Guidelines Summary

Guidelines on coronavirus disease 2019 (COVID-19)

In May 2020, clinical recommendations out of Italy were published regarding the management of epistaxis during the coronavirus disease 2019 (COVID-19) pandemic.^[18]

Personal protection recommendations include the following^[18]:

Disposable equipment use is strictly recommended
FFP3 (Europe) or N99 (United States) masks are preferred, but if FFP3 masks are unavailable, FFP2 or N95 masks, covered by a surgical mask, can be used
It is strongly recommended that health-care personnel employ cap and shoe covers, goggles, gowns, and double nitrile gloves

Clinical assessment recommendations include the following^[18]:

Nosebleed risk factors (ie, blood pressure, coagulation factors, ongoing therapies with antithrombotic or anticoagulant drugs) should be controlled
The patient should be checked for fever, respiratory symptoms, and contacts at risk for COVID-19
Investigate sudden loss of smell and/or taste
If allowed, dress patients with a surgical mask
Promptly assess the nosebleed’s severity
It is recommended that noninvasive intervention (bidigital compression, administration of antifibrinolytic agents) be employed

Room setting recommendations include the following^[18]:

If conventional operating rooms are unavailable, employ well-demarcated areas within the emergency department complex
The patient should be treated by a reduced and experienced clinical staff, including a surgeon and a scrub nurse, with proper personal protective equipment (PPE)

Treatment recommendations include the following^[18]:

Avoid unnecessary interventions
If noninvasive procedures fail, nasal packing or cautery should be performed
Resorbable packing, if available, is recommended
If sphenopalatine artery ligation is needed for posterior epistaxis, the procedure should be postponed until COVID-19 testing has been performed
Avoid using local anesthetic atomized sprays, employing soaked pledgets instead
During the procedure, a suction system, within a closed system and employing a viral filter, should be used

Postprocedure recommendations include the following^[18]:

To reduce recurrence risk and optimize outcomes, the patient should receive postprocedural instructions on packing removal or antibiotic prophylaxis
Carefully execute gowning and degowning procedures
Standard PPE should be employed by personnel engaged in the decontamination of surgical equipment

Medication

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Moreau S, De Rugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope. 1998 Jun. 108(6):887-8. [Medline].
Abelson TI. Epistaxis. Schaefer SD. Rhinology and Sinus Disease 1st ed. New York: Mosby; 1998. 43-50.
Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. 2007 Jun. 15(3):180-3. [Medline].
Emanuel JM. Epistaxis. Cummings CW. Otolaryngology-Head and Neck Surgery. 3rd ed. St. Louis: Mosby; 1998. 852-865.
Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005 May. 81(955):309-14. [Medline]. [Full Text].
Cummings CW. Epistaxis. Cummings. Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005. Chap 40.
Padgham N. Epistaxis: anatomical and clinical correlates. J Laryngol Otol. 1990 Apr. 104(4):308-11. [Medline].
Guarisco JL, Graham HD 3rd. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. 1989 Jul. 68(7):522, 528-30, 532 passim. [Medline].
Purkey MR, Seeskin Z, Chandra R. Seasonal variation and predictors of epistaxis. Laryngoscope. 2014 Mar 15. [Medline].
Seidel DU, Sesterhenn AM, Kostev K. Seasonal Variation of Epistaxis in Germany. J Craniofac Surg. 2018 Feb 12. [Medline].
Jarjour IT, Jarjour LK. Migraine and recurrent epistaxis in children. Pediatr Neurol. 2005 Aug. 33(2):94-7. [Medline].
Knight YE, Goadsby PJ. The periaqueductal grey matter modulates trigeminovascular input: a role in migraine?. Neuroscience. 2001. 106(4):793-800. [Medline].
Sarhan NA, Algamal AM. Relationship between epistaxis and hypertension: a cause and effect or coincidence?. J Saudi Heart Assoc. 2015 Apr. 27 (2):79-84. [Medline].
Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD004461. [Medline].
Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. 2008 Jun. 41(3):525-36, viii. [Medline].
Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009 Feb 19. 360(8):784-9. [Medline].
[Guideline] D'Aguanno V, Ralli M, Greco A, de Vincentiis M. Clinical Recommendations for Epistaxis Management During the COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2020 May 5. 194599820926497. [Medline]. [Full Text].
Durr DG. Endoscopic electrosurgical management of posterior epistaxis: shifting paradigm. J Otolaryngol. 2004 Aug. 33(4):211-6. [Medline].
Newton E, Lasso A, Petrcich W, Kilty SJ. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol Head Neck Surg. 2016 Apr 11. 45:24. [Medline]. [Full Text].
Kundi NA, Raza M. Duration of nasal packs in the management of epistaxis. J Coll Physicians Surg Pak. 2015 Mar. 25 (3):202-5. [Medline].
García Callejo FJ, Muñoz Fernández N, Achiques Martínez MT, Frías Moya-Angeler S, Montoro Elena MJ, Algarra JM. [Nasal packing in posterior epistaxis. Comparison of two methods]. Acta Otorrinolaringol Esp. 2010 May-Jun. 61(3):196-201. [Medline].
Brinjikji W, Kallmes DF, Cloft HJ. Trends in Epistaxis Embolization in the United States: A Study of the Nationwide Inpatient Sample 2003-2010. J Vasc Interv Radiol. 2013 May 3. [Medline].
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Wormald PJ, Wee DT, van Hasselt CA. Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis. Am J Rhinol. 2000;Jul-Aug. 14(4):261-264.
de Bonnecaze G, Gallois Y, Bonneville F, Vergez S, Chaput B, Serrano E. Transnasal Endoscopic Sphenopalatine Artery Ligation Compared With Embolization for Intractable Epistaxis: A Long-term Analysis. Am J Rhinol Allergy. 2018 Jan 1. 1945892418768584. [Medline].
Strong EB, Bell DA, Johnson LP, Jacobs JM. Intractable epistaxis: transantral ligation vs. embolization: efficacy review and cost analysis. Otolaryngol Head Neck Surg. 1995 Dec. 113(6):674-8. [Medline].
Wang B, Zu QQ, Liu XL, et al. Transarterial embolization in the management of intractable epistaxis: the angiographic findings and results based on etiologies. Acta Otolaryngol. 2016 Apr 8. 1-5. [Medline].
Alderman C, Corlett J, Cullis J. The treatment of recurrent epistaxis due to hereditary haemorrhagic telangiectasia with intranasal bevacizumab. Br J Haematol. 2013 May 14. [Medline].
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Media Gallery

Posterior epistaxis from the left sphenopalatine artery.
Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery.
Nasal speculum.
Vaseline gauze packing.
Expandable (Merocel) packing (dry).
Nasal vascular anatomy

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Author

Quoc A Nguyen, MD Associate Clinical Professor, Director, Sinus and Allergy Center, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Medical Center

Quoc A Nguyen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, Phi Beta Kappa, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, The Triological Society, American Rhinologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa;Proforma;Neosoma<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .

Additional Contributors

Hassan H Ramadan, MD, MSc, FACS, FARS Professor and Chairman, Director of Rhinology and Allergy Center, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine

Hassan H Ramadan, MD, MSc, FACS, FARS is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

Epistaxis Guidelines

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