Little evidence for either packing or cautery in anterior epistaxis
Date First Published:
March 1, 2000
Last Updated:
April 17, 2001
Report by:
Kevin Mackway-Jones, Consultant (Manchester Royal Infirmary)
Search checked by:
Rosemary Morton, Manchester Royal Infirmary
Three-Part Question:
In [adult patients with spontaneous epistaxis and no underlying disease] is [cautery or packing] more effective at [stopping bleeding].
Clinical Scenario:
An adult patient presents to the emergency department with a nosebleed that came on spontaneously and which has not responded to simple first aid measures. The bleed appears to be from the front of the nose and the patient has no underlying disease. You wonder whether packing or cautery is the best method of obtaining haemostasis.
Search Strategy:
Medline 1966-10/98 using the OVID interface.
Search Details:
([exp epistaxis OR epistaxis.ti,ab,rw,sh OR nose bleed$.ti,ab,rw,sh] OR {[exp hemorrhage OR hemorrhage$.ti,ab,rw,sh OR haemorrhage$.ti,ab,rw,sh OR bleed$.ti,ab,rw,sh] AND [exp nose OR exp nasal mucosa OR nose.ti,ab,rw,sh OR nasal.ti,ab,rw,sh OR nares.ti,ab,rw,sh]}) AND [pack$.ti,ab,rw,sh OR exp cautery OR cauter$.ti,ab,rw,sh] AND maximally sensitive RCT filter LIMIT to human and english language.
Outcome:
103 papers found of which 80 irrelevant and 16 of insufficient quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of electro and chemical cautery in the treatment of anterior epistaxis. Toner JG, Walby AP. 1990 UK | 97 consecutive patients with anterior epistaxis attending the Emergency Department Randomised to either electro-cautery or cautery with silver nitrate |
PRCT | Number having further epistaxis | No statistical difference | Low power study. |
| Complications | No significant difference | ||||
| A new approach to the management of acute epistaxis. Nicolaides A, Gray R, Pfleiderer A. 1991 UK | 30 consecutive patients with acute epistaxis in the control vs 33 consecutive patients in the intervention group. Intervention group had visualisation using the operating microscope and hot wire cautery. |
Controlled clinical trial | Complete control of bleeding by cautery | 82% vs 23% | Not randomised. |
| Need for subsequent packing | 18% vs 77% (P < 0.001) | ||||
| Need for admission for longer than 24h. | 27% vs 76% | ||||
| A comparative study of calcium sodium alginate (Kalostat) and bismuthtribromophenate (xeroform) packing in the management of epistaxis McGlashan JA, Walsh MB, Dauod A et al. 1992 UK | 40 consecutive adult (> 16y) patients with significant epistaxis of at least 2h duration. Kalostat vs xeroform packs |
PRCT | Discomfort of insertion | ns | No power calculation |
| Rebleed rate | ns | ||||
| Microscope and hot wire cautery management of 100 consecutive patients with acute epistaxis - a superior method to traditional packing. Quine S, Gray RF, Rudd M et al. 1994 UK | 100 consecutive adult (> 16y) patients with acute epistaxis All hot wire cauterised |
Observational | Patients sent home immediately | 80% | Uncontrolled |
| The use of Merocel nasal packs in the treatment of epistaxis. Pringle MB, Beasley P, Brightwell AP. 1996 UK | 83 patients packed with merocel out of 149 patients with epistaxis presenting over 1 year. | Observational | Control of epistaxis | 91.50% | Uncontrolled. |
| Discomfort of insertion (n=34) | low VAS scores (median 3) |
Author Commentary:
There is a paucity of good evidence in this area. No head to head trials have been carried out. Hot wire cautery using an operating microscope requires skills unlikely to be found in the emergency department, while nasal packing is easier for the relatively unskilled to perform but is less comfortable for patients.
Bottom Line:
Both cautery and packing can be effective. In the absence of better comparative studies the operator should use the technique with which they are most familiar.
References:
- Toner JG, Walby AP.. Comparison of electro and chemical cautery in the treatment of anterior epistaxis.
- Nicolaides A, Gray R, Pfleiderer A.. A new approach to the management of acute epistaxis.
- McGlashan JA, Walsh MB, Dauod A et al.. A comparative study of calcium sodium alginate (Kalostat) and bismuthtribromophenate (xeroform) packing in the management of epistaxis
- Quine S, Gray RF, Rudd M et al.. Microscope and hot wire cautery management of 100 consecutive patients with acute epistaxis - a superior method to traditional packing.
- Pringle MB, Beasley P, Brightwell AP.. The use of Merocel nasal packs in the treatment of epistaxis.