Signs and Symptoms

• Any history of excess alcohol intake?
• Does the patient have uncontrolled hypertension?
• Are there any other signs of bleeding tendency?
• Nose picking
• Nasal steroid spray use
• Exclude red flags

History and Examination

Take a patient history

• Is the patient treated with warfarin, DOAC (e.g. rivaroxaban), aspirin, clopidogrel and/or prasugrel
• Is there any history of excess alcohol intake?
• Does the patient have uncontrolled hypertension?
• Are there any signs of bleeding tendency?

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

• Manage any reversible cause
• Apply antibiotic ointment for 5-7 days - see 12.2 Nose

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 12.2 Nose, then petroleum jelly applied to septum for 2 weeks

If patient is experiencing further nose bleeds following initial treatments as above

• Review antiplatlets/ anticoagulants
• Consider referral for specialist assessment

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 for specialist assessment if:

• Patient has recurrent nose bleeds
• Failed conservative management in primary care – see above

Referral Instructions

Referral for adults

e-Referral Service Selection

• Speciality: ENT
• Clinic Type: Nose/ Sinus
• Service: DRSS-Northern-Ear Nose and Throat - Devon ICB- 15N

Referral for children

e-Referral Service Selection

• Specialty: Children's & Adolescent Services
• Clinic Type: ENT
• Service: DRSS-Northern-Child & Adolescent Services- Devon ICB - 15N

Referral Form

DRSS 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: November 2017

Reviewed: April 2024