Recurring anterior epistaxis is a common problem. Identification of the causes is key to its management. Usually, clinical management is simple and progonosis is excellent.

1. Faculty Disclosure
I advise that the following presentation will NOT include discussion on
any commercial products or service and that there are NO financial
interests or relationships with any of the Commercial Supporters of The
Asia-Oceania Otolaryngology Congress.
04/03/2011 1

2. Recurring Anterior Epistaxis:
Long-Term Follow-Up
Edoardo Cervoni, M.D.
Central Lancashire PCT NHS
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3. Anatomy
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4. Frequency
Data on the true incidence of epistaxis may be
difficult to obtain due to the fact that not all cases are
seen in A&E or by a GP/FP.1
Epistaxis is estimated to occur in 60% of persons
worldwide during their lifetime, and approximately
6% of those with nosebleeds seek medical treatment2.
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5. Background and Aim
Background: Epistaxis mostly (80–90%) originates
from Little's area and it is self-limiting. However,
clinical intervention is often seek and the long-term
outcomes of the different form of intervention may
vary.
Aim: the objective of this study is to retrospectively
analyse what the long-term outcomes may be.
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6. Material and Methods
A cluster sample of 8275 subjects, 4206 males (50.8%)
and 4069 females (49.2%), was selected to undergo a
complete review of computerized GP medical records
for diagnosis of epistaxis (2008 ICD-9-CM Diagnosis
Code 784.7), and looked for recurring epistaxis.
The full medical records were then scrutinized for
type of epistaxis, intervention, co-morbidities, and
medications.
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7. Population demographic
characteristics
UK Census 2001 – Official data
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8. Population cluster characteristics
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9. Age distribution
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10. Results
Complete prevalence of recurring epistaxis was 1% in
males and 1% in females.
Total recurring epistaxis prevalence was 1%.
All ages were affected with a peak incidence in
children and young adults aged 5-24 years and in the
adults above 55.
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11. Medical History: active problems
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12. Medical History: Medications
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13. Clinical outcomes
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14. Treatments comparison
Silver nitrate cauterization seems to be
associated with higher long-term prevalence of
re-bleeding when compared to other forms of
intervention, including simple advice.
The amount of data was not large enough to compare
effectiveness of Mupirocin vs. Naseptin in recurring
anterior epistaxis.
Naseptin had been most commonly used.
Only Naseptin was applied after silver nitrate cautery.
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15. Other observations
At a mean follow-up of 90 months, recurrence rate
post-intervention was 13%, being higher in the group
treated with silver nitrate cauterization, with or
without antibiotic cream.
The average interval of re-bleeding post cautery was 2
years.
Hypertension and allergic rhinitis were the most
commonly reported co-morbidities, but they did not
appear to have an impact on the risk of re-bleeding.
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16. Previous studies
McNeill (1974) preferred the use of a silver nitrate
particularly in children3.
Ludman (1981) described silver nitrate tipped stick as
the treatment of choice for persistent epistaxis when
the bleeding vessel is visible4.
Toner and Walby (1990) with a prospective
randomized study showed that there was no
statistically significant difference between
galvanocautery and cautery with silver nitrate in
either controlling the epistaxis or in the incidence of
complications5.
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17. Subsequent Studies
Silver nitrate cautery offers no added advantage when
compared to antiseptic nasal cream (Murthy P et coll.,
1999) 6.
Antiseptic cream is an effective treatment for recurrent
epistaxis in children and silver nitrate cautery with
antiseptic cream in the short term (4 weeks) appears to
give a small but statistically significant benefit when
compared to antiseptic cream alone (Kubba H et coll.,
2001; Calder N et coll., 2009) 7,8.
Children treated for recurrent epistaxis who had
undergone cautery and received cream had the highest
on-going bleeding rate (Robertson S et coll., 2008)9.
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18. Study limitations
This study relies heavily on the fact that episodes of
recurring anterior epistaxis had been reported to
either Primary Care or Secondary Care practitioner.
Some episodes of epistaxis may have been reported,
but not coded in the electronic clinical records.
Subjects that underwent cauterization rather than
being treated with cream or observed may have had
different characteristics, such as more obvious
varices.
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19. Prospective studies
RCT comparing Naseptin® antiseptic cream with
Mupirocin cream 2%.
RCT comparing varices cauterization followed by
application of Mupirocin vs. Naseptin® antiseptic
cream .
Sub-analysis of patients with diagnosis of
hypertension and not taking anti-platelets, nor anti-
coagulants.
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20. References
1. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. Jun 2008;41(3):525-36.
2. Cummings CW. Epistaxis. In: Cummings: Otolaryngology: Head and Neck
Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005:Chap 40.
3. McNeill J. Coping with nose-bleeds. BMJ 13 April 1974; 118 (letter).
4. Ludman H. ABC of ENT: nose bleeds. BMJ (1981) 282, 967-9.
5. Toner JG, Walby AP. Comparison of electro and chemical cautery in the treatment of
anterior epistaxis. J Laryngol Otol. 1990 Aug;104(8):617-8.
6. Murthy P, Nilssen EL, Rao S, McClymont LG. A randomised clinical trial of antiseptic
nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior
epistaxis. Clin Otolaryngol Allied Sci. 1999 Jun;24(3):228-31
7. Kubba H, MacAndie C, Botma M et al. A prospective, single-blind, randomized controlled
trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol Allied
Sci. 2001 Dec;26(6):465-8.
8. Calder N, Kang S, Fraser L et al. A double-blind randomized controlled trial of management
of recurrent nosebleeds in children.Otolaryngol Head Neck Surg. 2009 May;140(5):670-4
9. Robertson S, Kubba H. Long-term effectiveness of antiseptic cream for recurrent epistaxis
in childhood: five-year follow up of a randomised, controlled trial. J Laryngol Otol. 2008
Oct;122(10):1084-7.
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