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Acute fractured nose
Acute nose bleeds
Acute sinusitis
Adult Snoring Surgery (in the absence of Obstructive Sleep Apnoea) clinical commissioning policy
AQP Audiology referral guide for practice staff
Benign Paroxysmal Positional Vertigo
Chronic recurrent nose bleeds
Chronic rhinosinusitis with or without polyps
Cough
Dysphonia
Ear Wax Removal
Feeling of something stuck in the throat
Hearing loss in children
Hearing problems in adults
Management of discharging ear
Myringotomy commissioning policies
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Perforated Tympanic Membrane
Recurrent Tonsillitis/Tonsillectomy
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Tonsillectomy commissioning policy
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Chronic recurrent nose bleeds
Scope
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, 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
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 ICB- 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 ICB - 15N
Referral 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.
- 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 on behalf of NHS Devon.
Publication date: 02 December 2016
Reviewed: April 2024
