Chronic 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, 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?
• Exposure to dust/irritants

• 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-Eastern-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-Eastern-Child & Adolescent Services-Devon CCG - 15N

Referral Forms

DRSS Referral forms

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.
• 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 Eastern Locality on behalf of NEW Devon CCG.

Publication date: 02 December 2016