Epistaxis. Claire M McLarnon Sean Carrie

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1 Epistaxis Claire M McLarnon Sean Carrie Abstract Epistaxis is extremely common and usually managed with simple first aid measures in the community. However it can also present with life-threatening haemorrhage which requires appropriate resuscitation and arrest of the bleeding. Of those patients presenting to local emergency services, knowledge of the assessment and management of epistaxis are essential. Epistaxis is classified as primary epistaxis, where no cause can be found or secondary epistaxis where there is a defined cause. It is also described in terms of the site of bleeding. Anterior bleeding from the nasal septum is found in 90% of cases and can be controlled with simple first aid measures or nasal packing and/or cautery. Posterior bleeding is more dramatic and may require a surgical procedure or radiological guided embolization. Many patients, particularly the elderly, have associated co-morbidities and medications that need to be addressed along with the standard treatment. This article discusses the assessment and appropriate management of patients with epistaxis and their associated morbidities. Keywords Anterior ethmoidal artery; endoscope; epistaxis; hereditary haemorrhagic telangiectasia; nasal cautery; nasal packing; sphenopalatine artery Introduction Epistaxis is defined as acute haemorrhage from within the nasal cavity including the nasopharynx. It is a common condition ranging in severity from a single short-lived episode to a less common life-threatening haemorrhage. The majority of cases are self-limiting and do not require medical intervention. Of those patients who do attend the accident and emergency department (A&E) with an epistaxis, the vast majority can be managed in A&E. Referral to ear, nose and throat (ENT) is reserved for the minority of cases where the epistaxis is severe and/or there are other associated patient factors or co-morbidities requiring admission. Epistaxis is classified as primary epistaxis, where no cause can be found or secondary epistaxis where there is a defined cause for example nasal trauma. Incidence The reported incidence of an episode of epistaxis occurring during a lifetime is approximately 60%, with less than 10% Claire M McLarnon MB ChB MSc FRCS (ORL-H&N) is a Year 5 Specialist Registrar in ENT currently based at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared. Sean Carrie MB ChB FRCS (ORL) is a Consultant ENT Surgeon at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared. requiring medical attention. 1 There is a bimodal distribution of epistaxis incidence with peaks in children and the older adult. Epistaxis is rare in children under the age of 2 years; however it does occur more commonly in childhood with a peak incidence between the ages of 3 and 8 years. The peak incidence of epistaxis in adults is in 45e65-year-olds in whom the incidence of severe posterior bleeding is greater. 2 The annual admission rate of adult epistaxis to otolaryngology wards in the UK is around 30 per 100,000 per year; however less than 10% of admitted patients go on to require a surgical procedure under general anaesthetic. 3 Anatomy Terminal branches of the external and internal carotid arteries supply the nasal cavity with frequent anastomosis between them on the nasal septum, lateral wall and midline. The anterior nasal septum is a particularly well-described site of anastomosis between the external and internal carotid arterial systems where an abundant plexus of vessels called Little s or Kiesselbach s area is found (Figure 1). This is the site at which up to 90% of epistaxis originates. The branches of the external carotid artery supplying Little s area include terminal branches of the internal maxillary artery which are the sphenopalatine artery and the greater palatine artery. The other external carotid branch is the facial artery which supply s the superior labial artery. The sphenopalatine artery enters the nose via the sphenopalatine foramen in the lateral nasal wall at the posterior end of the middle turbinate. It then branches to supply most of the nasal septum and much of the lateral nasal wall. The superior labial artery can be found entering the nose from below just lateral to the anterior nasal spine to supply the anterior nasal septum. This artery and the greater palatine are often overlooked as they need to be identified on or nearer the floor of the nose. The internal carotid artery supplies the superior part of the nasal cavity by way of the ophthalmic artery which gives off the anterior and posterior ethmoidal arteries. These arteries run into the roof of the nose from the orbit via their respective anterior and posterior foramina. The posterior ethmoidal artery is smaller than the anterior ethmoidal artery. It is absent in approximately 20% of individuals and can be found only a few millimetres (2e5 mm) anterior to the optic nerve as it exits the optic canal, and about 10e12 mm posterior to the anterior ethmoidal artery. Knowledge of the course and branching patterns of these arteries is essential in the surgical management of epistaxis involving these vessels. Aetiology Most causes of epistaxis can be identified through a directed history and physical examination. The patient history should include details of the initial presentation of bleeding, previous bleeding episodes and their treatment, comorbid conditions, and current medications. Risk factors and causes of secondary epistaxis can be divided into local and systemic aetiologies (Table 1). Despite no obvious cause in primary epistaxis, it is well recognized that there is an increased frequency of epistaxis in the autumn and winter months. 4 This correlates with changes in temperature and humidity, which may be the causative SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.

2 Causes of epistaxis Local causes of epistaxis Traumatic Nasal fracture Surgical procedures Nasal intubation Nose picking e digital trauma Topical medications (including intra-nasal steroids) Cocaine snuffing Nasal oxygen Nasal foreign bodies Structural Nasal septum deviation Septal perforation Inflammatory disease Systemic causes of epistaxis Coagulation disorders Anticoagulant drugs (aspirin, clopidogrel, non-steroidal anti-inflammatory drugs, warfarin, heparin) Thrombocytopenia Acquired coagulopathies Congenital coagulopathies Vitamin deficiencies (A,D,C,E,K) Liver disease including chronic alcohol abuse Renal failure Malnutrition Polycythaemia vera Multiple myeloma Leukaemia Vascular disease Figure 1 Anatomical sites for epistaxis. factors. It has also been found that there is a circadian rhythm, with peaks in incidence of epistaxis in the morning and late evening. 5 Epistaxis in children By far the most common cause of epistaxis in children is repeated digital trauma (nose picking) in combination with mucosal changes due to reduced humidification seen in the winter months. Other common causes include nasal injury, recurrent upper respiratory tract infections, rhinitis and nasal foreign bodies. Epistaxis from more serious systemic conditions such as leukaemia or tumours within the nasal cavity is rare. Clinical history and careful examination will direct the use of any further investigations to look for the less common and more serious causes. Epistaxis in adults The systemic causes of epistaxis are more relevant in adults with particular attention to the use of anti-coagulants. Hypertension is seen in many adults presenting with epistaxis, however there is no good evidence of a direct role, and in most patients a raised blood pressure is due to the anxiety of having a nose bleed. Trauma to the nose usually results in an associated epistaxis which in many cases stops spontaneously. Persistent heavy bleeding after trauma indicates an arterial cause most often from the anterior ethmoidal artery and sphenopalatine artery. Early reduction of a displaced nasal fracture can help, however the patient will most likely require a surgical intervention to stop the bleeding. Delayed bleeding of around 7 weeks following major facial trauma may indicate a post-traumatic aneurysm. In elderly adults, particularly those with dementia repeated digital trauma is a recognized cause Common colds and flu Nasal vestibulitis Rhinosinusitis Pyogenic granuloma Granulomatous disease (Wegner s, tuberculosis, sarcoidosis, syphilis) Environmental irritants (smoking, chemicals, pollution) Tumours and vascular malformations Table 1 Inverting papilloma, squamous cell carcinoma, adenocarcinoma, melanoma of nasal cavity and paranasal sinuses Angiofibroma Haemangioma Olfactory neuroblastoma Atherosclerosis Collagen abnormalities Hereditary haemorrhagic telangiectasia Cardiovascular conditions Cardiac failure, mitral valve stenosis Hypertension and keeping fingernails short can be a simple preventative measure. Chronic crusting and inflammation from repeated digital trauma can lead on to a septal perforation. Here troublesome recurrent bleeding is seen from both nasal cavities. Patients using regular intra-nasal steroid sprays, typically used in the treatment of rhinosinusitis, also have an increased risk of recurrent epistaxis. 6 Epistaxis that is unilateral and recurrent should be referred on to an ENT specialist for endoscopic rhinoscopy and further investigation to exclude a tumour within the nasal cavity or nasopharynx. SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.

3 History and initial assessment The initial assessment of any patient presenting with bleeding should always start with checking their airway, breathing and circulation. A patient with persistent bleeding and a reduced conscious level as seen in alcohol/drug intoxication or head injury is at risk of aspirating and will require prompt action to protect the airway. A quick assessment of the vital signs and any available laboratory results should be done. Any haemodynamic compromise should be addressed urgently with intravenous access and fluid resuscitation. Most patients with epistaxis will not have any significant compromise; however special attention should be paid to the elderly and those patients with significant underlying cardiopulmonary disease. After ensuring the patient is stable a more in-depth history should then be taken. This should include: side of bleeding, duration, amount and frequency of bleeding, a judgement on amount of blood swallowed or spat out, any preceding trauma or precipitating causes. Any previous history of epistaxis and any previous treatments for it should be asked. The past medical history and current medications are also important especially with respect to the systemic causes given in Table 1. Examination Before going to examine a patient it is important to remember to put on a disposable apron and gloves, and if available a surgical face mask and eye protection. Patients will be extremely anxious and it is always worth having an assistant with you to help support the patient and help with passing and holding equipment. Good lighting is essential and ideally a headlight should be worn, but if one is not available a bright torch, lamp or the auroscope can be used. Suction is essential and you should remember to provide a bowl and tissues for the patient who should be sat up preferably in a proper examination chair. If the bleeding has been controlled with first aid measures or stopped spontaneously then routine examination of the oropharynx to check for any on-going posterior bleeding or clots is done followed by anterior rhinoscopy. In patients that continue to bleed the examination is often combined with the management so as to stop or reduce bleeding to allow for a better assessment. Therefore it is important to make sure you have equipment and topical agents to hand before starting. Equipment should include nasal dressing forceps, nares dilators and a tongue depressor. In the scenario of a patient continuing to bleed getting the patient to blow their nose and removing the clots with the sucker may enable you to have a look in the nose to see if you can see where the bleeding is coming from. If you cannot, then the nose will need to be gently packed with plain gauze ribbon soaked in a topical decongestant and local anaesthetic agent. Examples of agents used include 2% lidocaine with 1 in 80,000 adrenaline or 1 in 100,000 plain adrenaline with 1% lidocaine. These should be left in the nasal cavity for 5e10 minutes. During this time you can continue your head and neck examination including examination of the external nose and face, ears, neck, oral cavity and oropharynx. It is important to do this as you may find other physical signs such as telangiectasia seen in hereditary haemorrhagic telangiectasia (HHT), or petechiae as a result of thrombocytopenia, or a neck mass secondary to a sinonasal malignancy. The application of topical vasoconstrictors in many cases temporarily stops the bleeding. So once you have removed the impregnated gauze dressing this is the best opportunity to inspect the nasal cavity. Anterior rhinoscopy is ideally performed with a nares dilator (e.g. a Thudicum nasal speculum), looking for any obvious vessel especially in Little s area. Again the auroscope can also be used to look at the anterior nasal septum. Any obvious bleeding source can be cauterized at this point. If no obvious cause is seen anteriorly then a look posteriorly is required especially looking at the lateral wall in the area of the sphenopalatine artery. It is difficult to do this with a headlight and a rigid nasal endoscope is recommended. While inspecting the nose it is also important to note any abnormal findings such as septal deviations and perforations, and any masses or polyps. The ultimate goal of your examination is to determine the side and site of bleeding and any relevant pathology to the cause of bleeding. Management Thankfully most patients presenting to A&E will not present in severe haemodynamic shock, although many may display varying degrees of shock in relation to their blood loss, age and underlying cardiovascular status. All patients who continue to bleed should have intravenous access and have a blood sample collected for full blood count and group and save. Other laboratory tests may include coagulation studies, urea and electrolytes, liver function and international normalized ratio for those patients on warfarin. It is useful to divide epistaxis into anterior and posterior when discussing their management. 7 First aid Position the patient sitting, with their head over a bowl. Their nostrils should be pinched together firmly for at least 5e10 minutes, alongside cooling with an icepack on the nose or sucking an ice lolly if available. Squeezing the top part of the nose over the bony dorsum never works. Persistent bleeding after 20 minutes requires further intervention. Anterior epistaxis This is bleeding from Little s area in most cases (90%). First aid measures to control bleeding should be attempted initially. If this fails then the nose should be decongested and the clots cleared as described above in examination. Any prominent vessel which bleeds easily on touch or area with a fresh clot is the likely site of bleeding. Nasal cautery provides an effective treatment for bleeding here. The area should be anesthetized with a topical local anaesthetic agent if some has not already been applied. Silver nitrate on a special applicator is commonly used. Electrocautery is very effective however should only be used by appropriately trained ENT medical personnel. Application of silver nitrate is done by rolling the applicator stick between your thumb and first finger whilst gently applying the tip to the area you wish to cauterize for 10e20 seconds. Care should be taken to not accidently burn the nasal skin, when you introduce the applicator stick into the nose. It is worth starting in an area immediately adjacent to the vessel making an orbit around the vessel before rolling the tip in to the centre, directly on the vessel. Going straight for the vessel usually culminates in making it bleed again. The danger here is continuing to keep going and ending up with a large area of septal mucosa cauterized and the SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.

4 patient still bleeding. Occasionally anterior bleeding occurs from the margins of a septal perforation where cautery can similarly be effective. If cautery cannot control the bleeding then a nasal pack will be required. There are numerous types ranging from impregnated ribbon with Vaseline or bismuth iodoform paraffin paste (BIPP), nasal tampons and anterior nasal balloons (Figure 2). Availability and familiarity tend to dictate choice as all are similarly effective. 8 Nasal packs should be introduced into the nose directly front to back following the floor of the nose which is the same as the roof of the mouth (Figure 3). Never try to place a pack in an upwards direction as this will not work and will be painful. Dry packs such as the Merocel Ò nasal tampon need to moistened with saline after insertion so they expand. The Rapid Rhino Ò consists of an air-inflatable balloon and a self-lubricating hydrocolloid fabric covering that provides for ease of insertion and removal. This pack has to be soaked in water for 30 seconds prior to insertion. Once in place the balloon is inflated with air using a 20 ml syringe until the pilot cuff is tense. Most of these manufactured nasal tampons have either a string or tubing which should be taped to the patient s cheek to secure it. Any dressing or pack placed within the nasal cavity has the potential risk of being aspirated; this risk alongside the potential for further bleeding and haemodynamic instability makes it standard UK practice to always admit any patient with a pack in-situ. Typically packs will be left in place for 24e48 hours, and the patient instructed to refrain from exertion and straining. Any co-existing medical problems (e.g. coagulopathy) needs to be addressed and the patient s medications reviewed. Antibiotics are not routinely indicated, but should be considered in any patient who requires prolonged nasal packing or has an underlying medical condition requiring antibiotic prophylaxis such as an artificial heart valve. Toxic shock syndrome is a rare condition seen where by colonized Staphylococcus aureus on the pack releases an enterotoxin in to the circulation. Although a rare complication it can lead to multiple organ failure, shock and death. Posterior epistaxis This tends to present with much heavier bleeding and many patients will have signs of haemodynamic shock. Bleeding is Figure 2 From left to right: (1) Rapid Rhino nasal pack; (2) Netcell tampon; (3) co-phenylcaine nasal spray; (4) nasal dressing forceps; (5) ribbon gauze; (6) silver nitrate cautery stick. Figure 3 Correct position for insertion of a nasal tampon pack. from larger arterial vessels, namely the sphenopalatine artery at the back of the nasal cavity. There is usually a pattern of rapid profuse bleeding over 10e20 minutes. It can be difficult to assess which side the bleeding is from as blood tends to pour down into the throat and out of both sides of the nose. As the vessel goes into a reactionary vasospasm the bleeding subsides, however it will most certainly start again as the vessel relaxes and opens up. Therefore if you suspect this type of bleeding, even if it has stopped it is unwise to send the patient home. Because much of the bleeding goes down the back of the throat, it is then swallowed and some patients present with a clinical picture more like an upper gastrointestinal (GI) bleed with haematemesis. This can be an even more confusing picture in a patient with a background of alcoholic liver disease, and a multidisciplinary approach with ENT and gastroenterology may be needed. After decongestion and topical anaesthetic the nasal cavity should ideally be inspected with a zero degree rigid nasal endoscope in one hand and a small nasal sucker in the other hand. With experience and the use of the endoscope the point of bleeding can be identified in the majority of patients (approximately 80%). Once identified cauterization with either silver nitrate or electrocautery can be done under endoscopic visualization. With this approach unnecessary nasal packing and admission can be avoided. However if bleeding persists then nasal packing will be required. Options here include BIPP gauze dressing, posterior Rapid Rhino Ò packs, Foley catheter posterior packing. Posterior packing is usually done in conjunction with anterior nasal packing. Occasionally bilateral nasal packs may be required to control a heavy bleed. Undoubtedly pre-manufactured posterior packs such as the Rapid Rhino are easier to insert and use, however they may not always be available so knowledge of how to perform traditional anterior/posterior nasal packing is essential. Typically a 12 French Foley catheter is used in conjunction with BIPP impregnated ½ inch ribbon gauze dressing. The Foley catheter balloon should be tested with saline prior to use and all equipment as discussed earlier should be set up ready. Nasal decongestion and a topical local anaesthetic solution should be applied to the nasal cavity on ribbon gauze dressing as before. The procedure is explained to the patient and analgesia with paracetamol and codeine can be offered. It is essential to have an assistant when placing this type of packing. The Foley catheter is lubricated and advanced into the nose until the tip can just be SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.

5 seen passing the soft palate in the mouth. At this point the catheter needs to be pulled back a centimetre as the balloon should be inflated in the nasopharynx. Between 5 and 10 ml of saline is used to inflate the balloon and once inflated the catheter is pulled taught so that the balloon is effectively occluding the posterior choanae at the back of the nasal cavity. While your assistant maintains tension on the catheter an anterior BIPP pack is placed tightly into the nasal cavity by way of folding layers of ribbon on top of each other. The catheter can then be secured at the front of the nose with an umbilical clamp. Great care must be taken that the clamp is not in direct contact with the skin of the nose as pressure necrosis can occur early on and results in a lasting nasal deformity. BIPP dressing at the front of the nose can be used to provide a barrier between skin and the clamp. After insertion inspection of the oropharynx is vital to make sure no packing or blood clots have come into the throat and to check that the bleeding has stopped. These packs are typically left in situ for not more than 24e48 hours with antibiotic prophylaxis and can provide effective bleeding control before definitive intervention. This type of packing is extremely uncomfortable and makes swallowing very difficult, so regular analgesia should be prescribed. An interesting alternative treatment is hot water irrigation which has shown efficacy in approximately 80% of patients treated, however this technique is not standard practice in the UK. 9 Surgical intervention This is reserved for patients in whom nasal packing has been ineffective, or where the patient has required repeated re-packing to control bleeding. A falling blood count despite apparent anterior control should also be taken into account. The type of surgical intervention is tailored to the cause and site of bleeding. Currently endoscopic sphenopalatine artery ligation is the commonest procedure performed. Endoscopic sphenopalatine artery ligation This is usually performed under general anaesthetic, but can be done under local anaesthetic. The nasal cavity is inspected with a0 endoscope to confirm the site of bleeding. Once confirmed topical decongestion is administered. Using the endoscope a small flap of lateral wall nasal mucosa is elevated about 1 cm anterior to the posterior end of the middle turbinate. A crest of bone (crista ethmoidalis) is found projecting medially and the sphenopalatine foramen is encountered just behind this. The sphenopalatine artery exits here and needs to be closely inspected as it has variable branching patterns. The artery and any associated branches are ligated with clips as near to the foramen as possible, and are either divided or electro-cauterized (Figure 4). Anterior ethmoidal artery ligation Bleeding from the anterior ethmoidal artery is more common following nasal trauma or iatrogenic following endo-nasal surgery. Traditionally it is ligated via an open approach, using a Lynch incision in the medial canthus however an experienced surgeon may attempt endoscopic ligation. A sub-periosteal flap is raised along the medial wall of the orbit until the vessel is visualized approximately 24 mm posterior to the anterior lacrimal crest. The posterior ethmoidal artery can be found about Figure 4 Picture demonstrating clips on the sphenopalatine artery. (Kindly supplied by G. McGarry, Glasgow.) a further 12 mm posteriorly. The artery is then clipped and divided and/or cauterized. Care must be taken to avoid damage to the optic nerve which lies in very close proximity to the posterior ethmoidal artery. The wound is irrigated, a small drain inserted and closed. Internal maxillary artery ligation This has been mostly superseded by endoscopic sphenopalatine artery ligation. Traditionally the artery is approached by an incision in the buccal mucosa to gain entry into the maxillary sinus via the canine fossa (CaldwelleLuc approach). The back wall of the maxillary sinus is opened to reveal the pterygopalatine fossa. Here the neurovascular bundles are encountered, the internal maxillary artery and any branches identified and ligated or cauterized. External carotid artery ligation Rarely performed, this procedure still has a role in refractory bleeding not controlled by other means. The artery is approached via a neck incision, the carotid vessels are found medial to the sternocleidomastoid muscle which is retracted laterally. The external artery must be differentiated from the internal carotid artery by identification of at least two branches, before ligation. Septal surgery Septoplasty and submucous resection (SMR) have a role in epistaxis management. Elevating the mucoperiosteum from the septum interrupts the blood supply here and provides effective bleeding control. 10 Straightening of the nasal septum is a useful adjunct for other procedures where a deviated septum makes access difficult to assess where the bleeding is coming from and to manage it. Arterial embolization Selective angiography and embolization of external carotid arterial branches is an effective and comparatively successful (80e90%) alternative to surgical arterial ligation. It is performed by an experienced interventional radiologist under local anaesthetic. Contraindications include severe atherosclerotic disease, untreated coagulopathies and allergy to contrast material. The SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.

6 very easily causing recurrent epistaxis. Chronic respiratory and GI bleeding leads to serious health problems which can be life threatening so many of these patients are frail and extra care is needed in managing their epistaxis. As well as traditional cautery and nasal packing, other treatments include laser ablation of the telangiectasia s, septodermoplasty (split skin grafting), and closure of the nasal cavity e Young s procedure. Permanent surgical closure of the nasal cavity prevents bleeding by removing desiccating airflow which is thought to lead to rupture of the fragile telangiectasias. A Figure 5 Intra-oral mucosal telangiectasia on hard palate in a patient with hereditary haemorrhagic telangiectasia. (Reproduced care of: Herbert L, Fred, MD and Hendrik A. van Dijk.) risk of serious cerebrovascular injury is around 4%. 11 The choice of surgical ligation or embolization depends on numerous factors including patient status, availability of personnel and local resources. Medical therapies The usefulness of locally applied haemostatic agents in epistaxis is currently under review in a Cochrane collaboration. 12 Products include fibrin-based agents which are typically packaged as a two-vial system containing fibrinogen, thrombin, factor XIII and calcium. Other agents include gelatin, collagen, and cellulose. Floseal is a gelatin and thrombin combination which can be used for anterior and posterior epistaxis. It is a costly alternative to traditional methods of cautery and nasal packing but can be an effective second-line treatment particularly in frail patients for whom a general anaesthetic is risky. 13 Hereditary haemorrhagic telangiectasia (HHT) HHT, also known as OslereRendueWeber disease is an autosomal dominant genetic disease characterized by the presence of malformed, ectatic vessels in the skin, mucosa and viscera (Figure 5). The small telangiectasias in the nasal cavity rupture REFERENCES 1 Petruson B, Rudin R. The frequency of epistaxis in a male population sample. Rhinol 1975; 13: 129e33. 2 Watkinson JC. Epistaxis. In: Mackay IS, Bull TR, eds. Scott Brown s otolaryngology, 18. London: Butterworths, 1997; 5e7. 3 Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl 1996; 78: 4444e6. 4 Nunez DA, McClymont LG, Evans RA. Epistaxis: a study of the relationship with weather. Clin Otolaryngol 1990; 15: 49e51. 5 Manfredini R, Portaluppi F, Salmi R, Martini A, Gallerani M. Circadian variation in onset of epistaxis: analysis of hospital admissions. Br Med J 2000; 321: Benninger MS. Epistaxis and its relationship to handedness with use of intranasal steroid spray. Ear Nose Throat J 2008 Aug; 87: 463e5. 7 Oneal RM, Beil Jr RJ, Schlesinger J. Surgical anatomy of the nose. Clin Plast Surg 1999; 32: 145e81. 8 Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci 1995 Aug; 20: 305e7. 9 Schlegel-Wagner C, Siekmann U, Linder T. Non-invasive treatment of intractable posterior epistaxis with hot-water irrigation. Rhinol 2006 Mar; 44: 90e3. 10 Cumberworth VL, Narula AA, Bradley PJ. Prospective study of two management strategiesforepistaxis. JRCollSurgEdinb1991; 36: 259e Cullen MM, Tami TA. Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. Otolaryngol Head Neck Surg 1998 May; 118: 636e Kullar P, Weerakkody R, Cathcart R, Yates P. Locally applied haemostatic agents in the management of acute epistaxis (nosebleeds). Cochrane Database Syst Rev 2011;. CD Issue 10. Art. No.:CD Cote D, Barber B, Diamond C, Wright E. FloSeal hemostatic matrix in persistent epistaxis: prospective clinical trial. J Otolaryngol Head Neck Surg 2010 Jun; 39: 304e38. ˇ SURGERY 30: Ó 2012 Elsevier Ltd. All rights reserved.