In 2020, the American Academy of Otolaryngology–Head and Neck Surgery Foundation published a comprehensive clinical practice guideline. Management of a nosebleed with an identified anterior nasal bleeding site involves several options. Initial therapy can include topical vasoconstrictors like oxymetazoline, phenylephrine, epinephrine, or cocaine, and nasal cautery. After bleeding stops, lubricants and moisturizers can prevent rebleeding. Oxymetazoline and phenylephrine are over-the-counter vasoconstrictors commonly used with a reported resolution rate of 65-75%. However, these agents may pose cardiac and systemic risks, especially in patients with hypertension, cardiac, or cerebrovascular conditions. In young children, oxymetazoline is used with caution, and more dilute phenylephrine solutions are available for younger ages. Though effective in controlling nasal bleeding, epinephrine's systemic absorption and potential cardiovascular effects make oxymetazoline preferable. Cocaine is rarely used due to potential cardiac side effects and abuse risks. A small trial showed no difference between antiseptic cream and nasal cautery for controlling epistaxis in children. In adults, topical vasoconstrictors followed by silver nitrate cautery were more effective than nasal pinching alone. The British Rhinological Society recommends cautery as the first-line treatment, with vasoconstrictors used beforehand despite low-quality evidence. Without high-quality evidence directing specific treatments, clinicians might opt for humidification, intranasal emollients, vasoconstrictor agents, or nasal cautery. Tranexamic acid (TXA), an antifibrinolytic agent, has shown effectiveness in controlling acute nosebleeds, particularly in patients on antiplatelet drugs. However, further research is needed to understand TXA's indications and efficacy, considering newer epistaxis treatment techniques with endoscopes and cautery. [1]
Several review articles describe a variety of treatment options for epistaxis, which involves bleeding from the nostrils, nasal cavity, or nasopharynx. Initial management often includes basic first aid measures such as applying external pressure and using ice packs. Topical vasoconstrictors like Afrin (oxymetazoline) are frequently effective, reportedly controlling 65-75% of nosebleeds in emergency settings. Electrocautery tends to be more effective than chemical cauterization, with lower rates of recurrence (approximately 14.5% versus 35.1%). Notably, TXA has demonstrated superior efficacy in promoting hemostasis, achieving control in about 78% of cases compared to 35% with oxymetazoline and 31% with nasal packing. Nasal packing remains a common intervention and can be performed with a range of materials. Non-absorbable options include petroleum jelly, bismuth iodoform paraffin paste (BIPP) gauze, polyvinyl alcohol nasal tampons such as Merocel, Foley catheters, and balloon devices like Rapid Rhino. Absorbable materials, such as Nasopore, offer an alternative with potential comfort benefits. Newer hemostatic agents, including Surgicel (oxidized regenerated cellulose), thrombin matrix (Floseal), gelatin sponge (Spongostan), and fibrin glue, have shown promising results, providing effective bleeding control with fewer complications. [2], [3]
For more persistent or severe bleeding, endoscopic interventions are increasingly utilized. Endoscopic ligation of arteries, particularly the sphenopalatine artery, yields higher success rates than traditional nasal packing (approximately 97% versus 62%). Endoscopic cauterization may offer even greater efficacy than ligation. In refractory cases, embolization serves as a minimally invasive alternative with a reported success rate around 80%, using materials such as gelatin sponge, foam, polyvinyl alcohol, or coils. Treatment selection should be individualized, taking into account the patient’s history, severity of bleeding, and available resources. The integration of newer hemostatic agents and endoscopic techniques appears to enhance outcomes compared to traditional methods. [2], [3]
When managing epistaxis in the outpatient setting, care typically follows a gradual escalation from conservative to more invasive approaches as needed. The initial step is to assess airway patency because brisk anterior bleeding can cause blood to pool in the posterior pharynx, increasing the risk of airway obstruction. Any suspicion of a compromised airway warrants urgent evaluation in an emergency setting. Once airway safety is confirmed, firm compression of both nostrils just below the nasal bones should be applied continuously for 10 to 15 minutes. This can be achieved by manual pinching or by using a homemade nasal clip fashioned from taped tongue depressors. Topical vasoconstrictors can complement compression; oxymetazoline may be sprayed directly into the nostrils, or cotton pledgets soaked in oxymetazoline or epinephrine 1:1,000 can be inserted to help control bleeding. However, caution is advised with epinephrine due to potential systemic absorption that may lead to elevated blood pressure and tachycardia. [2], [3], [4]