Chronic Recurrent Nose Bleeds Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refer to:

  • Adults and children over 12 years of age suffering recurrent nose bleeds.

This guidance does not cover:

  • Children under 12 years of age

Assessment

Causes

  • Trauma- picking
  • Inflammation – infection, allergy, polyps
  • Drugs
    • Anticoagulants, antiplatelet, etc
    • Topical – decongestants, steroids
    • Nasal O2
    • Recreational- cocaine
  • Vascular or haematological conditions
  • Excess alcohol
  • Hypertension – although insufficient evidence to establish causative relationship with epistaxis
  • Post operative bleeds
  • Tumours

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Unilateral nasal mass
  • Nasal obstruction
  • Facial pain
  • Hearing loss
  • Eye symptoms (proptosis, double vision)
  • Persistent lymphadenopathy

if suspected Nasopharyngeal tumour discuss with the senior ENT clinician on call or refer on 2ww Head & Neck Care Pathway (with explanation)

Management

  • As per first aid and acute epistaxis guidance
  • Determine if any underlying causes and treat reversible causes
    • Consider FBC in adults with recurrent epistaxis
  • If not high risk (see referral section) discuss options:
    • Naseptin QDS 10 days (on BD for 14 days if compliance an issue)
    • If neomycin, peanut or soya allergy do not use Naseptin and use mupirocin BD-TDS 5-7 days instead
    • Nasal cautery – similarly effective to Naseptin but may be more uncomfortable. Consider if appropriate expertise and facilities and bleeding point can be identified and it can be tolerated. Also consider cautery if topical treatment has failed. Use naseptin/mupirocin as above if successful
  • No further bleeding:
    • Continue conservative treatment
    • Advice re nose care
    • Use petroleum jelly
  • Review as appropriate

Referral

Referral Criteria

  • Red Flags
  • All children under 2 with epistaxis should be referred to a paediatrician as epistaxis in this age in unusual and normally suggests underlying cause
  • Consider referral to ENT in following high risk groups:
      • Males aged 12–20 years of age — angiofibroma (benign tumour) is possible (but rare).
      • Middle-aged people of Chinese origin — due to the high incidence of nasopharyngeal cancer.
      • People older than 50 years of age — nasal, sinus, and nasopharyngeal cancers are more common in this age group.
      • People with telangiectasia and a family history of hereditary haemorrhagic telangiectasia.
      • People with occupational exposure to wood dust or chemicals
  • Also consider if:
    • Recurrent epistaxis
    • Failed treatment in primary care


Referral Instructions

  • e-consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 09.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 09.2017
  • Publication Date: 09.2017
  • Review Date: 09.2019
  • Ref No: ENT8 - 09.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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