent lidocaine) and topical vasoconstrictor (eg, oxymetazoline). Proper patient positioning and pretreatment are discussed above. (See 'Physical examination' above.)

●Coat the tampon with bacitracin ointment to facilitate placement, and possibly decrease the risk of toxic-shock syndrome.

●Insert the catheter by sliding it along the floor of the nasal cavity until the plastic proximal fabric ring lies within the naris.

●Large nares can be packed with two tampons (be sure to leave the tips of both exposed for removal); small nares can be packed with a pediatric tampon or an adult tampon trimmed with an iris scissor.

●Expand the tampon by infusing approximately 10 mL of saline, or bacitracin solution if available. A 22-gauge angiocatheter on a saline-filled syringe can be used to expand the deep portion of the tampon first and to speed diffusion.

Gauze packing — Nasal packing can be achieved using ribbon gauze, which is dispensed in 180 cm (72 inches) lengths, though this approach requires greater skill. The gauze is impregnated with petrolatum (eg, Xeroform) or bismuth subnitrate and iodoform paste (BIPP). The procedure involves stacking layers of gauze in an accordion fashion, starting on the floor of the nasal cavity.

To insert the packing, grasp the gauze with a bayonet forceps, leaving an approximately 10 cm (4 inches) tail [16]. Next, gingerly advance the gauze as far as possible into the nasal cavity without touching the walls of the nasopharynx. Then, grasp another 8 to 10 cm of gauze and advance it atop the prior layer. Repeat this process until the nose is tightly packed.

One small randomized trial found no difference between the Merocel tampon and BIPP-impregnated gauze packing (similar to Xeroform) in controlling epistaxis [60].

Nasal balloon catheters — Overall, balloon catheters are easier to use than gauze packing, particularly for clinicians with little experience performing packing. However, the techniques are probably equally effective. Both procedures are uncomfortable and may require the use of parenteral opioids or anxiolytics.

Several balloon-style products are available to tamponade anterior, and posterior, nosebleeds. The Epistat and Storz T-3100 balloons have a lumen that allows for oxygen delivery and both anterior and posterior balloons. (See 'Treatment of posterior bleeding' below.)

The Rapid Rhino is a balloon catheter with a large, low-pressure air balloon encased in a carboxymethylated cellulose (CMC) mesh, available in a 5 cm length for anterior bleeds and 7.5 cm for posterior epistaxis. The Rapid Rhino becomes slick when it is placed in water for 30 seconds, making placement easier. Upon contact with blood, the CMC fibers act to promote thrombosis.

The Rapid Rhino is inserted as follows [61]:

●Position the patient properly and pretreat with a topical anesthetic (eg, 2 percent lidocaine) and topical vasoconstrictor (eg, oxymetazoline). Proper patient positioning and pretreatment are discussed above. (See 'Physical examination' above.)

●Soak the catheter in sterile water for 30 seconds. Do NOT use saline and do NOT apply lubricants or topical antibiotics, which impair the CMC fibers.

●Insert the catheter by sliding it along the floor of the nasal cavity until the plastic proximal fabric ring lies within the nares.

●Inflate the catheter with air only using a 20 mL syringe; stop inflating when the pilot cuff is round and firm. The appropriate amount of air varies with the size of the nasal cavity.

●After 10 to 15 minutes, reassess the pilot cuff. Add air if it is no longer round and firm. Tape the pilot cuff to the patient's cheek.

The results of two small, randomized trials and observational data suggest there is no difference between a nasal tampon and the Rapid Rhino balloon catheter in controlling epistaxis, but note that the Rapid Rhino appears to cause less discomfort and is easier to insert [62-64]. No significant differences in rebleeding after removal of the devices were reported.

Thrombogenic foams and gels — Gel and foam products that promote thrombogenesis are being developed and tested for treatment of epistaxis. Quixil, a fibrin glue, is safe, and probably as effective as cautery and packing [65]. Floseal, a bovine-derived thrombin gel, was associated with an absolute 26 percent lower rebleeding rate compared with nasal packing and was easier to insert and judged more satisfactory by both providers and patients in a randomized trial of 70 patients with acute anterior nosebleeds [66]. In another prospective study, FloSeal effectively controlled posterior bleeds in 8 of 10 patients whose initial hemostatic packing failed [67].

Surgicel, Gelfoam, and Avitene, all common conformable hemostatic materials, have each been described in reviews or small case series as useful in nasal bleeding refractory to cautery [14,39]. These materials can be trimmed to an appropriate size using an iris scissor and then applied directly to the bleeding source with a bayonet forceps. Once applied, the material should be held in place with firm pressure for approximately one minute to ensure adherence.

Tranexamic acid — Evidence regarding the use of tranexamic acid (TXA) for epistaxis is growing, and we believe it has a role in the management of refractory cases. For such patients, our approach is to use a Merocel tampon saturated with 500 mg of the IV formulation of TXA, in lieu of saline. No trials have assessed this approach, and simple atomization and compression may be as effective and less invasive [68]. All such interventions should be undertaken with caution in patients in whom the potential dangers of systemic thrombosis are high (eg, known coronary or cerebrovascular disease), as the systemic absorption of TXA through the nose is not well characterized.

A meta-analysis of seven randomized trials and one observational study involving 1299 patients with epistaxis found that, compared with controls, patients treated with TXA were significantly more likely to have cessation of bleeding at the first reassessment (OR 3.5; 95% CI 1.3–9.7) and less likely to return for treatment of rebleeding at 24 to 72 hours (OR 0.37; 95% CI 0.20–0.66) [69]. However, not all studies support the use of TXA. In the largest trial to date, the NoPAC multicenter trial (which was excluded from the meta-analysis), 500 subjects were randomly assigned to receive 10 to 20 minutes of treatment with cotton pledgets soaked in 200 mg TXA or saline after both received initial management with compression or ice [70]. No significant differences among groups were found in the need for packing in the emergency department or over the next seven days. Limitations to this trial include a lower initial dose of TXA, a relatively high admission rate, suggesting a sicker patient cohort, and a high rate of anticoagulant use among patients.

Persistent bleeding — If bleeding persists despite the initial packing, the contralateral naris may be packed, thereby providing a counterforce to promote tamponade. Some clinicians obtain otolaryngologic consultation once bilateral packing is needed, although the risk of aspiration, hypoxic complications, and treatment failure is small in this setting [60,71]. In most cases, 24 to 48 hour follow-up with the consultant is adequate.

Nasal packing in anterior bleeding has about a 90 to 95 percent success rate [60,71]. If bilateral anterior packing fails to produce hemostasis, the odds of a posterior source increase greatly. Patients with posterior bleeds need posterior packing and probably hospitalization. (See 'Treatment of posterior bleeding' below.)

As mentioned above, patients with hereditary hemorrhagic telangiectasia can have severe recurrent epistaxis that is resistant to usual management measures. A report of one such case found that application of five drops (about 0.25 mL) of 100 mg/mL tranexamic acid (an antifibrinolytic agent) at the onset of bleeding reduced the need for blood transfusions and iron supplements [72]. (See "Clinical manifestations and diagnosis of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)", section on 'Epistaxis'.)

Antibiotics and toxic shock syndrome — The incidence of toxic shock syndrome (TSS) following postoperative nasal packing is estimated at about 16 per 100,000 packings. Although the incidence in primary nasal packing has not been established, it is prudent for clinicians and patients to be alert for signs of toxic shock syndrome (fever, hypotension, desquamation, and mucosal hyperemia). (See "Staphylococcal toxic shock syndrome".)

Systemic antibiotics appear to be of little use in reducing nasal carriage of Staphylococcus aureus (S. aureus) [59,73,74]. There are no studies that have directly examined the effect of systemic antibiotics on rates of TSS since it is such a rare event. In addition to the lack of proven efficacy of antibiotics, significant adverse outcomes might occur more commonly than TSS if antibiotics were given routinely. Such outcomes include allergic reactions and the development of bacterial strains with resistance to antibiotics.

Use of antibiotics has also been suggested for prevention of secondary bacterial sinus infections, but again, there are no studies to support this approach. Multiple observational studies of patients treated with anterior nasal packing for epistaxis report minimal, if any, risk of infection [75-78].

Nevertheless, despite the lack of proven efficacy, many ear, nose, and throat (ENT) specialists prefer to provide prophylaxis against TSS and antibiotics are commonly prescribed in patients with nasal packing for the duration of the packing [60,63,66,71,79-81]. We prefer to avoid giving antibiotics and believe they should not be given routinely for prophylaxis against infection in patients with anterior nasal packing. The decision to prescribe antibiotics is appropriately individualized to the patient. It may be reasonable to treat patients at greater risk of infection, such as those with diabetes, advanced age, or immunosuppression.

If prescribed, an antibiotic with staphylococcal coverage should be selected, such as amoxicillin-clavulanate or a first-generation cephalosporin; topical mupirocin may also be used [79].

Follow-up — If vital signs and respiratory function remain normal after packing, the patient may be safely referred for specialist follow-up in 24 to 48 hours, with advice to present to an emergency department sooner if bleeding recurs.

Some clinicians opt for urgent otolaryngologic consultation once acute anterior epistaxis has progressed to the point of needing bilateral packing, although the risk of aspiration, hypoxic complications, and treatment failure is small in this setting [60,71]. In most cases, 24 to 48 hour follow-up is adequate.

After 24 to 48 hours, a more thorough examination may be possible, although tumors or other abnormalities that may have been missed in the acute setting are seldom found. Nasal packing, particularly Merocel, should be rehydrated with saline drops prior to removal for patient comfort.

Specialty referral may not be necessary for healthy patients with stable vital signs and uncomplicated bleeding from a clearly identified source that resolves with simple cautery or one-time packing. Such patients should be reassessed when the packing is removed at 48 hours. Referral to an otolaryngologist is warranted in patients who do not meet ALL of these criteria, or about whom the clinician has questions or concerns.

Prevention — Patients with uncomplicated anterior bleeds should be advised to sleep in a humidified environment. Although proof of efficacy is not available [82], a topical antibacterial (eg, mupirocin) or bacteriostatic (eg, bacitracin) ointment may be gently applied to the nasal mucosa with a cotton-tipped swab in an attempt to prevent recurrence. Directing nasal medication sprays away from the septum may decrease the risk of epistaxis.

TREATMENT OF POSTERIOR BLEEDING — The acute management of a posterior nosebleed differs from that of an anterior bleed, although it is also based upon the principle of tamponade. Of the several methods of posterior packing described, we prefer balloon catheters. If balloon catheters are not available, alternatives include a Foley catheter and cotton packing.

A list of the equipment that may be needed for epistaxis management is provided (table 1). Immediate otolaryngologic consultation is necessary if bleeding is heavy and cannot be controlled with posterior packing.

Balloon catheters — Balloon catheters were developed to simplify posterior nasal packing. Examples include the Epistat and Storz T-3100. One model of the balloon catheter combines a small posterior balloon and a large anterior balloon. Such double balloon catheters are inserted as follows:

●Position the patient properly and pretreat with a topical anesthetic (eg, 2 percent lidocaine) and topical vasoconstrictor (eg, oxymetazoline). Proper patient positioning and pretreatment are discussed above. (See 'Physical examination' above.)

●Advance the catheter along the floor of the nasal cavity until the retention ring reaches the entrance of the naris.

●Inflate the posterior balloon with 10 mL of sterile water.

●Retract the catheter gently until it lodges against the posterior choana in the nasopharynx.

●Once the posterior balloon is seated, inflate the anterior balloon with 30 mL of sterile water. If the patient experiences severe pain or deviation of the nasal septum or soft palate, gradually deflate the anterior balloon until the pain or deviation resolve.

●Pad and protect the alae and naris entrance as necessary to prevent excessive pressure.

Some balloon catheters are designed to be used with air. The Epistat II has a posterior balloon and an anterior Merocel nasal tampon. Some devices are built around a central air passage to facilitate nose breathing. All balloon catheters are designed for temporary control of bleeding and should NOT be left in place for more than three days.

Foley catheter — If a balloon catheter is not available, posterior tamponade can be achieved by insertion of a 10 to 14 French Foley catheter using the following approach:

●Position the patient properly and pretreat with a topical anesthetic (eg, 2 percent lidocaine) and topical vasoconstrictor (eg, oxymetazoline). Proper patient positioning and pretreatment are discussed above. (See 'Physical examination' above.)

●Before insertion, coat the catheter with a suitable, petroleum-free lubricant and trim the tip of the catheter to minimize irritation of the posterior structures.

●Advance the catheter along the floor of the nose until it is visible in the posterior oropharynx.

●Partially fill the balloon with 5 to 7 mL of sterile water.

●Retract the catheter gently until it lodges against the posterior choana in the nasopharynx.

●Complete the filling of the balloon by adding another 5 mL of sterile water. Pain or distention of the soft palate suggests overfilling.

●Clamp the catheter in place with an umbilical clamp or small c-clamp, as from a nasogastric tube. Place padding between the clamp and the alae to prevent excessive pressure, which otherwise can lead to necrosis.

Some clinicians prefer filling the balloon with air to minimize the risk of aspiration in case of balloon failure (which has not been reported in this setting). However, the use of air in a balloon designed for fluid is associated with premature deflation [80,83].

Many practitioners still pack the anterior nose at this point because, without perfect apposition, some blood will pool anteriorly and exit the naris. Furthermore, some epistaxis episodes involve both anterior and posterior sources, especially in the setting of a coagulopathy or hereditary hemorrhagic telangiectasia. Be sure to maintain gentle traction on the Foley catheter while placing the anterior packing to avoid dislodgement of the former [43].

Be aware that petroleum-based products used for packing (such as BIPP or bacitracin ointment) can degrade the rubber of the balloon, possibly leading to rupture [80].

Cotton packing — Prior to the availability of balloon and Foley catheters, tamponade was achieved by means of cotton packing. This process involves feeding a small caliber red rubber hose through the nose and retrieving it from the oropharynx with a ring forceps (figure 6). A cotton pack is then tied to the oral end of the tube, with ties left long. The hose is then retracted through the nose, while digitally guiding the pack posteriorly, until it lodges against the posterior choana in the nasopharynx. The ties should now protrude through the nose. A second cotton pack or gauze roll is secured to the nasal end of the ties against the nares to anchor the pack. When such posterior cotton packing is placed, anterior packing is also generally needed.

Although direct posterior packing has been superseded in many United States settings, a small European trial, comparing this technique with a bicameral balloon device demonstrated that it remains an effective and safe alternative [84].

This type of posterior packing usually necessitates hospitalization out of concern for hypoxic complications, as well as the risk of asphyxiation should the packing become dislodged.

HOSPITALIZATION — Most patients with a suspected posterior source of bleeding require hospitalization in a bed with cardiac monitoring. Hospital admission may also be needed for patients with anterior packing who cannot be reasonably expected to return for prompt follow-up or who have serious comorbidities or concerning symptoms.

Prolonged retention of nasal packing (greater than 72 hours) increases the risk of complications, including necrosis, toxic shock syndrome, sinus or nasolacrimal infections, and dislodgment. At 24 to 48 hours, the consultant is likely to remove any packing to inspect the site; further care may involve observation, repacking and observation, surgical intervention, or arterial embolization in an interventional radiology suite.

MANAGEMENT OF PATIENTS WITH COVID-19 OR SIMILAR ILLNESS — Patients with known or suspected infection with coronavirus disease 2019 (COVID-19) or similar highly infectious respiratory illness who present for care of epistaxis should be managed using standard precautions against transmission. This includes appropriate use of personal protective equipment. These precautions are reviewed in detail separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)

Additional steps to prevent transmission specifically in patients with epistaxis may include the following [85,86]:

●Perform evaluation and treatment in a room with negative air flow if possible.

●Avoid using sprays (eg, oxymetazoline drops can be used instead of spray); apply topical medications directly or via gauze or pledgets.

●Use an absorbable material (eg, Surgicel) for initial anterior packing, if available, to reduce the risk of re-exposure on removal of packing.

COMPLICATIONS — A retrospective review of 250 patients hospitalized for epistaxis (including both anterior and posterior bleeds) found a 3 percent complication rate [14]. Complications included synechiae (intranasal adhesions), aspiration, angina, myocardial infarction, and hypovolemia.

The risks of posterior packing do NOT include the hypothetical "nasopulmonary reflex," which was once believed to account for hypoventilation and decreased arterial oxygen tension in patients with posterior nasal packs, leading to recommendations for early surgery [87]. Studies have failed to identify physiologic changes attributable to posterior packing. As examples, one report of 10 healthy volunteers who underwent posterior nasal packing found no changes in pulmonary or cardiac function [88], and a prospective study of 19 hospitalized patients with posterior packing who were observed with continuous pulse oximetry for a total of 1200 patient-hours found only two episodes of transient desaturation, both of which were attributable to other causes [49].

TREATMENT FAILURES — The management of conservative treatment failures varies according to available resources and the clinical scenario. Surgical treatment is often performed endoscopically and can include ligation of the sphenopalatine or anterior ethmoid artery (figure 3) [32,79,89]. Angiographic embolization is increasingly common, with results that approximate those of surgical treatment (90 percent range) [90-92]. The rate of severe complications (eg, stroke, blindness) with embolization is approximately four percent [15].

A number of studies have attempted to determine the likelihood of success and the relative costs of packing and observation, surgery, and embolization [31,32,41,79,93]. Interpretation of the results is made difficult by the small number of patients (ranging from 9 to 106), inability to perform blinded trials, and continual changes in surgical and nonsurgical management. As an example, past comparisons of medical and surgical management generally involve data obtained prior to the widespread use of endoscopic techniques [81].

Despite the limited data, an otolaryngology consultant would likely make a recommendation for definitive treatment based upon individual patient factors, individual expertise, and available resources. Nasal packing and hospital admission for observation remains a viable alternative to the more technology-intensive approaches to intractable epistaxis.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Nosebleeds (The Basics)")

●Beyond the Basics topic (see "Patient education: Nosebleeds (epistaxis) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy and epidemiology – Most epistaxis is anterior, occurring in Kiesselbach's plexus (picture 4); posterior bleeds can cause significant hemorrhage. Anterior bleeds arise most commonly from trauma; other etiologies for anterior and posterior bleeds include coagulation or platelet disorders, vascular lesions, nasal tumors, and hereditary telangiectasias. Hypertension does not cause, but may prolong, epistaxis. (See 'Anatomy' above and 'Etiology' above.)

●Laboratory testing – We suggest not ordering coagulation studies routinely; they are indicated for anticoagulated patients. Obtain a complete blood count and a type and crossmatch for all patients with profuse bleeding. (See 'Coagulation studies and other tests' above.)

●Initial interventions – Initial measures for a patient with a nosebleed should include evaluating the airway and hemodynamic stability (algorithm 1), and then having the patient perform basic tamponade maneuvers (picture 1 and picture 2). (See 'Initial assessment' above and 'Initial tamponade' above.)

●Anterior bleeding – The nose should be examined with a nasal speculum. If an anterior bleeding source is seen, we suggest cautery with silver nitrate or electrocautery (Grade 2B). Both sides of the septum should not be cauterized at the same time, to avoid septal necrosis. If no bleeding source is identified, the patient should be taught basic tamponade technique and instructed to return for recurrent bleeding. (See 'Physical examination' above and 'Cautery' above.)

If bleeding continues despite cautery, nasal packing should be inserted into the anterior naris. Endoscopic cautery is an alternative, if available. We suggest the use of nasal tampons or nasal balloon catheters rather than gauze nasal packing (Grade 2B). The inserts are easier to apply and better tolerated than gauze packing, although the treatments appear equally effective in controlling bleeding. In cases refractory to these measures, we suggest use of a Merocel nasal tampon saturated with 500 mg of the IV formulation of tranexamic acid (Grade 2C). (See 'Nasal packing' above and 'Thrombogenic foams and gels' above.)

●Prophylactic antibiotics – The appropriate use of antibiotic prophylaxis in patients with nasal packing remains controversial. We suggest that antibiotics not be given routinely for prophylaxis against infection in patients with anterior nasal packing (Grade 2C). The decision to prescribe antibiotics is appropriately individualized to the patient. It may be reasonable to treat patients at greater risk of infection. Patients should be evaluated by an ear, nose, and throat (ENT) specialist within 24 to 48 hours after packing is placed and should be warned about symptoms suggestive of toxic shock syndrome. (See 'Antibiotics and toxic shock syndrome' above and 'Follow-up' above.)

●Posterior bleeding – Patients who continue to bleed after anterior packing most likely have a posterior bleed, and require posterior packing with a specially developed nasal balloon catheter or a Foley catheter. Petroleum-based products (eg, bacitracin ointment) may damage the balloon and should be avoided with posterior packing. (See 'Treatment of posterior bleeding' above.)

Most patients who require posterior packing should be hospitalized for observation and assessment of the need for further intervention with surgery or angiographic embolization. (See 'Hospitalization' above.)