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Purpose: Posterior epistaxis is a common emergency in ENT practice varying in severity and treatment. Many management guidelines have been proposed, all of which are a product of retrospective analyses due to the nature of this pathology, as large-scale double-blind studies are impossible-even unethical-to conduct. The purpose of this review is to perform a thorough analysis and comparison of every treatment plan available and establish guidelines for the best possible outcome in accordance to every parameter studied. Given the extensive heterogeneity of information and the multitude of studies on this topic, along with the comparison of various treatment options, we opted for a literature review as our research approach., Methods: A review of the literature was performed using PubMed Database and search terms included "posterior epistaxis", "treatment", "management", "guidelines", "algorithm" "nasal packing", "posterior packing", "surgery", "SPA ligation", "embolization", "risk factors" or a combination of the above., Results: Initial patients' assessment invariably results in most cases in posterior packing. There seems to be a superiority in recent literature of early surgery over nasal packing as a definitive treatment. Embolization is usually used after surgery failure, except for specific occasions., Conclusion: Despite the vast heterogeneity of information, there seems to be a need for re-evaluation of the well-established treatment plans according to more recent studies., (© 2023. The Author(s).)

Purpose: This retrospective study assesses the risks and benefits linked to the non-use of nasal packing after a (rhino)septoplasty, compared with post-operative care with anterior nasal packing such as Merocel®., Methods: Complication rates observed during the first week after surgery were compared between groups with and without use of classic nasal packing over a large sample of 534 patients, who had undergone either a closed or open procedure, with bilateral turbinoplasty, and with or without osteotomies. Complications listed include epistaxis, haematoma, impetiginization, septal perforation, hyperalgesia, and dyspnoea., Results: No significant difference was observed between the group with and without packing regarding the immediate post-operative complications of epistaxis (4.4% of the cases with nasal packing versus 3% without, p = 0.918) and impetiginization (3% of the cases with nasal packing versus 4.2% without, p = 0.478). The technique used, as well as any osteotomies performed, had no impact on the results., Conclusion: Non-use of nasal packing after a (rhino)septoplasty is a safe alternative to classic post-operative methods. Provided that there is a rigorous surgical technique and strict clinical control, it should be used as a principal technique in any routine practice due to its safety for patients immediately post-surgery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed., Study Design: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given., Setting: Patients with nonabsorbable nasal packing placed., Methods: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model., Results: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective., Conclusions: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence., Level of Evidence: 3a.

Background: There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing., Objective: Our aim was to assess both rates of utilization and evidence of benefit for prophylactic antibiotics in patients with nasal packing for epistaxis., Methods: A single-institution retrospective review of 275 cases of anterior nasal packing in an urban emergency department between September 2013 and April 2017 was performed. Chi-square statistical analysis was used to evaluate results., Results: Among 275 cases studied, there were no instances of toxic shock syndrome. Roughly 73% of patients with nonabsorbable packing received prophylactic antibiotics. Only one (1.1%) case of sinusitis was noted among the nonabsorbable packing with prophylaxis group, with no such complication in the nonprophylaxis group. In contrast, 95% of patients with absorbable nasal packing were not given prophylactic antibiotics. Analysis of all cases given prophylactic antibiotics vs. no prophylaxis, regardless of packing type, revealed no statistically significant difference in the development of acute sinusitis (1% vs. 0.56%; p = 0.6793)., Conclusions: There was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Epistaxis is the most common ENT emergency. The aim was to determine population-based data on severe epistaxis needing inpatient treatment., Methods: Retrospective population-based cohort study in the federal state Thuringia in 2016 performed on all 840 inpatients treated for epistaxis in otolaryngology departments (60.1% male, median age: 73 years; 63.9% under anticoagulation). The association between patients' and treatment characteristics and longer inpatient stay (≥ 4 days) as well as readmission for recurrent epistaxis was analyzed using univariable and multivariable statistics., Results: The overall incidence of epistaxis needing inpatient treatment was higher for men (42 per 100,000) than for women (28 per 100,000). The highest incidence was reached for men > 85 years (222 per 100,000). Most important independent predictors for longer inpatient stay were localization of the bleeding not in the anterior nose (OR = 2.045; CI = 1.534-2.726), recurrent bleeding during inpatient treatment (OR = 2.142; CI = 1.508-3.042), no electrocoagulation (OR = 2.810; CI = 2.047-3.858), and blood transfusion (OR = 2.731; CI = 1.324-5.635). Independent predictors for later readmission because of recurrent epistaxis were male gender (OR = 1.756; CI = 1.155-2.668), oral anticoagulant use (OR = 1.731; CI = 1.046-2.865), and hereditary hemorrhagic telangiectasia (OR = 13.216; CI 5.102-34.231)., Conclusions: Inpatient treatment of epistaxis seems to be variable in daily routine needing standardization by clinical guidelines and strategies to shorten inpatient treatment and to reduce the risk of readmission.

Objective: Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the great majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds., Purpose: The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It will focus on nosebleeds that commonly present to clinicians with phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients, patients with hemorrhagic telangiectasia syndrome (HHT) and patients taking medications that inhibit coagulation and/or platelet function, are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the working group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based upon their experience and assessment of individual patients., Action Statements: The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome (HHT). (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation about examination of the nasal cavity and nasopharynx using nasal endoscopy was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Objective: The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolization were compared., Material and Method: Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively., Results: Eleven patients (17%) underwent embolization, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolization was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolization. One patient suffered a hemispheric stroke after embolization. No post-surgical complications were observed., Conclusions: Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient., (Copyright © 2018 Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Septoplasty or septal reconstruction is a corrective surgical procedure performed to straighten the nasal septum. It may be associated with numerous complications. To minimize these complications, both nasal cavities are frequently packed with different types of nasal packing., Materials and Methods: This prospective, observational, and comparative study was undertaken in the Department of ENT, Rajindra Hospital, Patiala, Punjab, India. A total of sixty patients fulfilling the inclusion criteria participated in the study. They were divided into two groups, Groups A and B. After septoplasty, the nasal cavity was packed with gloved Merocel ® in Group A and ungloved Merocel ® in control group (Group B). The efficacy and patient tolerance for both nasal packings were compared and assessed. The data collected were compiled and analyzed statistically., Results: In our study, it was demonstrated that gloved Merocel ® produces less pain during pack insertion (P = 0.001) and produces less pain while insertion of pack in situ (P = 0.001) and during pack removal (P = 0.001). Saccharin transit time (STT) returned back to normal in gloved Merocel ® group (P = 0.001) in most of patients (27) by the 2 nd week, whereas STT in ungloved Merocel ® group returned back to normal by the 4 th week postoperatively. The differences in impairment in STT between the two groups were found to be statistically significant. There was no statistical significance between both groups for other parameters., Conclusion: Gloved Merocel ® may be preferred over ungloved Merocel ® as nasal packing following septoplasty since both types of packs had similar hemostatic, adhesion prevention properties and similar incidence in postoperative complications and gloved Merocel ® produces less pain during its insertion, while it is in situ, during its removal with early recovery of nasal mucociliary clearance mechanism of nose., Competing Interests: There are no conflicts of interest.

Background: Epistaxis is the most prevalent ENT emergency and a significant burden on ENT services. Our objective was to study the incidence and outcomes of patients presenting with epistaxis at a major teaching hospital., Methods: A retrospective descriptive study of 721 patients, who presented with epistaxis over a 1-year period, was carried out. Data collected was analysed using SPSS software version 20., Results: Of the 721 patients, initial treatment consisted of nasal cautery (298), nasal packing (200), or no treatment (223). Fifty-nine patients were admitted. The mean age of admitted patients was 66.8 years and the male to female ratio was 2:1. 69.5% had hypertension and 78% used an antiplatelet/anticoagulation medication. The majority of admitted and return patients were out of hours referrals from ED and the mean admission duration was five nights. Surgical treatment for intractable epistaxis included arterial ligation or endovascular embolisation. Successful treatment was defined as no recurrent epistaxis following pack removal or no readmission with epistaxis within 24 h of hospital discharge. Six hundred forty-four patients had successful treatment., Conclusion: More return and admitted patients presented at out-of-hours times with less clinical staff on site. Most non-admitted patients received no treatment. These factors possibly lead to increased stress on the ENT casualty service. Cautery and nasal packing are the most common treatment modalities in first-time and admitted patients yet result in considerable rates of representation.

This article provides an organized foundation that facilitates the management of acute epistaxis and an understanding of features that merit further diagnostic workup. Prompt management, including measures such as holding pressure and using nasal packing, takes precedence over comprehensive diagnostic workup. Severe, recurrent, and posteriorly based bleeds should prompt consideration of alternate interventions and expert consultation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: There is limited data on epistaxis presentation and management patterns in U.S. emergency departments (EDs). We aim to characterize patients who present to the ED with epistaxis and identify factors associated with nasal-packing use., Study Design: Retrospective review of Nationwide Emergency Department Sample (NEDS) from 2009 to 2011., Methods: NEDS was queried for patient visits with a primary diagnosis of epistaxis (International Classification of Diseases, Ninth Revision, Clinical Modification code 784.7). Patient demographics, comorbidities, and hospital characteristics were obtained. Predictors of nasal packing were determined by multivariable logistic regression., Results: There were 1,234,267 ED visits for epistaxis. The highest proportion of patients were seen in the winter (37.2%) at nontrauma hospitals (76.9%), and were discharged home (95.5%). Fifteen percent of patients were on long-term anticoagulation, 33% had hypertension, and 0.9% had a coagulopathy. Nasal packing was utilized in 243,268 patients (19.7%). Predictors strongly associated with nasal packing included lower socioeconomic quartile (odds ratio [OR] 1.30, 95% confidence interval [CI] = 1.10-1.53), hospital located in the geographic South (OR 1.62, CI = 1.12-2.34) and Midwest (OR 1.85, P < 0.0001), and nontrauma hospital (OR 1.56, CI = 1.19-2.05). Other factors included long-term anticoagulation (OR 1.21, CI = 1.10-1.33), winter season (OR 1.20, CI = 1.12-1.23), male gender (OR 1.14, CI = 1.10-1.17), and older age (OR 1.01, CI = 1.01-1.02). Mean ED charge was greater for patients who were packed ($1,473 vs. $1,048, P < 0.0001)., Conclusion: Several factors, including lower socioeconomic status, geographic location, and nontrauma hospital designation, predict use of nasal packing. These results raise concerns about potential treatment disparities that may result in increased patient morbidity and costs., Level of Evidence: 2C. Laryngoscope, 128:356-362, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Epistaxis is the most common emergent consultation to otolaryngology-head & neck surgery (OHNS) and with 60% of the population having experienced an episode and 1.6 in 10,000 requiring hospitalization in their lifetime. In preliminary studies Floseal® (Baxter, USA) Hemostatic Matrix has shown efficacy in up to 80% of persistent anterior epistaxis. We sought to evaluate the clinical efficacy and cost-effectiveness of Floseal® (Baxter, USA) compared to traditional nasal packing for persistent epistaxis., Methods: A prospective, randomized controlled trial was conducted on all adult patients consulted to the OHNS service at the tertiary referral centers of the University of Alberta Hospital and Royal Alexandra Hospital for persistent epistaxis. Patients were randomized to the Floseal® (Baxter, USA) or traditional packing study arms. Our main clinical outcome measures were: 1) Hemostasis directly following treatment and at 48 h post-treatment, and 2) self-reported patient comfort at 48 h post-treatment. Further, trial data was used for a formal cost-effectiveness analysis to determine incremental cost-effectiveness ratio (ICER). Univariate sensitivity analysis and uncertainty analysis were performed., Results: There were no significant differences between groups for initial hemostasis (76.9% vs. 84.6%, p = 1.000) or, hemostasis at 48 h (76.9% vs. 69.2%, p = 1.000), requirement for admission (15.4% vs. 46.1%, p = 0.2016) or 30-day re-presentation rates (15.4% vs. 46.1%, p = 0.2016). Floseal® (Baxter, USA) was superior for decreased pain during placement (2.42 vs. 7.77, p = 0.0022), treatment (0.50 vs. 4.46, p = 0.0007) and removal (0 vs. 3.85, p = 0.0021). Floseal® (Baxter, USA) provides an average $1567.61 per patient savings from the single-payer system point of view and has an ICER of - $11,891 per re-bleed prevented (95% CI: -$37,658 to +$473). Uncertainty analysis shows that Floseal® has >90% chance of not only being cost-effective, but the dominant (preferred) treatment., Conclusions: Floseal® (Baxter, USA) was demonstrated to be an effective, comfortable and cost-effective alternative treatment of persistent epistaxis when compared to traditional packing methods for patients referred to OHNS with a normal coagulation profile., Trial Registration: Trial registration number: NCT02488135 . Date registered: June 26, 2015.

The aim of this study is to present our management protocol of sphenopalatine artery bleeding, demonstrating that nasoendoscopic cautery (NC) was a more effective method than the nasal packing, in terms of shorter inpatient stay and reduced complications rate. We present ten posterior epistaxis not resolved by nasal packing. Tabotamp ® was placed in the area of sphenopalatine foramen and/or in those parts of the posterior nasal cavity, where it was suspected that bleeding origins. In two cases, the bleeding was resolved in this way, instead eight cases needed of subperiosteal cauterization of sphenopalatine artery by Dessi bipolar forceps (MicroFrance ® ). 4 of these 8 patients evidenced a remarkable bleeding removing nasal packing (Hb before-nasal packing = 15 ± 0.69 versus Hb after-nasal packing = 13.3 ± 0.81; t student = 2.94; p value = 0.025). These four patients showed a deviation of the nasal septum ipsilateral to epistaxis, and according our experience, a traumatism of sphenopalatine area can be caused by Merocel ® nasal packing in this condition. During follow-up, no recurrences of nasal bleeding have been observed in such patients. Nasal packing must be considered if posterior epistaxis is severe, but always taking into account the specific anatomy of patient and in particular septal spurs that can further compromise sphenopalatine artery. In our experience, the endoscopic endonasal cauterization of the sphenopalatine branches represented a safe and effective procedure.

Objective: We compare the management of patients with severe epistaxis before and after the implementation a clinical care pathway (CCP) to standardize care, minimize hospital stay, and decrease cost., Study Design: Single prospective analysis with historical control., Setting: Tertiary academic hospital., Subjects and Methods: Patients treated for epistaxis between October 2012 to December 2013 were compared with a prospective analysis of patients treated for severe epistaxis after implementation of a CCP from June 2014 to February 2015. Severe epistaxis was defined as nasal bleeding not able to be controlled with local pressure, topical vasoconstrictors, or simple anterior packing., Results: Severe epistaxis was similar in the pre- and post-CCP cohorts: 24.7% (n = 42) vs 18.9% (n = 22), respectively. Implementation of early sphenopalatine artery ligation resulted in decreased number of days packed (3.2 ± 1.6 to 1.4 ± 1.6; P = .001), decreased hospital stay (5.2 ± 3.9 to 2.1 ± 1.3 days; P < .001), an increased percentage of sphenopalatine artery ligations (31.0% vs 54.5%; P = .035), admission to an appropriate hospital location with access to key resources (41.7% vs 83.3%; P = .007), and decreased overall cost of hospitalization by 66% ($9435 saved). No patients received embolization after the CCP was implemented., Conclusions: Implementation of a CCP decreased hospital stay and days of packing, facilitated definitive care in patients with severe epistaxis, improved patient safety, and decreased cost. The results of this study can serve as a model for the management of severe epistaxis and for future quality improvement measures., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objective: Sphenopalatine artery ligation is a commonly employed surgical intervention for control of posterior epistaxis unresponsive to nasal packing. The objective of the present study was to evaluate the outcome of sphenopalatine artery ligation for control of epistaxis at our institution and the impact of timing and other factors on outcome., Study Design: Case series with chart review., Setting: Academic tertiary referral center., Subjects and Methods: Case notes were reviewed for 45 consecutive patients undergoing sphenopalatine artery ligation for control of epistaxis between October 2008 and October 2014., Results: Forty-one patients had nasal packing prior to sphenopalatine artery ligation, with 33 undergoing ≥2 packings. Postoperatively, 6 patients had rebleeding, which was treated with repacking (n = 4) and return to the operating room (n = 2). The overall success rate of sphenopalatine artery ligation was 87% (39 of 45). Rebleeding rate was not affected by concomitant septoplasty, anterior ethmoidal artery ligation, or postoperative nasal packing. Patients undergoing SPA ligation within the first 24 hours of admission had a significantly shorter hospital length of stay (3 vs 6 days, P = .02) and treatment cost (€5905 vs €10,001, P = .03). Length of stay was not influenced by sphenopalatine artery ligation after ≤1 nasal pack versus ≥2 packs. Timing of sphenopalatine artery ligation did not affect blood transfusion requirement (P = .84)., Conclusion: Sphenopalatine artery ligation is an effective management strategy for surgical control of refractory epistaxis. Early timing of sphenopalatine artery ligation may lead to reductions in length of stay., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objectives/hypothesis: To compare the extent of bleeding and patient discomfort during packing removal of three different polyvinyl alcohol (PVA) packs: 1) a standard PVA sponge (s-PVA) (Mondocel Standard 10 cm; Mondomed NV, Hamont-Achel, Belgium); 2) a PVA sponge with oxidized cellulose (oc-PVA) (Merocel Hemox 10 cm; Medtronic Xomed Surgical Products, Jacksonville, FL); and 3) a PVA sponge with polyethylene film (pf-PVA) (Merocel 2000 8 cm; Medtronic Xomed Surgical Products, Jacksonville, FL), after functional endoscopic sinus surgery and inferior turbinoplasty., Study Design: A prospective, randomized, blinded, controlled trial., Methods: Ninety consecutive patients were enrolled and randomized to receive in each side one pack in the middle meatus and another pack of the same material in the nasal fossa. The patients were equally divided in three groups of 30 patients each. Group A received the pf-PVA; group B received oc-PVA; and group C received s-PVA. Postoperatively, bleeding after removal of the entire nasal packing was evaluated by an observer, whereas the severity of pain was rated by patients with visual analog scales., Results: Our study evaluated three nasal packing materials, demonstrating that the pf-PVA is less painful than the others but with intermediate bleeding ratio. However, the oc-PVA has an intermediate pain score but minimum bleeding. The s-PVA showed the worst pain and bleeding results., Conclusions: Considering that removal of the second pack (middle meatus) is more painful than the first (nasal fossa), our results suggest that a pf-PVA can be placed in the middle meatus and a oc-PVA in the nasal fossa in order to reduce patient's discomfort in terms of pain and bleeding., Level of Evidence: 1b., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Aim: To describe the prevalence, diagnosis, treatment, and outcomes of end stage liver disease (ESLD) patients with severe epistaxis thought to be severe upper gastrointestinal hemorrhage (UGIH)., Methods: This observational single center study included all consecutive patients with ESLD and epistaxis identified from consecutive subjects hospitalized with suspected UGIH and prospectively enrolled in our databases of severe UGIH between 1998 and 2011., Results: A total of 1249 patients were registered for severe UGIH in the data basis, 461 (36.9%) were cirrhotics. Epistaxis rather than UGIH was the bleeding source in 20 patients. All patients had severe coagulopathy. Epistaxis was initially controlled in all cases. Fifteen (75%) subjects required posterior nasal packing and 2 (10%) embolization in addition to correction of coagulopathy. Five (25%) patients died in the hospital, 12 (60%) received orthotopic liver transplantation (OLT), and 3 (15%) were discharged without OLT. The mortality rate was 63% in patients without OLT., Conclusion: Severe epistaxis in patients with ESLD is (1) a diagnosis of exclusion that requires upper endoscopy to exclude severe UGIH; and (2) associated with a high mortality rate in patients not receiving OLT.

Background: The purpose of this study was to examine litigation involving epistaxis and analyze factors that determine liability., Methods: Jury verdicts and settlements regarding cases involving epistaxis were gathered utilizing the Westlaw database. Factors involved in litigation gathered included demographics, defendant specialty, procedure, alleged cause of malpractice, outcome, monetary award, and other variables., Results: A total of 26 cases were analyzed. The majority of cases (57.7%) were decided in favor of the plaintiff or settled out of court. Total awards amounted to $24,501,252. Average awards for cases decided in favor of the plaintiff were $2,260,893 and ranged from $499,845 to $9,022,643. Settlements averaged $1,084,375 and ranged from $300,000 to $3,800,000. Common causes of malpractice encountered included delay in diagnosis, complications from medical procedures, and failure to recognize complications in a timely manner., Conclusion: Contrary to previous reports analyzing malpractice for varying medical procedures and complications, litigation in epistaxis is more commonly resolved in favor of the plaintiff or resolved through out-of-court settlements. Substantial financial awards and therapeutic complications from blindness to death make epistaxis a candidate for litigation. Of importance from a medicolegal stand is the fact that 30.8% (8) of the patients involved in epistaxis litigation died, either from complications of therapy or from experiencing epistaxis as a complication of another procedure/pathology. Using necessary diagnostic imaging, ensuring proper management techniques, and recognizing complications in a timely manner can serve to limit legal liability and enhance patient safety., (© 2013 ARS-AAOA, LLC.)

Objective: This study explored the outcomes of epistaxis treatment modalities to optimize management and enable the development of a therapeutic algorithm., Study Design: Case series with chart review., Setting: Tertiary care hospital., Subjects and Methods: Adult patients presenting between 2005 and 2011 with epistaxis underwent cauterization, tamponade, and/or proximal vascular control. Outcomes of treatment modalities were compared. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for coagulopathy, hypertension, and bleeding site., Results: The population included 147 patients (94 men, 53 women). For initial epistaxis, nondissolvable packing demonstrated the highest initial treatment failure rate of 57.4% (OR, 3.37; 95% CI, 1.33-8.59 compared with cautery). No significant differences were noted among initial posterior epistaxis treatment modalities. Length of nondissolvable pack placement for 3, 4, or 5 days had no significant impact on recurrence. Among patients who failed initial management, those who next underwent cautery or proximal vascular control required a significantly shorter inpatient stay of 5.3 vs 6.8 days compared with those who underwent packing (OR, 0.16; 95% CI, 0.04-0.68). There were no treatment failures following surgical arterial ligation., Conclusion: Initial management of anterior epistaxis with chemical cautery had a higher success rate and a lower number of total required interventions than did nondissolvable packing. Duration of packing did not affect recurrence. In patients who failed initially, progression to cautery or proximal vascular control led to significantly shorter inpatient stays than did packing.

Background: The advent of endoscopic sphenopalatine artery ligation (ESPAL) for the control of posterior epistaxis provides an effective, low-morbidity treatment option. In the current practice algorithm, ESPAL is pursued after failure of posterior packing. Given the morbidity and limited effectiveness of posterior packing, we sought to determine the cost-effectiveness of first-line ESPAL compared to the current practice model., Methods: A standard decision analysis model was constructed comparing first-line ESPAL and current practice algorithms. A literature search was performed to determine event probabilities and published Medicare data largely provided cost parameters. The primary outcomes were cost of treatment and resolution of epistaxis. One-way sensitivity analysis was performed for key parameters., Results: Costs for the first-line ESPAL arm and the current practice arm were $6450 and $8246, respectively. One-way sensitivity analyses were performed for key variables including duration of packing. The baseline difference of $1796 in favor of the first-line ESPAL arm was increased to $6263 when the duration of nasal packing was increased from 3 to 5 days. Current practice was favored (cost savings of $437 per patient) if posterior packing duration was decreased from 3 to 2 days., Conclusion: This study demonstrates that ESPAL is cost-saving as first-line therapy for posterior epistaxis. Given the improved effectiveness and patient comfort of ESPAL compared to posterior packing, ESPAL should be offered as an initial treatment option for medically stable patients with posterior epistaxis., (© 2013 ARS-AAOA, LLC.)

A survey of otolaryngologists and advanced practice providers specializing in otolaryngology found that almost half of respondents always or almost always prescribed antibiotic prophylaxis after nasal packing for epistaxis, despite limited evidence supporting this practice. The frequency of antibiotic prescribing was not related to gender, degree, fellowship status, geographic region, or years of training. The results suggest a need for providers to carefully assess the appropriateness of routine antibiotic prescribing given the lack of benefits in the literature and potential serious adverse events. Shared decision-making with patients should play a greater role in prescribing practices until further research clarifies the uncertainty regarding antibiotic benefit. [Extracted from the article]

Epistaxis is the most common emergency in otorhinolaryngology affecting up to 60% of the population in their lifetime. There are various local and systemic cause and includes both medical and surgical management. This study has been undertaken to study various etiopathogenesis and management of epistaxis. This is a prospective hospital-based study conducted on 100 patients of all age groups and both genders presenting with epistaxis to the Department of Otorhinolaryngology both on outpatient and inpatient basis. A detailed history taking with clinical examination is done. Data is entered in a structured performa, master chart prepared and is subjected to statistical analysis by SPSS software version 23. The most common age group was first decade (26%) followed by fourth decade (15%) with male (71%) predominance. Anterior epistaxis (87%) and bilateral nasal cavity involvement (65%) was predominantly seen. Most common causes for epistaxis are trauma (20%) followed by nasal infections (18%) and hypertension (17%). Majority of the patients underwent medical line of treatment (80%) followed by anterior nasal packing (12%), surgical intervention (7%), posterior nasal packing (1%). Epistaxis needs immediate restoration of hemodynamic parameters with first aid, airway assessment and control of bleeding. Majority of the cases were managed conservatively which is safe and cost effective method. Patients should be advised to avoid strenuous activity, nose picking and vigorous nose blowing. Severe recurrent epistaxis needed invasive interventions like nasal packing and blood transfusion. [ABSTRACT FROM AUTHOR]

Epistaxis is a common problem that can affect the whole population and is the most common ENT presentation to the emergency department.1 The majority of cases are self-limiting and do not require any medical intervention, however epistaxis can be associated with morbidity and even death in very rare circumstances. If epistaxis does not resolve with first aid measures, or episodes are frequent, patients may require specialist assessment and treatment by ENT, either in the outpatient clinic or via an unscheduled (emergency) admission to the hospital. Here, we provide an overview of the management of epistaxis in the outpatient setting and during an emergency admission in both paediatric and adult patients. We highlight the key considerations in the history and management, covering the common and rare conditions that are associated with epistaxis. This article provides an update from our most recent version published in 2021 including updated resources from British Rhinology Society guidance and review of the recent literature regarding epistaxis management. [ABSTRACT FROM AUTHOR]

BACKGROUND: Nosebleeds, or epistaxis, are a frequent emergency in the ear, nose, and throat (ENT) department.Epistaxis can arise from both local and systemic factors. Locally, bleeding can occur within the nasal cavity, either in the anterior or posterior region. The most common site of anterior epistaxis is Kiesselbach's plexus.Epistaxis management can be complex and requires a thoughtful approach, with most cases being successfully treated through conservative measures, while others may necessitate surgical intervention. MATERIALS AND METHODS: A hospital-basedprospective observational study was conducted in the Department of Otorhinolaryngology, Assam Medical College and Hospital for one year (1 st April 2023 to 31st March 2024) in patients presenting with epistaxis in Department of Otorhinolaryngology, AMCH. RESULTS: Most of the patients belonged to the age group of 41-50 years. Male: female ratio was 2.55%. Hypertension was the leading cause of nasal bleed in 28.125% of cases. This was followed by trauma in 25% of cases. Conservative management was the most common modality of treatment. CONCLUSION: This study provides insights into effective epistaxis management, emphasizing a tailored approach based on severity and cause, with conservative measures suitable for most cases and surgery reserved for a few. [ABSTRACT FROM AUTHOR]

Background: Due to a myriad of risk factors, epistaxis is a very frequent presentation to the emergency room (ER). This study aims to ascertain the prevalence of epistaxis in our population, risk factors, effectiveness of ER treatment, complications, and ER outcome. Materials and Methods: This was a prospective observational study performed in the ER of a referral tertiary care center in south India. Data were categorized, coded, and analyzed to determine the objective of the study. Results: During the study's six-month duration, 188 (0.6%) patients presented with epistaxis. The mean age was 42.9 (SD: 16.49) years, with a male preponderance of 143 (76.1%). A majority of these patients (n: 156; 82.9%) were triaged as priority II, with hypertension (n: 53, 28.2%) as the commonest comorbidities. Trauma-related epistaxis (n: 107, 56.9%) was the most frequent cause. Anterior nasal packing was carried out for 85 (45.2%) patients, posterior nasal packing was carried out for one (0.5%) patient, and bleeding had spontaneously resolved in the majority (n: 102; 54.3%) patients. Seven (3.7%; p-value: 0.001) patients had recurrent epistaxis, and of those, three (1.6%) required urgent resuscitation with crystalloid fluid and blood products. Two of these patients had bleeding dyscrasias, four had history of trauma, and one patient presented with uncontrolled hypertension. Two (1.1%) patients came back to us with recurrent bleeding within 12 h of discharge. Majority (69.2%; 130) were discharged stable, (23.9%; 45) were admitted for observation and (6.9%; 13) were discharged against medical advice. There was no mortality among these study populations. Conclusion: Middle-young, aged males most commonly presented with epistaxis. Most of them were secondary to trauma. Anterior nasal bleeding was the most common source and hemostasis could be obtained by anterior nasal packing. Majority could be discharged stable from the ER. However, this cohort had seen patients in life-threatening conditions, so the severity cannot be overlooked.

Background: Epistaxis is a common condition but with diverse etiology dependent on geography, season, climate, and demography. Aims and Objectives: To describe the demographic, clinical, and etiological profile and management strategies of epistaxis cases at a tertiary center in U.P. (west). Materials and Methods: Patients were identified from the emergency and outpatient department, and their demographic and clinical details were noted. Local examination was performed, and necessary investigations were carried out. Management strategies were noted. Duration of hospital stay and mortality, if any, was documented. Descriptive analytics were used. Data were represented as numbers and percentages, mean±standard deviation, and median. Results: A total of 189 epistaxis patients were enrolled in the study. The mean age of patients was 32.89±17.92 (range 1–85 years). The sex ratio (M: F) was 2.71. Majority of patients presented to the emergency department (60.3%) within 1 day (64.6%), had single episode (66.7%), the presence of old clot (72%) and the anterior location of bleeding (91.5%). 119 (63%) cases required admission. Nasal endoscopy and computed tomography scan were performed in 49 (25.9%) and 24 (12.7%) cases, respectively. The most common etiology was trauma (49.2%), followed by idiopathic cause (14.8%), hypertension (12.7%), and others. Nasal packing and cauterization were required in 16.4% and 15.9% of cases, respectively. Surgery was required in 5 (2.6%) cases. A minuscule percentage of cases required blood transfusion. There was no mortality. Conclusion: Epistaxis is a common emergency with males predominating over females. Causes are varied. Most patients can be managed conservatively with favorable outcomes if timely intervention is done.

Background: Due to a myriad of risk factors, epistaxis is a very frequent presentation to the emergency room (ER). This study aims to ascertain the prevalence of epistaxis in our population, risk factors, effectiveness of ER treatment, complications, and ER outcome.Materials and Methods: This was a prospective observational study performed in the ER of a referral tertiary care center in south India. Data were categorized, coded, and analyzed to determine the objective of the study. Results: During the study's six-month duration, 188 (0.6%) patients presented with epistaxis. The mean age was 42.9 (SD: 16.49) years, with a male preponderance of 143 (76.1%). A majority of these patients (n: 156; 82.9%) were triaged as priority II, with hypertension (n: 53, 28.2%) as the commonest comorbidities. Trauma-related epistaxis (n: 107, 56.9%) was the most frequent cause. Anterior nasal packing was carried out for 85 (45.2%) patients, posterior nasal packing was carried out for one (0.5%) patient, and bleeding had spontaneously resolved in the majority (n: 102; 54.3%) patients. Seven (3.7%; p-value: 0.001) patients had recurrent epistaxis, and of those, three (1.6%) required urgent resuscitation with crystalloid fluid and blood products. Two of these patients had bleeding dyscrasias, four had history of trauma, and one patient presented with uncontrolled hypertension. Two (1.1%) patients came back to us with recurrent bleeding within 12 h of discharge. Majority (69.2%; 130) were discharged stable, (23.9%; 45) were admitted for observation and (6.9%; 13) were discharged against medical advice. There was no mortality among these study populations. Conclusion: Middle-young, aged males most commonly presented with epistaxis. Most of them were secondary to trauma. Anterior nasal bleeding was the most common source and hemostasis could be obtained by anterior nasal packing. Majority could be discharged stable from the ER. However, this cohort had seen patients in life-threatening conditions, so the severity cannot be overlooked. [ABSTRACT FROM AUTHOR]

Abstract Background To help ensure adequate hemostasis immediately following potassium titanyl phosphate (KTP) laser treatment, many centres treating hereditary hemorrhagic telangiectasia (HHT) routinely use nasal packing post‐operatively. The purpose of this study was to compare hemostatic thrombin matrix with standard packing for postoperative bleeding, patient pain, and comfort. Methods A prospective, randomized, double‐blinded, non‐inferiority study was conducted with participants at an HHT centre of excellence (COE) and randomized to the treatment group with reconstituted thrombin gelatin matrix (Surgiflo®) or control group with a biodegradable synthetic polyurethane foam (NasoPore®). Adult subjects with confirmed HHT and moderate to severe epistaxis (a minimum calculated epistaxis severity score [ESS] of 4.0) warranting KTP laser treatment were recruited. Data was collected 2 weeks post operatively by a blinded reviewer completing a visual outcomes evaluation and each patient completing a subjective symptoms questionnaire. Non‐parametric statistical analysis was employed. Results Twenty‐eight adult patients were randomized to the treatment and control arms with comparable preoperative epistaxis severity scores. Postoperative nasal bleeding was equivalent. Significantly less pain was found in the treatment arm (p = .005). While there were trends towards less obstruction and increased satisfaction in the treatment group as well as less crusting in the control group, these findings were not statistically significant. Allocation to the treatment group was associated with an approximately $75 higher cost. Conclusions When compared to NasoPore® for hemostasis, Surgiflo® hemostatic matrix performed equivalently while causing less discomfort in HHT patients following nasal KTP treatment. Level of evidence 1b.

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. [ABSTRACT FROM AUTHOR]

Epistaxis, commonly encountered in the Otolaryngology practice, refers to bleeding that occurs as a result of vascular pathologies and coagulation disorders. It can develop due to traumatic, iatrogenic, or spontaneous etiologies. In our study, we aim to retrospectively examine the epistaxis patients treated in our clinic to investigate the etiology causing epistaxis, associated diseases, and the use of anticoagulants-antiplatelets. Additionally, we plan to evaluate hemogram and coagulation parameters. The study included patients diagnosed with epistaxis and admitted for treatment at Samsun Education and Research Hospital ENT Clinic between 2019 and 2022. A retrospective analysis of the patients' medical records was conducted to gather data on demographic characteristics, comorbidities, medications used regularly, laboratory values, and clinical findings. A total of 130 patients were included in the study. No statistically significant difference was observed between the location of the bleeding focus and gender, presence of hypertension, use of antihypertensive medication, or anticoagulant use. When comparing patients with and without antiplatelet-anticoagulant use, a significantly longer nasal packing duration was found in patients who used these medications. In terms of the need for electrocauterization, statistically significant higher intervention rates were observed in patients who did not use anticoagulant medication. Our study identified a higher rate of surgical intervention in hospitalized epistaxis patients, potentially due to the inclusion of more severe cases requiring specialized care. Further research is needed to investigate the factors influencing the need for surgical management and to develop appropriate guidelines for the management of different severities of epistaxis. [ABSTRACT FROM AUTHOR]

Background: There is limited evidence supporting the usage of prophylactic antibiotics in the setting of nasal packing for epistaxis. It is unclear what current antiobiotic usage patterns are by otolaryngologists. Objectives: Characterize the antibiotic prescribing practices employed by otolaryngologists in the management of epistaxis patients treated with packing as well as the underlying rationale. Explore the impact of experience, geography, and academic affiliation on treatment decisions. Methods: An anonymous survey of antibiotic prescribing patterns for patients with epistaxis requiring nasal packing was distributed to all physician members of the American Rhinologic Society. Responses to each question were descriptively summarized including 95% confidence intervals and were linked to demographics using Fisher's exact tests. Results: One thousand one hundred and thirteen surveys were distributed with 307 responses (27.6%). Antibiotic prescription rates varied based on packing type, with 20.0% prescribing antibiotics for dissolvable packing compared to 84.2% to 84.6% for nondissolvable packing. The absorbance of nondissolvable packing does not impact the decision to prescribe antibiotics (P >.999). Precisely 69.7% (95% CI: 64.0%-74.8%) stop antibiotics immediately following packing removal. Precisely 85.6% (95% CI: 81.6%-89.9%) cite the risk of toxic shock syndrome (TSS) when prescribing antibiotics. Notable regional differences include greater utilization of amoxicillin-clavulanate in the Midwest (67.6%) and Northeast (61.4%) as compared with the South (42.1%) and West (45.1%) (P =.013). Further, years in practice were positively associated with several patterns including prescribing antibiotics for patients with dissolvable packing (P =.008), citing prevention of sinusitis as a rationale for antibiotic use (P <.001), and a higher likelihood of having treated a patient with TSS (P =.002). Conclusions: Antibiotic use in patients with epistaxis controlled with nondissolvable packing is common. Treatment patterns are influenced by geography, years in practice, and practice type. Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Background: Epistaxis is a common condition but with diverse etiology dependent on geography, season, climate, and demography. Aims and Objectives: To describe the demographic, clinical, and etiological profile and management strategies of epistaxis cases at a tertiary center in U.P. (west). Materials and Methods: Patients were identified from the emergency and outpatient department, and their demographic and clinical details were noted. Local examination was performed, and necessary investigations were carried out. Management strategies were noted. Duration of hospital stay and mortality, if any, was documented. Descriptive analytics were used. Data were represented as numbers and percentages, mean±standard deviation, and median. Results: A total of 189 epistaxis patients were enrolled in the study. The mean age of patients was 32.89±17.92 (range 1-85 years). The sex ratio (M: F) was 2.71. Majority of patients presented to the emergency department (60.3%) within 1 day (64.6%), had single episode (66.7%), the presence of old clot (72%) and the anterior location of bleeding (91.5%). 119 (63%) cases required admission. Nasal endoscopy and computed tomography scan were performed in 49 (25.9%) and 24 (12.7%) cases, respectively. The most common etiology was trauma (49.2%), followed by idiopathic cause (14.8%), hypertension (12.7%), and others. Nasal packing and cauterization were required in 16.4% and 15.9% of cases, respectively. Surgery was required in 5 (2.6%) cases. A minuscule percentage of cases required blood transfusion. There was no mortality. Conclusion: Epistaxis is a common emergency with males predominating over females. Causes are varied. Most patients can be managed conservatively with favorable outcomes if timely intervention is done. [ABSTRACT FROM AUTHOR]

Background: Epistaxis is a common otorhinolaryngological condition. It is often self-limiting, and only 6-10% of individuals seek medical care. Epistaxis is common in children and elderly. It is commonly of anterior type, originating from the Kieselbach plexus following trauma. It can be posterior type, usually in the elderly. Various treatment options are available such as nasal packing, hemocoagulase, cautery, embolization, etc. The causative factors, types of epistaxis and the treatment options employed are variable. Objectives: The present study was conducted to know the common type of epistaxis requiring medical attention in the patients attending our tertiary care hospital, the treatment commonly provided and the outcome. Methods: Retrospective observational hospital-based study design was used. Data of patients of all age groups and both genders newly presenting with epistaxis to the emergency department from October 2017 to September 2018 were included. Details of causative risk factors, types of epistaxis and treatment given along with the outcome were collected and analyzed. Result: Among the 60 patients studied, 44 were male and 16 were female. Anterior epistaxis (75%) was commoner than posterior epistaxis (25%). Predominant causative risk factors for anterior epistaxis were trauma (56%) and conditions with low platelet counts (31%), while hypertension (93%) was the commonest causative risk factor associated with posterior epistaxis. Nasal packing was used to stop epistaxis in 62% of patients irrespective of the cause (51% of anterior epistaxis and 93% of posterior epistaxis). Conclusion: Anterior type of epistaxis is common following trauma or platelet disorders. Nasal packing is used as an effective treatment, followed by hemocoagulase and cautery for epistaxis.

Background: To help ensure adequate hemostasis immediately following potassium titanyl phosphate (KTP) laser treatment, many centres treating hereditary hemorrhagic telangiectasia (HHT) routinely use nasal packing post‐operatively. The purpose of this study was to compare hemostatic thrombin matrix with standard packing for postoperative bleeding, patient pain, and comfort. Methods: A prospective, randomized, double‐blinded, non‐inferiority study was conducted with participants at an HHT centre of excellence (COE) and randomized to the treatment group with reconstituted thrombin gelatin matrix (Surgiflo®) or control group with a biodegradable synthetic polyurethane foam (NasoPore®). Adult subjects with confirmed HHT and moderate to severe epistaxis (a minimum calculated epistaxis severity score [ESS] of 4.0) warranting KTP laser treatment were recruited. Data was collected 2 weeks post operatively by a blinded reviewer completing a visual outcomes evaluation and each patient completing a subjective symptoms questionnaire. Non‐parametric statistical analysis was employed. Results: Twenty‐eight adult patients were randomized to the treatment and control arms with comparable preoperative epistaxis severity scores. Postoperative nasal bleeding was equivalent. Significantly less pain was found in the treatment arm (p =.005). While there were trends towards less obstruction and increased satisfaction in the treatment group as well as less crusting in the control group, these findings were not statistically significant. Allocation to the treatment group was associated with an approximately $75 higher cost. Conclusions: When compared to NasoPore® for hemostasis, Surgiflo® hemostatic matrix performed equivalently while causing less discomfort in HHT patients following nasal KTP treatment. Level of evidence: 1b. [ABSTRACT FROM AUTHOR]

Quincy K Tran,1,2 Jeremy Barnett,3 Francis O’Connell,3 Brian D’Anza,4 Ali Pourmand3 1Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; 2Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; 3Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; 4Department of Otolaryngology - Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USACorrespondence: Quincy K Tran Email qtran@som.umaryland.eduAbstract: We performed a narrative review of epistaxis management in the emergency department. First, we examined the pathophysiology, the current types of treatment that are available to emergency clinicians. When nasal packing is indicated, we examined the efficacy of nasal packing in addition to other topical treatment such as tranexamic acid and the evidence of prophylactic antibiotics. We detailed current studies involving tranexamic acid and prophylactic antibiotics for nasal packing. Finally, we introduced an epistaxis clinical care pathway, based on current evidence, to aid emergency clinicians with their clinical decision-making processes.Keywords: epistaxis, tranexamic acid, nasal packing, clinical care pathway

Objective: To determine histopathological changes in nasal mucosa associated with duration of nasal packing with Merocel tampons. Methods: This study included 24 healthy rabbits, 6 rabbits per group. In group A, no tampon was applied. In group B, Merocel nasal tampons were applied and removed after 24 hours. In group C, the tampons were removed after 48 hours. In group D, the tampons were removed after 5 days. Specimens were obtained from the septum of each rabbit, including cartilage. Histopathological examination was performed. Results: Significant differences were observed in terms of inflammatory infiltration and loss of cilia between groups A and B. Significant differences were also observed in terms of inflammatory infiltration, haematoma, cilia loss, epithelium dysplasia and cartilage degeneration between groups B and C. There were significant differences in terms of cilia loss, epithelium dysplasia and subepithelial fibrosis between groups C and D. Cartilage degeneration was mild in one animal in group B and in two animals in group C, and was moderate in four animals in group C. Conclusion: It is recommended that Merocel nasal tampons are removed within 48 hours to preserve nasal mucosal function. Keeping the pack longer may cause cartilage degeneration and other complications. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Nasal packing is used to stop bleeding in cases of epistaxis. Different topical drugs are preferred to these packs in the emergency department. In this study, we aimed to compare the efficacy of lidocaine, epinephrine and tranexamic acid (TXA) in stopping bleeding in patients with epistaxis. PATIENTS AND METHODS: Patients with non-traumatic epistaxis were evaluated in three treatment groups as topical lidocaine, epinephrine, and TXA. These treatments were applied prospectively in a double-blind manner and randomized manner. The bleeding stop times of the patients were recorded with bleeding time parameters. RESULTS: A total of 108 patients were included in the study. The mean age of the patients was 55.7±17.7 years. When the bleeding stop times were compared between the groups, there was no statistically significant difference (lidocaine vs. epinephrine, p=0.870; lidocaine vs. TXA, p=0.502; and epinephrine vs. TXA, p=0.242). The systolic blood pressure value statistically significantly differed between the lidocaine and epinephrine groups (p=0.034) and between the epinephrine and TXA groups (p=0.003). There was also a statistically significant difference between the diastolic blood pressure values of the epinephrine and TXA groups (p=0.020). CONCLUSIONS: We found that nasal packing with lidocaine, epinephrine and TXA was not superior to each other in terms of stopping bleeding time. [ABSTRACT FROM AUTHOR]

Background: Severe epistaxis is a frequent emergency condition encountered by otolaryngologists and is often treated with nasal packing. In the event of failure surgical treatment is considered. We aimed to evaluate the efficacy of Nasal Packing (NP) and Endoscopic Sphenopalatine Artery Ligation (ESPAL) as treatment of severe epistaxis in terms of failures and recurrences including risk factors. Methodology: Retrospective descriptive study of patients with epistaxis treated with NP, admitted to an ENT department from 2011-2017. If initial treatment with NP failed, patients were considered for ESPAL. Results: An analysis of 511 patients was performed. All patients were treated with NP at the time of admission, and 14% of patients were treated with ESPAL due to failure of NP. The majority of patients was only admitted once. Twelve percent were readmitted within 30 days, 7% were readmitted >30 days later. Treatment failure after ESPAL was 7.9%. No significant difference in the risk of readmission was found between patients treated with NP alone and patients treated with ESPAL. Conclusion: The majority of epistaxis patients were effectively treated with NP alone. We found good effect of ESPAL although no significant differences in risk of readmission NP vs. ESPAL were identified.

The main objective of this study was to determine the rate of outpatient management in a population of patients undergoing bilateral ethmoidectomy. The secondary objectives were to evaluate the quality of outpatient management (rate of unscheduled overnight admission, readmission rate, complications) and to compare inpatient and outpatient groups to determine which elements of the phenotype and care pathway favored outpatient management. A single-center observational study included 204 patients operated on for bilateral ethmoidectomy. Study variables comprised: type of care pathway (outpatient/inpatient), outpatient quality indicators (unscheduled admission, readmission, complications), care pathway, and population characteristics. One hundred and twenty (58.8%) outpatients were operated on. No deaths occurred. The unscheduled admission rate was 7.5%, and the readmission rate 4.1%; at the P < 0.005 threshold, there were no significant differences between in- and out-patient groups. Outpatients had earlier surgery (P < 0.005), and nasal packing rates and pain on VAS were lower (P < 0.005). Ethmoidectomy could be carried out as an outpatient procedure in 58.8% of cases, with acceptable quality of care. Selection of patients and the organization of a dedicated care pathway seem to be elements favoring this management. [ABSTRACT FROM AUTHOR]

Problem description: Otorhinolaryngology services are not available in all hospitals and atraumatic epistaxis is a common presentation to Emergency Departments (ED). Not all ED staff are experienced in managing epistaxis and there appeared to be a high rate of re-bleeding after treatment provided. We aimed to improve outcome for ED patients presenting with atraumatic epistaxis and staff conditions by creating a Departmental pathway outlining a management plan and ensuring all equipment needed was readily available. Methods: A retrospective 6-month audit was done to assess current management and re-bleed percentage rates post nasal packing. A team was assembled, stocked a trolley, created an Atraumatic epistaxis ED pathway and promoted its use by staff. Repeated Plan-Do-Study-Act cycles were undertaken.Chosen measures were (1) Reduced re-bleed rates post nasal packing from initial audit levels; (2) Increased nasal packing duration; (3) Improved qualitative feedback by ED doctors (4) 100% E.N.T. trolley stock. Results: Audit showed minimal use of vasoconstrictor spray, a 7-hour mean nasal pack duration, a re-bleed rate post nasal packing of 39% and staff reports of difficulties accessing items required.After introduction of the E.N.T. trolley, there was positive staff feedback regarding improved availability of treatment items and full stocking of the trolley was achieved after repeated cycles.Following introduction of the Epistaxis pathway and staff education, average re-bleed rates post nasal packing dropped* from 39% to 20% in the first cycle; 21% in the third cycle; 25% in the fourth cycle and 14% in the fifth cycle- (*Isolated re-bleed average of 40% observed in the second cycle).Mean nasal packing duration increased from 7 h to 9, 10, 10, 12 and 8 h in the 2-monthly cycles successively. Conclusion: The project's aims of improving epistaxis patients' outcomes and improved convenience for ED staff were achieved.

Objective: To assess safety and efficacy of an asymmetrical balloon in the treatment of epistaxis in adult patients (≥18 years) managed in an emergency setting. Methodology: Pilot, open label, monocenter, prospective, interventional non comparative study in adult patients. The patients were hospitalized for 48h, timepoint at which the device was removed. Primary endpoints were the assessment of bleeding arrest and pain score evaluated on a Visual Analogic Scale. Secondary endpoints were the nature and number of adverse events reported and patient quality of life evaluated with the RhinoQoL questionnaire. Results: Ten patients were included, and nine were treated. In Intent to Treat (ITT), bleeding was stopped upon positioning in 9/10 patients. Efficacy was maintained in 8/10 patients during treatment. Pain was moderate at insertion, inflation and during treatment and mild upon and post-removal. Minor bleeding recurrence occurred in two patients during the post-treatment period. The reported adverse events considered device-related were consistent with the ones observed with other intranasal devices. The mean and median RhinoQoL impact scores tend to decrease upon the different control visits. Conclusion: This pilot study provides promising preliminary safety and efficacy data for CAVI-T™ in the management of epistaxis in an emergency setting.

Primary care, urgent care, and emergency department providers periodically treat epistaxis, either as recurrent nosebleed or an acute persistent episode. Silver nitrate application to the decongested and anesthetized nasal mucosa addresses the former in most cases. The plethora of commercial nasal packing devices testifies to the discomfort, technical difficulty, and frustration associated with traditional gauze-packing methods. Inflatable anterior nasal balloon packs reliably control most nosebleeds. Addition of a Foley catheter nasopharyngeal balloon pack manages most posterior epistaxis. Cautery and the two packing techniques mentioned above should treat most cases not requiring otolaryngology consultation or interventional radiology. Appropriate anesthetic and analgesics lessen the unpleasantness for both the patient and the provider. Topical moisturizing facilitates mucosal healing. Oxymetazoline 0.05% nasal spray provides the patient means to address rebleeding after discharge from treatment. [ABSTRACT FROM AUTHOR]

Epistaxis is a common problem that can affect the whole population. The majority of cases are self-limiting and do not require any medical intervention, but epistaxis can be associated with morbidity and even death in very rare circumstances. If epistaxis does not resolve with first aid measures, or episodes are frequent, patients may require specialist assessment and treatment by ENT, either in the outpatient clinic or via an unscheduled (emergency) admission to the hospital. Here, we provide an overview of the management of epistaxis in the outpatient setting and during an emergency admission in both paediatric and adult patients. We highlight the key considerations in the history and management, covering the common and rare conditions that are associated with epistaxis. This article provides an update from our previous article published in 2018 to include the more recent literature and a useful learning resource for examinations. [ABSTRACT FROM AUTHOR]

Introduction: Epistaxis is a common otolaryngological emergency condition. It occurs due to local and systemic cause. Local cause lies within the nose bleeding either anterior or posterior. Commonest site of bleeding anterior epistaxis is kiesselbach’s plexus. In posterior epistaxis, it is difficult to locate bleeding site. Epistaxis is controlled by simply pinching of nose, decongested nasal drop and abgel packing. Some cases become more challenging required nasal packing and arterial ligation. Objectives: To study the epidemiological pattern and management of epistaxis. Methods: This was a retrospective study on pattern of epistaxis man­aged at Gandaki Medical College Teaching Hospital over a period from April 2015 to April 2016. Information regarding demographic profile, presentation and management of epistaxis was obtained from the Hospital records, ENT Outpatient clinic, Emergency Department, ENT ward and operation theatre. Results: A total of 78 cases were managed during study period. There was a significant male preponderance with male to female ratio 1.78:1. Patients’ age varied from eight to 80 years with mean age 40.7 years. The peak age of incidence was 21 - 30 years group. Idiopathic nasal bleeding 27 (34.6%) was commonest followed by nasal trauma 23 (29.5%) cases and hypertension 16 (20.5%) cases. Seventeen (21.8%) cases managed in day care basis with decongested nasal drop, chemi­cal cautery and abgel packing. Remaining cases required nasal packing and bipolar cautery and other specific form of treatment. Five (6.4%) cases required sphenopalatine artery ligation with no recurrence of bleeding. Conclusions: Epistaxis is common ENT emergency. Most common causes are idiopathic followed by nasal trauma and hypertension. Prompt management is instituted according to cases. Most of the cas­es are managed by non-surgical method.

Aim: In this study, it was aimed to make a general evaluation of patients who applied to our outpatient clinic with epistaxis. Methods: The files of approximately 300 patients who were admitted to the Otorhinolaryngology outpatient clinics of a tertiary hospital with the complaint of nasal bleeding between January 2009 and January 2019 were retrospectively evaluated. The patients were analyzed in terms of age, gender, month of epistaxis, etiological factors, concomitant diseases, whether blood transfusion was required, treatment methods applied and length of hospital stay. Results: Of the 300 evaluated patients, 128 were female (42.8%) and 172 (57.2%) were male. The mean age of the patients was determined as 34.38 ± 23.63 (min 1-max: 89). The patients applied most frequently in February (14%) and at least in July (2.6%). The number of patients detected idiopathically was 240 (80%). Among the identified reasons, the most frequent use of anticoagulants was 11% and hypertension was 4.6%. Conservative treatment was applied to 98.4% of the patients. Hospitalization periods ranged from 1 to 11 days. Only 2 patients needed blood transfusion. Conclusion: Considering the possible complications and mortality; Taking detailed anamnesis from patients and planning the necessary treatment as soon as possible constitute the basis of diagnosis and treatment management in patients with epistaxis.

BACKGROUND: The use of anticoagulants and high-flow oxygen therapy are therapies that may predispose to epistaxis. Both factors often coexist in patients affected by SARSCoV-2, which caused the recent global pandemic of COVID-19. OBJECTIVE: To investigate the clinical-epidemiological characteristics of patients with COVID-19 who develop epistaxis, as well as its triggers and management, among others. MATERIALS AND METHODS: A multicenter, retrospective, descriptive study in COVID-19 patients with a positive PCR test who presented epistaxis throughout the disease. Study was done from January 31st May 19th, 2020. Demographic data were collected on previous comorbidities, treatments, complications related to COVID-19, triggers, severity of epistaxis, treatment indicated and evolution, among others. RESULTS: A total of 18 patients between the ages of 54 and 88 were included, and 72% were male. They were attended in 9 different hospitals throughout Spain, presenting between 1 to 3 cases each. In 83.3% of the patients epistaxis had some specific trigger, being multiple in 16.6% of them. However, nasopharyngeal smear taken for PCR was not the cause in any case. The most frequent type of treatment was an anterior nasal packing.\\\CONCLUSIONS: Although patients with COVID-19 constitute a special risk group for epistaxis given their associated comorbidities, severe epistaxis is rare in this group of patients. The management of these patients is also complex due to the working conditions when assisting these patients and should always keep healthcare workers safe. [ABSTRACT FROM AUTHOR]

Abstract Background Epistaxis is the most common emergent consultation to otolaryngology-head & neck surgery (OHNS) and with 60% of the population having experienced an episode and 1.6 in 10,000 requiring hospitalization in their lifetime. In preliminary studies Floseal® (Baxter, USA) Hemostatic Matrix has shown efficacy in up to 80% of persistent anterior epistaxis. We sought to evaluate the clinical efficacy and cost-effectiveness of Floseal® (Baxter, USA) compared to traditional nasal packing for persistent epistaxis. Methods A prospective, randomized controlled trial was conducted on all adult patients consulted to the OHNS service at the tertiary referral centers of the University of Alberta Hospital and Royal Alexandra Hospital for persistent epistaxis. Patients were randomized to the Floseal® (Baxter, USA) or traditional packing study arms. Our main clinical outcome measures were: 1) Hemostasis directly following treatment and at 48 h post-treatment, and 2) self-reported patient comfort at 48 h post-treatment. Further, trial data was used for a formal cost-effectiveness analysis to determine incremental cost-effectiveness ratio (ICER). Univariate sensitivity analysis and uncertainty analysis were performed. Results There were no significant differences between groups for initial hemostasis (76.9% vs. 84.6%, p = 1.000) or, hemostasis at 48 h (76.9% vs. 69.2%, p = 1.000), requirement for admission (15.4% vs. 46.1%, p = 0.2016) or 30-day re-presentation rates (15.4% vs. 46.1%, p = 0.2016). Floseal® (Baxter, USA) was superior for decreased pain during placement (2.42 vs. 7.77, p = 0.0022), treatment (0.50 vs. 4.46, p = 0.0007) and removal (0 vs. 3.85, p = 0.0021). Floseal® (Baxter, USA) provides an average $1567.61 per patient savings from the single-payer system point of view and has an ICER of - $11,891 per re-bleed prevented (95% CI: -$37,658 to +$473). Uncertainty analysis shows that Floseal® has >90% chance of not only being cost-effective, but the dominant (preferred) treatment. Conclusions Floseal® (Baxter, USA) was demonstrated to be an effective, comfortable and cost-effective alternative treatment of persistent epistaxis when compared to traditional packing methods for patients referred to OHNS with a normal coagulation profile. Trial registration Trial registration number: NCT02488135 . Date registered: June 26, 2015.

Otorhinolaryngology services are not available in all hospitals and atraumatic epistaxis is a common presentation to Emergency Departments (ED). Not all ED staff are experienced in managing epistaxis and there appeared to be a high rate of re-bleeding after treatment provided. We aimed to improve outcome for ED patients presenting with atraumatic epistaxis and staff conditions by creating a Departmental pathway outlining a management plan and ensuring all equipment needed was readily available. A retrospective 6-month audit was done to assess current management and re-bleed percentage rates post nasal packing. A team was assembled, stocked a trolley, created an Atraumatic epistaxis ED pathway and promoted its use by staff. Repeated Plan-Do-Study-Act cycles were undertaken. Chosen measures were (1) Reduced re-bleed rates post nasal packing from initial audit levels; (2) Increased nasal packing duration; (3) Improved qualitative feedback by ED doctors (4) 100% E.N.T. trolley stock. Audit showed minimal use of vasoconstrictor spray, a 7-hour mean nasal pack duration, a re-bleed rate post nasal packing of 39% and staff reports of difficulties accessing items required. After introduction of the E.N.T. trolley, there was positive staff feedback regarding improved availability of treatment items and full stocking of the trolley was achieved after repeated cycles. Following introduction of the Epistaxis pathway and staff education, average re-bleed rates post nasal packing dropped* from 39% to 20% in the first cycle; 21% in the third cycle; 25% in the fourth cycle and 14% in the fifth cycle- (*Isolated re-bleed average of 40% observed in the second cycle). Mean nasal packing duration increased from 7 h to 9, 10, 10, 12 and 8 h in the 2-monthly cycles successively. The project's aims of improving epistaxis patients' outcomes and improved convenience for ED staff were achieved. [ABSTRACT FROM AUTHOR]