Topical Vasoconstrictors for the management of spontaneous epistaxis
Date First Published:
May 21, 2015
Last Updated:
May 28, 2015
Report by:
Elizabeth Florey, Specialty Doctor in Emergency Medicine (Royal Devon and Exeter Hospital)
Three-Part Question:
In [adults with spontaneous epistaxis in the acute care setting], are [topical vasoconstrictors] useful in the [control of bleeding]?
Clinical Scenario:
A 64 year old patient with a history of epistaxis presents to the emergency department with a 3 hours history of spontaneous epistaxis. Simple first aid measures have been ineffective, and nor has the application of ice. You wonder whether there is any evidence base behind the use of topical vasoconstrictors or decongestants in the management of adult patients with epistaxis.
Search Strategy:
Medline 1946 - May 2015 week 3 using OVID interface.
Search Details:
((exp vasoconstrictor) AND ((exp epistaxis) OR (exp nose AND bleed)))
Outcome:
7 papers of which 2 are relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Use of Oxymetazoline in the Management of Epistaxis Krempl GA, Noorily AD 1995 United States | 60 adult patients who presented to the emergency department with ongoing epistaxis had their charts reviewed following discharge. | Retrospective Cohort Study | Arresting bleeding within 30 minutes with oxymetazoline alone | 39 patients (65%) | Small study group. No control group with first aid alone for comparison was looked at. Short follow up period to assess the reoccurence of epistaxis. |
| Arresting bleeding within 30 minutes with oxymetazoline and cautery | 11 patients (18%) | ||||
| Rebleeding within 5 days | 1 patient returned from the group treated with oxymetazoline solely | ||||
| Topical Terlipressin (Glypressin) Gel Reduces Nasal Mucosal Blood Flow but Leaves Ongoing Nose-bleeding Unaffected Bende M Pipkorn U Jul-90 Sweden | Adult patients presenting with ongoing posterior epistaxis to an ENT-clinic were treated with either terlipressin gel or placebo gel | Double-blind Randomised Controlled trial | Bleeding arrested within 45 minutes, and not recurring in the next 4 hours | 39% in Terlipressin group vs. 62% in placebo group (p=0.23, n.s) | Small study May not be relevant to Ed as posterior epistaxis only, and based in ENT clinic, not emergency department. No evidence of sample size or power calculation. Trend towards placebo. Half of the paper looks at the effect of Terlipressin on normal mucosal blood flow in patients without epistaxis. |
Author Commentary:
Very limited evidence, with underpowered studies and no large RCTs.
Poor evidence for topical vasoconstrictors for use in the Emergency Department, and studies mainly look at its use in the outpatient ENT setting.
There is evidence for the use of intranasal vasoconstrictors to prevent epistaxis in patients who are to be nasally intubated, but little exists to demonstrate its use in the actively bleeding patient.
Poor evidence for topical vasoconstrictors for use in the Emergency Department, and studies mainly look at its use in the outpatient ENT setting.
There is evidence for the use of intranasal vasoconstrictors to prevent epistaxis in patients who are to be nasally intubated, but little exists to demonstrate its use in the actively bleeding patient.
Bottom Line:
Insufficient evidence, and more robust randomised controlled trials needed to provide a higher level of evidence before this treatment can be proven to be beneficial to patients with spontaneous epistaxis in the emergency department.
References:
- Krempl GA, Noorily AD. Use of Oxymetazoline in the Management of Epistaxis
- Bende M Pipkorn U. Topical Terlipressin (Glypressin) Gel Reduces Nasal Mucosal Blood Flow but Leaves Ongoing Nose-bleeding Unaffected