Epistaxis: From Veronese's Banquet to the Modern Trauma Room.

Nasal Packing Causing Occlusion of Contralateral Internal Carotid Artery During Control of Pseudoaneurysm Bleed

A rapid nasal packing catheter for emergency evaluation and management of epistaxis

Epistaxis is a very common complaint seen by many types of physicians including otolaryngologists, family physicians, and others. Management of epistaxis is often challenging and requires many types of intervention. The following review describes the different types of past and current treatment modalities including cautery, nasal packing, maxillary artery ligation, anterior artery ligation, and sphenopalatine artery ligation. The paper also proposes an algorithm for managing such cases.

Epistaxis, defined as bleeding from the nose, is one of the common ENT cases coming to emergency department. Epistaxis is experienced by at least 60% of the population once in their life time and about 6% of them will require medical attention. The different treatment modalities include: local pressure, application of topical vasoconstrictor substances, or nasal packing depending on personal physician preference. Tranexamic acid (TXA), a synthetic analogue of the amino acid lysine, belongs to a class of drugs known as antifibrinolytics. It acts by reversibly binding four to five lysine receptor sites on plasminogen and can be used in emergency department for reducing the bleeding time in epistaxis. To evaluate the efficacy of topical application of injection TXA compared to cases managed with anterior nasal packing for the treatment of patients with epistaxis. 100 patients presenting with epistaxis in emergency department, above the age of 18years were randomly divided into two groups with 50 patients each. Group 1 were managed with anterior nasal packing with gel foam and Group 2 with topical application of injection TXA. Causes,duration to control epistaxis, and occurrence of rebleeding were recorded. Our study showed homogenous distribution of age and sex among the patients. Bleeding stopped within 10min in 38 patients in group 2 compared to 17 patients in group 1. For 31 patients in group 1, bleeding stopped between 10 and 15min compared to 12 in group 2. In group 1, 8 patients had rebleeding compared to 2 patients in group 2. Our study showed that topical application of TXA reduces the bleeding time and number of rebleeds compared to anterior nasal packing with gelfoam. Since it is easily available in an emergency setup and cheaper compared to gelfoam, it can be used as an elective method in managing epistaxis in emergency department.

To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents. Prospective cohort study. A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures. There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods. This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety. NA. Laryngoscope, 126:1501-1503, 2016.

Insertion of a second nasal pack as a prognostic indicator of emergency theatre requirement in epistaxis patients

A prospective study was undertaken to compare the efficacy of calcium sodium alginate fibre (Kaltostat) to petrolatum gauze impregnated with bismuth tribromophenate (Xeroform) for the control of epistaxes that require hospital admission. Forty patients presenting with severe epistaxis requring hospital admission were treated with either Kaltostat or Xeroform nasal packs. Allocation to either treatment group was made randomly. The composition of each group in terms of age, sex distribution, aetiology of epistaxis and severity of bleed was not significantly different. There was no significant difference in the efficacy or patient acceptability of either therapeutic agent. It is concluded that calcium sodium alginate fibre should be considered as an acceptable alternative to traditional gauze packing.

Epistaxis

Despite epistaxis being a common presentation to emergency departments there is a lack of guidelines, both nationally and internationally, for its management. The authors reviewed the current management of epistaxis and then introduced a new pathway for management to see if care could be improved. The aims were to evaluate the impact of the pathway on reduction of emergency department breaches, emergency ambulance transfers and hospital admissions. The study was an interrupted time series analysis over 29 months and included 903 participants. A pathway for the management of adults with non-traumatic epistaxis was designed and implemented in a university teaching hospital with an emergency department annual attendance rate of 105 495 in 2019-20. The pathway led to a 14-minute longer stay in the emergency department, a 5% increase in emergency department breaches, an 8.2% reduction in admissions, a 3.6% reduction in emergency ambulance transfers, a 14.1% increase in nasal cautery and a 3.2% reduction in nasal packing. The authors calculate that these results equate to roughly 56 hospital bed days saved, providing better care closer to home for patients, in addition to beneficial knock-on effects for other emergency department and admitted patients.

Aim Improving the standard of epistaxis management in Ayrshire &amp; Arran. Method A survey was distributed to doctors assessing their familiarity with epistaxis assessment and management. Working with the ENT department, a teaching programme was then developed aimed at improving skill in nasal packing, cautery and first aid, based on local guidelines. After the first session, all participants filled in a post-education questionnaire and results collated. Results The survey collected information throughout Ayrshire &amp; Arran, from 21 doctors across 10 different specialities, ranging from Foundation, Clinical Fellows, and Core Trainee's. Using a rating of one to five, least confident to most confident respectively. 95% of participants chose between one and three when asked about independently managing epistaxis, which significantly reduced to 0%. 52% of participants chose ‘least confident’ with familiarity of nasal packing and nasal cauterisation, reducing to 0%. In addition, 40% of doctors were unfamiliar with options for packing, which increased to 100%. Conclusions Epistaxis is one of the most common acute ENT presentations. 86% of cases will be initially managed by junior doctors using first aid management, packing, or cauterisation. This is not taught as standard in undergraduate or postgraduate education. Currently, there are no nationally accepted guidelines for its management, regardless of its high presentation, readmission, and mortality rate. There is an observable gap in epistaxis education, crucial when considering majority of its’ management will be handled by junior doctors. We have seen an increase in participants confidence and familiarity of the condition which merits running this teaching programme.

Haemolacria is a condition caused by a group of disorders resulting in production of tears that are partly composed of blood. It can be unilateral or bilateral. The etiology includes ocular, systemic, psychological, pharmacological, and idiopathic.[123] We present an unusual case scenario of unilateral hemolacria in a 62-year-old previously fit and well gentleman who presented to ER (emergency consultation room) with sudden onset epistaxis from the right nostril. Immediate evaluation included local examination by an ENT (Ear Nose and Throat department) colleague and systemic evaluation by the physician. The Physician diagnosed severe hypertension (BP recorded was 190/110 mm hg) and antihypertensive therapy was initiated. The source of the nasal bleed was identified as the Little's area (Kiesselbach's plexus). An attempt to cauterize the bleed under local anesthesia was made by the ENT colleague, following which anterior nasal packing was done. Within a few minutes of packing the nose, patient started shedding blood mixed tears from the right eye (Haemolacria) [Fig. 1]. The BP continued to stay high at 160/100 mm of Hg. Following this the antihypertensive measures were intensified resulting in complete resolution of the symptoms within the next 6 hours.Figure 1: Shows blood mixed tears coming out of right eye of the patient. It shows right haemolacria and the free end/thread of the anterior nasal pack in the right nostrilPreliminary ophthalmic evaluation revealed no local ocular causes of haemolacria, no previous trauma or lacrimal surgeries. We suspect retrograde blood flow through the Nasolacrimal duct to the conjunctival cul de sac following mechanical attempts at stopping the epistaxis, which alone was apparently ineffective as the underlying primary pathology was uncontrolled systemic hypertension. The authors also suspect a possible congenital absence of the valve of Hasner[4] or iatrogenic damage to the valve of Hasner at the inferior meatus at the time of primary mechanical attempts at haemostasis[5] that resulted in the above presentation. The patient was lost to further follow up thus preventing a further lacrimal outflow reassessment and a formal nasal endoscopic re-assessment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement Dr. Sujay Siddharthan, TMS Eye hospital.

We found moderate-quality evidence that there is probably a reduction in the risk of re-bleeding with the use of either oral or topical tranexamic acid in addition to usual care in adult patients with epistaxis, compared to placebo with usual care. However, the quality of evidence relating solely to topical tranexamic acid was low (one study only), so we are uncertain whether or not topical tranexamic acid is effective in stopping bleeding in the 10-day period after a single application. We found moderate-quality evidence that topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes.There have been only three RCTs on this subject since 1995. Since then there have been significant changes in nasal cauterisation and packing techniques (for example, techniques including nasal endoscopy and more invasive approaches such as endoscopic sphenopalatine artery ligation). New trials would inform us about the effectiveness of tranexamic acid in light of these developments.

Epistaxis is one of the most common ear, nose and throat emergencies. The management of epistaxis has evolved significantly in recent years, including the use of nasal cautery and packs. However, a correct treatment requires the knowledge of nasal anatomy, potential risks, and complications of treatment. Epistaxis is often a simple and readily treatable condition, even though a significant bleed may have potentially severe consequences. At present, there are very few guidelines concerning this topic. The current Survey explored the pragmatic approach in managing epistaxis. A questionnaire, including 7 practical questions has been used. The current International Survey on epistaxis management reported a relevant prevalence (21.7%), mainly during childhood and senescence, an important hospitalization rate (11.8%), the common use of anterior packing and electrocoagulation, and the popular prescription of a vitamin supplement and intranasal creams. (www.actabiomedica.it)

Medically Clear

Background Epistaxis is one of the most common emergencies encountered across all age groups. However, its etiological patterns and management outcomes exhibit significant regional variation. This retrospective study aims to assess the epidemiology, etiology, clinical presentation, treatment modalities, and outcomes of epistaxis in a tertiary referral hospital. Methods A retrospective, observational study was conducted at our center involving 384 patients who presented with epistaxis between January 2020 and June 2025. Patient records were reviewed for demographics, etiology, treatment modalities, and outcomes. Descriptive statistics were used to summarize the data. Results Anterior epistaxis constituted 68.7% (264/384) of cases. Trauma was the most common etiology (59.9%, 230/384), followed by hypertension (20.1%, 77/384) and dengue fever (5.9%, 23/384). The most common intervention was anterior nasal packing (59.9%, 230/384), followed by conservative management (26.6%, 102/384). Cauterization was used in 5.9% (23/384) of cases, and combined anterior and posterior packing in 6.3% (24/384). Surgical ligation was rarely required (1.3%, 5/384). Initial bleeding control was achieved in 93.7% (360/384) of patients, and 6.3% (24/384) required repeat intervention. Documented complications included re-bleeding (5.9%), sinusitis (3.9%), and septal ulceration (2.1%). Conclusion Trauma and hypertension were the primary etiologies of epistaxis, with anterior nasal packing constituting the fundamental approach to management. These results emphasize the significance of targeted prevention, early etiological identification, and structured management protocols to enhance outcomes.