Chronic Recurrent Nose Bleeds

Adults and children over 12 years suffering recurrent nose bleeds.


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, 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


  • Manage any reversible cause
  • Apply antibiotic ointment for 5-7 days
If patient is experiencing further nose bleeds
  • Cautery 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 the Formulary 12.2 Nose, then petroleum jelly applied to septum for 2 weeks
If patient is experiencing further nose bleeds following initial treatments as above
No further nose bleeds
  • Continue conservative treatment
  • Advice re nose care
  • Use petroleum jelly
  • 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 via e-Referral service selection
  • Speciality: ENT
  • Clinic Type: Nose/ Sinus
  • Service: DRSS-Western-ENT- Devon CCG-15N
Referral to ENT for children e-Referral service selection
  • Specialty: Children's & Adolescent Services
  • Clinic Type: ENT
  • Service: DRSS-Western-ENT - (Children)-Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

Nose Bleeds leaflet


  • Van Wyk FC, Massey S, Worley G, Brady S. Do all epistaxis patients with a nasal pack need admission? A retrospective study of 116 patients managed in accident and emergency according to a peer reviewed protocol. J Laryngol Otol. Mar 2007;121(3):222-7
  • Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14
  • This guideline has been developed by Royal Devon and Exeter Healthcare Foundation Trust based on local guidelines.

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: March 2016


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