REMEDY : BNSSG referral pathways

Epistaxis

Checked: 11-09-2017 by Rob.Adams Next Review: 11-09-2018

Principles of Management

See CKS guidelines for advice on management of acute and recurrent epistaxis.

Determine if there is an underlying cause for epistaxis. Consider arranging a full blood count for adults with recurrent epistaxis.

Be aware that an underlying cause is likely in children younger than 2 years of age.

Red flags

Red Flags:

Males aged 12–20 years of age — angiofibroma (benign tumour) is possible (but rare).

People with symptoms suggestive of cancer, such as nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), or persistent lymphadenopathy.

Middle-aged people of Chinese origin — due to the high incidence of nasopharyngeal cancer.

People older than 50 years of age — nasal, sinus, and nasopharyngeal cancers are more common in this age group.

People with telangiectasia and a family history of hereditary haemorrhagic telangiectasia.

People with occupational exposure to wood dust or chemicals.

Consider referral to a paediatrician for children younger than 2 years of age who present with epistaxis as epistaxis is unusual in this age group

Treatment in Primary Care

  • If the person is not at high risk of having a serious underlying cause, discuss treatment options for recurrent epistaxis. These include:

  • Topical treatment with an antiseptic preparation to reduce crusting and vestibulitis.

    Prescribe Naseptin® (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days. If compliance is a problem, advise that it can be used twice daily for up to 2 weeks.

    If the person is allergic to neomycin, peanut, or soya, do not prescribe Naseptin®. Consider prescribing mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.

  • Nasal cautery . This is similarly effective to Naseptin® antiseptic cream but may be more uncomfortable. Consider it for use in primary care only if:

    The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available, and

    The bleeding point can be identified, and It can be tolerated (for example adults and older children, but not younger children).

Referral Guidance

If nasal cancer is suspected (see Red Flags) then refer via 2WW pathway (if there is no tick box on form for some of these indications then free text you concerns and patient should be seen).

Consider referral to ENT HOT clinic (via on call team) if recurrent bleeding which cannot wait for a routine appointment.

Contact paediatric on call team for children aged <2.