Epistaxis: A Contemporary Evidence Based Approach
Introduction
Epistaxis is the second most common cause for emergency admission to ear/nose/throat services (following sore throat). In 2009/2010, there were more than 21,000 emergency admissions in England with a mean inpatient stay of 1.9 days. The majority of admissions are aged 60 to 70 years,1 but there is a bimodal age incidence, with an earlier peak in childhood.2
Death due to epistaxis is rare. In 2005 in the United States, 7 epistaxis-related deaths were recorded, all from the population 75 years or older3; an approximate incidence in that age group of 1:2,500,000, and an overall incidence of 2:100 million. The epidemiology of epistaxis in Scotland has been well reviewed,4 and readers are referred here for more details.
Despite the heavy caseload there are no national or consensus guidelines to inform management decisions, and the most junior members of staff are often the main caregivers.5 Across different centers, investigation profiles and treatment preferences vary. There are areas of controversy, and non-standardized practice exists. This situation needs to be addressed in an evidence-based fashion. The purpose of this article, therefore, is to review the literature concerning the management of epistaxis and to make recommendations (evidence-based where available) for treatment.
Section snippets
Methods
A literature review was performed in July 2011. PubMed was searched using the term “Epistaxis”[Majr], limited to reviews within the last 10 years. Relevant articles were identified and obtained, as well as important ancestor references. Further specific searches were conducted without limits, to address each theme within the review, for example, “Epistaxis”[Majr] AND “Blood Coagulation Disorders”[Mesh]. More than 200 articles were reviewed, although few provided primary evidence beyond expert
Management of Epistaxis
A stepwise approach to epistaxis management is advocated. In order, this should be initial management, followed by direct therapy, tamponade, and vascular intervention. When control of bleeding is not achieved, timely progression through the management steps is essential (Fig. 1).
Pathway Progression: Uncontrolled Epistaxis
Direct therapy or tamponade will almost invariably reduce bleeding, but sometimes control is not absolute, and intermittent or minor ongoing bleeding may occur. In such cases, a clinical decision must be made as to
Literature review on epistaxis
In reviewing the epistaxis literature, one is confronted with a wealth of expert opinion and descriptive articles. Few primary research studies are conducted, and those available focus on management techniques rather than on pathway decisions. Without placing the patients in the context of a management pathway, these studies may lack transferability; one’s own patients may represent a different population at a different point in the pathway. It is for these reasons that a management pathway
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