Chronic recurrent nose bleeds

Scope

Adults and children over 12 years suffering recurrent nose bleeds.

Assessment

Signs and Symptoms

  • Any history of excess alcohol intake?
  • Does the patient have uncontrolled hypertension?
  • Are there any other signs of bleeding tendency?
  • Nose picking
  • Nasal steroid spray use
  • Exclude red flags

History and examination

Take a patient history

  • Is the patient treated with warfarin, DOAC (e.g. rivaroxaban), aspirin, clopidogrel and or prasugrel?
  • Is there any history of excess alcohol intake?
  • Does the patient have uncontrolled hypertension?
  • Are there any signs of bleeding tendency?

Red flags

  • Unilateral nasal mass
  • Proptosis
  • Altered facial sensation
  • Loose teeth

Management

If patient is experiencing further nose bleeds
  • Cauterise of local area unilaterally with silver nitrate according to local skills
    • Do not cauterise opposite side for at least 6 weeks
  • 5 days of antibiotic ointment according to Joint Formulary, then petroleum jelly applied to septum for 2 weeks
If patient is experiencing further nose bleeds following initial treatments as above
  • Review antiplatelets/ anticoagulants
  • Consider referral to ENT
No further nose bleeds
  • Continue conservative treatment
  • Give advice on nose care
  • Use petroleum jelly - apply just inside the nose
  • Review as appropriate

Joint Formulary Chapter 12 ENT

Referral

Referral Criteria

Consider referral to ENT for:

  • Patient has recurrent nose bleeds
  • Failed conservative management in primary care – see above

Referral Instructions

Referral to ENT for adults

e-Referral Service Selection

  • Speciality: ENT
  • Clinic Type: Nose/ Sinus
  • Service: DRSS-South Devon & Torbay-Ear Nose and Throat- Devon CCG -15N
Referral to ENT for children

e-Referral Service Selection

  • Specialty: Children's & Adolescent Services
  • Clinic Type: ENT
  • Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon CCG - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Supporting information

Patient Information

Nose Bleeds -patient.co.uk leaflet

Evidence

  • Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14.

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG.

Publication date: October 2017

 

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