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Epistaxis

Key sources
The following summarized guidelines for the evaluation and management of epistaxis are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2020) and the Hereditary Haemorrhagic Telangiectasia Working Group (HHT-WG 2020).
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2

Guidelines

1.Diagnostic investigations

Initial assessment
Distinguish patients with nosebleed requiring prompt management from patients who do not, at the time of initial contact.
B
Document factors increasing the frequency or severity of bleeding in patients with nosebleeds, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use.
B
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  • Anterior rhinoscopy

2.Diagnostic procedures

Nasal endoscopy
Perform, or refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding.
B
Consider performing, or referring to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
C

3.Medical management

General principles: treat patients with an identified site of bleeding with an appropriate intervention, which may include ≥ 1 of the following:
moisturizing or lubricating agents
topical vasoconstrictors
nasal cautery
B

4.Nonpharmacologic interventions

Nasal compression: apply firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for ≥ 5 minutes in patients with active nasal bleeding requiring prompt management.
B

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  • Nasal packing

5.Therapeutic procedures

Nasal cautery: anesthetize the bleeding site and restrict application of cautery only to the active or suspected site of bleeding when nasal cautery is chosen for treatment.
B

6.Surgical interventions

Ligation and embolization: evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization in patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization.
B

7.Specific circumstances

Patients on anticoagulant and antiplatelet therapy
Initiate first-line treatments before transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications in patients using these medications, in the absence of life-threatening bleeding.
B
Use resorbable packing for nasal packaging in patients using anticoagulation or antiplatelet medications.
B

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  • HHT (evaluation)

  • Patients with HHT (topical therapy)

  • Patients with HHT (medical therapy)

  • Patients with HHT (ablative therapy)

  • Patients with HHT (surgery)

8.Patient education

Patient education: educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care.
B

9.Follow-up and surveillance

Follow-up: document the outcomes of intervention within 30 days or document transition of care in patients treated with non-resorbable packing, surgery, or arterial ligation/embolization.
B