Epistaxis

Background: Nosebleeds are very common and often self-limiting. There are often multiple factors which contribute to recurrent epistaxis, rather than a single treatable cause.

Possible contributing factors include:

• Nose picking
• Age
• Anticoagulation therapy
• Trauma
• Bleeding disorders e.g. von willebrands, factor VIII deficiency etc
• Recent surgery
• Recent URTI
• Liver disease
• Haematological disorders e.g. leukaemia

Most epistaxis comes from littles area on the anterior septum. Topical nasal ointments such as nasptin or bactroban or Vaseline can help reduce scabbing and provide a barrier which reduces the frequency of nosebleeds. If this fails, cautery can effectively reduce the frequency of epistaxis. However, recurrences are common and patients should be informed of this from the outset.

How to assess:

Examine the nose by lifting the tip of the nose up and using a light / otoscope – look for prominent vessels on the septum which may indicate a bleeding source, look for nasal masses that might indicate malignancy

How to manage:

Reinforce first aid advice:

               Sit forward over a bowl and spit out any blood

               Pinch the soft part of the nose for 20 minutes with thumb and finger without letting go

               If doesn’t stop after 20 minutes of basic first aid, go to nearest A&E

If stops, use naseptin cream TID for 7-10 days. This helps any clots to come off gently and reduces this risk of rebleeding.  Avoid nose blowing, nose picking, heavy exercise/straining,  very hot drinks / showers for 7-10 days as all of these can precipitate further nosebleeds

Referral guidelines:

For recurrent, small volume epistaxis with failed topical therapy, ENT referral on a routine basis

If epistaxis with suspicion of a nasal mass, refer as urgent suspected cancer. Photos can be helpful in triaging referrals appropriately if possible

Caution:

Frequently, the inferior turbinates are confused with a nasal mass. Always compare sides.