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?

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

• Manage any reversible cause
• Apply antibiotic ointment for 5-7 days

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 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 ICB - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

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 on behalf of NHS Devon.

Publication date: October 2017