29.1 Aetiology

29.1.1 Common Conditions

• Atherosclerosis, i.e., hypertensive patients

• Anticoagulants, e.g., warfarin

• Antiplatelet agents, i.e., aspirin

• Trauma (inc. finger picking)

• Iatrogenic (i.e., postop, inc. septal perforation)

29.1.2 Uncommon Conditions

• Congenital: haemophilia, HHT

• Infective: rhinosinusitis, TB, syphilis, leprosy

• Inflammatory: atrophic rhinitis, granulomatous disease (e.g., granulomatosis with polyangiitis)

• Metabolic: vitamin deficiency, alcohol abuse

• Endocrine: pregnancy, (menstruation)

• Trauma: foreign bodies

• Idiopathic

• Iatrogenic: chemotherapy, non-steroidal anti-inflammatory drugs, ABx

• Neoplastic: any sinonasal tumour, especially lymphoma, leukaemia, widespread mets, angiofibroma, others

• Bleeding dyscrasias: hepatic/renal failure, massive transfusion

29.1.3 Assessment

• In all patients:

Check ABC, cardiovascular status

• History:

Site, frequency, and duration of epistaxis.

Aspirin/warfarin/bleeding disorders

Possibility of trauma

Hypertension, alcohol consumption

29.2 Management/Examination

29.2.1 General Measures

• Remember ABCDE

• Ensure FBC, coag, G&S for all patients admitted with epistaxis

• IV fluids and O₂ may well be required

• Control BP

• Stop anticoagulants if possible

• Antibiotics if indicated (should be given when packs in place for more than 24 h)

• Blood transfusion

• Haematology advice

29.2.2 Specific Measures

• Local pressure and ice

• Suction clearance

• Co-phenylcaine (lidocaine + phenylephrine)/cocaine paste/other combinations of decongestant and anaesthetic

• Anterior rhinoscopy ± nasendoscopy (ideally with rigid scope to allow for treatment)

• Silver nitrate cautery

• Packing if required—various packs available

• Check oropharynx

• Gold standard pack remains as BIPP gauze and Foley catheter secured with gate/umbilical clamp

29.2.3 Surgical Measures

• Options will depend on local resources and skills available