Introduction
Epistaxis is the most common otolaryngological presentation to accident
and emergency (A&E) in the UK1. The incidence of
patients attending UK emergency departments with epistaxis is reported
as 108 per 100 000 local population annually2. In
2017, NHS hospital statistics reported 25 000 A&E attendance with
epistaxis3. Of the total attendances, approximately
25% require admission or specialist treatment2. In
our local centre, we noted that patients presenting with epistaxis were
frequently treated with non-dissolvable nasal packs in A&E,
necessitating admission under the Ear, Nose & Throat (ENT) team.
Current National Institute for Health and Care Excellence (NICE)
guidelines for the management of acute epistaxis suggest 15 minutes of
first aid, followed by silver nitrate cautery if possible and then
non-dissolvable packs such as nasal tampons (e.g.
Merocel®) or inflatable packs (e.g.
Rapid-Rhino®) if bleeding
continues4. A 2020 nationwide epistaxis audit found
that 54.4% of patients attending with epistaxis were packed with
non-dissolvable packing in A&E, and a further 18.9% by an ENT
specialist doctor5.
Non-dissolvable packing is classically associated with hospital
admission1, whereas British Rhinological Society (BRS)
guidelines advocate discharge for patients with dissolvable
packing3 (e.g. NasoPore®). In March
2020, in light of covid-19, ENT-UK published new guidelines for
epistaxis management which introduced the use of dissolvable packing in
the treatment algorithm6. Reasons for this were
two-fold. Firstly, to reduce exposure to the upper aerodigestive tract
by healthcare professionals, and secondly to reduce admissions, both
preserving bed capacity and reducing patient exposure to covid-19 in
hospital1.
Despite the above BRS guidance, subsequent national audit of epistaxis
management found A&E utilisation of dissolvable packing to be only
2%1. On call ENT doctors reported that
non-dissolvable packs were already inserted by A&E in 45% of cases,
prior to their attendance, necessitating admission1.
A 2017 systematic review of intranasal packing for epistaxis noted no
complications related to the use of dissolvable packing in the
management of epistaxis7. Strategies to reduce A&E
use of non-dissolvable nasal packs, in favour of dissolvable packing,
could reduce epistaxis admissions in UK hospitals whilst maintaining
patient safety.
As well as reducing admission rates, it is important to consider length
of admission and risk of re-bleeding. Systematic review has demonstrated
reduced re-bleeding rates and shorter admissions in epistaxis patients
treated with topical tranexamic acid (TXA), without increased
complication rates8. A 2018 Cochrane review of TXA use
in epistaxis found a 23% reduction in risk of re-bleeding within 10
days when topical TXA was utilised, however noted a small number of
studies specifically investigating this9.