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.