Abstract
Epistaxis means bleeding from nostrils, nasal cavity or nasopharynx. To summarize the available epistaxis treatment options. Methods: 61 articles published in the last 20 years were included. Duplicate records, irrelevant and inaccessible ones were excluded. Epistaxis can be treated with first aid measures such as external pressure and ice packing and applying topical agents, e.g. oxymetazoline that stops 65–75% of nosebleeds in A&E. Also, with electrocautery which is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization and applying tranexamic acid that promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing. Furthermore, nasal packing can be applied with non-absorbable materials, e.g. petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino), absorbable materials, e.g. nasal tampon (Nasopore), and with newer hemostatic materials which are more effective and with fewer complications, e.g. hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) and fibrin glue. Moreover, epistaxis can be achieved with endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing (97% vs. 62%), and with endoscopic cauterization which is more effective than ligation. Finally, for intractable cases embolization can be applied using gelatin sponge, foam, PVA and coils with 80% success rate and comparable efficacy and complications to surgical methods. Epistaxis can be dealt with various methods depending on patient's history and available resources. Newer hemostatic agents in combination with endoscopic methods have advantages over traditional methods.
Similar content being viewed by others
References
Kucik CJ, Clenney T (2005) Management of epistaxis. Am Fam Physician 71(2):305–311
Svider P, Arianpour K, Mutchnick S (2018) Management of epistaxis in children and adolescents: avoiding a chaotic approach. Pediatr Clin North Am 65(3):607–621
Khan M, Conroy K, Ubayasiri K, Constable J, Smith ME, Williams RJ et al (2017) Initial assessment in the management of adult epistaxis: systematic review. J Laryngol Otol 131(12):1035–1055
Hajimaghsoudi M, Largani HA, Baradaranfar MH, Aghabagheri M, Jafari MA, Saeedi M (2018) A novel method for epistaxis management: randomized clinical trial comparing nose clip with manual compression. Am J Emerg Med 36(1):149–150
Béquignon E, Teissier N, Gauthier A, Brugel L, De Kermadec H, Coste A et al (2017) Emergency Department care of childhood epistaxis. Emerg Med J 34(8):543–548
Tran QK, Barnett J, O’Connell F, D’Anza B, Pourmand A (2021) Nasal packing in the emergency department: a practical review for emergency providers. Open Access Emerg Med 13:527–533
Beck R, Sorge M, Schneider A, Dietz A (2018) Current approaches to epistaxis treatment in primary and secondary care. Dtsch Arztebl Int 115(1–02):12–22
Middleton PM (2004) Epistaxis. Emerg Med Australas 16(5–6):428–440
Meccariello G, Georgalas C, Montevecchi F, Cammaroto G, Gobbi R, Firinu E et al (2019) Management of idiopathic epistaxis in adults: What’s new. Acta Otorhinolaryngol Ital 39(4):211–219
Michel J, Prulière Escabasse V, Bequignon E, Vérillaud B, Robard L, Crampette L et al (2017) Guidelines of the French Society of Otorhinolaryngology (SFORL). Epistaxis and high blood pressure. Eur Ann Otorhinolaryngol Head Neck Dis 134(1):33–35
Bastianpillai J, Saxby C, Coyle P, Armstrong A, Mohamid W, Mochloulis G (2019) Evaluating nasal cautery techniques in epistaxis. J Laryngol Otol 133(10):923–927
Shargorodsky J, Bleier BS, Holbrook EH, Cohen JM, Busaba N, Metson R et al (2013) Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg 149(3):390–398
Bequignon E, Vérillaud B, Robard L, Michel J, Prulière Escabasse V, Crampette L, Malard O, SFORL work-group (2017) Guidelines of the French Society of Otorhinolaryngology (SFORL). First-line treatment of epistaxis in adults. Eur Ann Otorhinolaryngol Head Neck Dis 134(3):185–189. https://doi.org/10.1016/j.anorl.2016.09.008
Johnson N, Faria J, Behar P (2015) A comparison of bipolar electrocautery and chemical cautery for control of pediatric recurrent anterior epistaxis. Otolaryngol Head Neck Surg 153(5):851–856
Mcleod RWJ, Price A, Williams RJ, Smith ME, Smith M, Owens D (2017) Intranasal cautery for the management of adult epistaxis: systematic review. J Laryngol Otol 131(12):1056–1064
Henderson A, Larkins A, Repanos C (2013) The use of bipolar electrocautery in adult epistaxis management: using audit of one hundred and twenty-four cases to define a standardised protocol. Clin Otolaryngol 38(6):554–558
Kindler RM, Holzmann D, Landis BN, Ditzen B, Soyka MB (2016) The high rate of long-term recurrences and sequelae after epistaxis treatment. Auris Nasus Larynx 43(4):412–417
Koçak HE, Bilece ZT, Keskin M, Ulusoy HA, Koç AK, Kaya KH (2021) Comparison of topical treatment methods used in recurrent anterior epistaxis: a randomized clinical trial. Braz J Otorhinolaryngol 87(2):132–136
Calder N, Kang S, Fraser L, Kunanandam T, Montgomery J, Kubba H (2009) A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngol Head Neck Surg 140(5):670–674
Logan JK, Pantle H (2016) Role of topical tranexamic acid in the management of idiopathic anterior epistaxis in adult patients in the emergency department. Am J Health Syst Pharm 73(21):1755–1759
Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M (2018) Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med 25(3):261–266
Gottlieb M, DeMott JM, Peksa GD (2019) Topical tranexamic acid for the treatment of acute epistaxis: a systematic review and meta-analysis. Ann Pharmacother 53(6):652–657
Whitworth K, Johnson J, Wisniewski S, Schrader M (2020) Data on the hemostasis in epistaxis with topically administered txa versus topical oxymetazoline spray. Data Brief 29:105283
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M (2013) A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 31(9):1389–1392
Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ (2018) Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev 12:CD004328
Janapala RN, Tran QK, Patel J, Mehta E, Pourmand A (2022) Efficacy of topical tranexamic acid in epistaxis: a systematic review and meta-analysis. Am J Emerg Med 51:169–175
Hilton L, Reuben A (2014) Best evidence topic reports. BET 3: topical intranasal tranexamic acid for spontaneous epistaxis. Emerg Med J 31(5):436–437
Reuben A, Appelboam A, Stevens KN, Vickery J, Ewings P, Ingram W et al (2021) The use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPAC): randomized controlled trial. Ann Emerg Med 77(6):631–640
Fox H, Hunter F (2015) BET 1: intravenous tranexamic acid in the treatment of acute epistaxis. Emerg Med J 32(12):969–970
Yüksel A, Kurtaran H, Kankiliç ES, Ark N, Uğur KS, Gündüz M (2014) Epistaxis in geriatric patients. Turk J Med Sci 44(1):133–136
Sethi RKV, Kozin ED, Abt NB, Bergmark R, Gray ST (2018) Treatment disparities in the management of epistaxis in United States emergency departments. Laryngoscope 128(2):356–362
Wang J, Cai C, Wang S (2014) Merocel versus nasopore for nasal packing: a meta-analysis of randomized controlled trials. PLoS ONE 9(4):e93959
Iqbal IZ, Jones GH, Dawe N, Mamais C, Smith ME, Williams RJ et al (2017) Intranasal packs and haemostatic agents for the management of adult epistaxis: systematic review. J Laryngol Otol 131(12):1065–1092
Yau S (2015) An update on epistaxis. Aust Fam Physician 44(9):653–656
Badran K, Malik TH, Belloso A, Timms MS (2005) Randomized controlled trial comparing merocel and rapidrhino packing in the management of anterior epistaxis. Clin Otolaryngol 30(4):333–337
Moumoulidis I, Draper MR, Patel H, Jani P, Price T (2006) A prospective randomised controlled trial comparing merocel and rapid rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol 263(8):719–722
Richardson C, Abrol A, Cabrera CI, Goldstein J, Maronian N, Rodriguez K et al (2021) The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation. Am J Otolaryngol 42(4):102941
Kilty SJ, Al-Hajry M, Al-Mutairi D, Bonaparte JP, Duval M, Hwang E et al (2014) Prospective clinical trial of gelatin-thrombin matrix as first line treatment of posterior epistaxis. Laryngoscope 124(1):38–42
Milinis K, Swords C, Hardman JC, Slovick A, Hutson K, Kuhn I et al (2021) Dissolvable intranasal haemostatic agents for acute epistaxis: a systematic review and meta-analysis. Clin Otolaryngol 46(3):485–493
Gurdeep S, Harvinder S, Philip R, Amanjit K (2006) Intranasal use of quickclot in a patient with uncontrollable epistaxis. Med J Malays 61(1):112–113
Shikani AH, Chahine KA, Alqudah MA (2011) Endoscopically guided chitosan nasal packing for intractable epistaxis. Am J Rhinol Allergy 25(1):61–63
Valentine R, Athanasiadis T, Moratti S, Hanton L, Robinson S, Wormald PJ (2010) The efficacy of a novel chitosan gel on hemostasis and wound healing after endoscopic sinus surgery. Am J Rhinol Allergy 24(1):70–75
Mathiasen RA, Cruz RM (2005) Prospective, randomized, controlled clinical trial of a novel matrix hemostatic sealant in patients with acute anterior epistaxis. Laryngoscope 115(5):899–902
Cho KS, Park CH, Hong SL, Kim MJ, Kim JY, Kim YW et al (2015) Comparative analysis of Cutanplast and Spongostan nasal packing after endoscopic sinus surgery: a prospective, randomized, multicenter study. Eur Arch Otorhinolaryngol 272(7):1699–1705
Riviello R, Brown A (2010) Otolaryngologic procedures. In: Roberts J, Hedges J (eds) Clinical procedures in emergency medicine, 5th edn. Saunders Elsevier, Philadelphia, pp 1204–1207
Novoa E, Schlegel-Wagner C (2012) Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting. J Laryngol Otol 126(1):58–60
Vis E, van den Berge H (2011) Treatment of epistaxis without the use of nasal packing, a patient study. Rhinology 49(5):600–604
Schwartzbauer HR, Shete M, Tami TA (2003) Endoscopic anatomy of the sphenopalatine and posterior nasal arteries: implications for the endoscopic management of epistaxis. Am J Rhinol 17(1):63–66
Nouraei SA, Maani T, Hajioff D, Saleh HA, Mackay IS (2007) Outcome of endoscopic sphenopalatine artery occlusion for intractable epistaxis: a 10-year experience. Laryngoscope 117(8):1452–1456
Kumar S, Shetty A, Rockey J, Nilssen E (2003) Contemporary surgical treatment of epistaxis. What is the evidence for sphenopalatine artery ligation. Clin Otolaryngol Allied Sci 28(4):360–363
Kitamura T, Takenaka Y, Takeda K, Oya R, Ashida N, Shimizu K et al (2019) Sphenopalatine artery surgery for refractory idiopathic epistaxis: systematic review and meta-analysis. Laryngoscope 129(8):1731–1736
Pádua FG, Voegels RL (2008) Severe posterior epistaxis-endoscopic surgical anatomy. Laryngoscope 118(1):156–161
Asanau A, Timoshenko AP, Vercherin P, Martin C, Prades JM (2009) Sphenopalatine and anterior ethmoidal artery ligation for severe epistaxis. Ann Otol Rhinol Laryngol 118(9):639–644
Kamani T, Shaw S, Ali A, Manjaly G, Jeffree M (2007) Sphenopalatine-sphenopalatine anastomosis: a unique cause of intractable epistaxis, safely treated with microcatheter embolization: a case report. J Med Case Rep 1:125
Camp AA, Dutton JM, Caldarelli DD (2009) Endoscopic transnasal transethmoid ligation of the anterior ethmoid artery. Am J Rhinol Allergy 23(2):200–202
Selcuk H, Soylu N, Albayram S, Selcuk D, Ozer H, Kocer N et al (2005) Endovascular treatment of persistent epistaxis due to pseudoaneurysm formation of the ophthalmic artery secondary to nasogastric tube. Cardiovasc Intervent Radiol 28(2):242–245
Krajina A, Chrobok V (2014) Radiological diagnosis and management of epistaxis. Cardiovasc Interven Radiol 37(1):26–36
Swords C, Patel A, Smith ME, Williams RJ, Kuhn I, Hopkins C (2017) Surgical and interventional radiological management of adult epistaxis: systematic review. J Laryngol Otol 131(12):1108–1130
Hoffman H, Ashok Kumar A, Raventhiranathan N, Masoud HE, Gould GC (2023) Endovascular embolization for the treatment of epistaxis: systematic review and meta-analysis. Interv Neuroradiol. https://doi.org/10.1177/15910199221081715
Christensen NP, Smith DS, Barnwell SL, Wax MK (2005) Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg 133(5):748–753
Vokes DE, McIvor NP, Wattie WJ, Chaplin JM, Morton RP (2004) Endovascular treatment of epistaxis. ANZ J Surg 74(9):751–753
Klotz DA, Winkle MR, Richmon J, Hengerer AS (2002) Surgical management of posterior epistaxis: a changing paradigm. Laryngoscope 112(9):1577–1582
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All the authors that they have no conflict of interst.
Human or Animal Rights Statement
Not Applicable.
Informed Consent
Not Applicable.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Mylonas, S., Skoulakis, C., Nikolaidis, V. et al. Epistaxis Treatment Options: Literature Review. Indian J Otolaryngol Head Neck Surg 75, 2235–2244 (2023). https://doi.org/10.1007/s12070-023-03824-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12070-023-03824-z