• 
• 

Three Part Question

In [children with spontaneous epistaxis and no underlying disease] is [silver nitrate cautery better than nasal antiseptic cream] at [stopping bleeding and preventing recurrences]?

Clinical Scenario

A child 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 silver nitrate cautery or application of nasal antiseptic cream is the best method of obtaining haemostasis.

Search Strategy

Medline 1966-12/00 using the OVID interface.
{(exp epistaxis OR epistaxis.mp OR nosebleed$.mp) OR [(exp hemorrhage OR hemorrhage.mp OR haemorrhage.mp OR bleed$.mp) AND (exp nose OR nose.mp OR exp nasal mucosa OR nasal mucosa.mp OR nasal.mp OR nares.mp)]} AND (exp cautery OR cauter$.mp OR exp silver nitrate OR nasal cautery.mp OR exp anti-infective agents OR anti-infective agents.mp) LIMIT to human AND english.

Search Outcome

Altogether 198 papers found of which 196 were irrelevant or of insufficient quality. The remaining two papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ruddy J et al, 1991, UK	48 consecutive children with anterior epistaxis attending an emergency department. Antiseptic nasal carrier cream (Naseptin) vs silver nitrate cautery	PRCT	Recurrent epistaxis rate	50% vs 46% (no significant difference)	Low power
Murthy P et al, 1999, UK	64 consecutive patients with recurrent epistaxis attending an outpatients clinic Antiseptic nasal carrier cream (Naseptin) alone vs silver nitrate cautery and antiseptic cream	PRCT	Recurrent epistaxis rate	9% vs 11% (p=0.7569)	14 lost to follow-up

Comment(s)

This BET combines two patient groups - children with primary anterior epistaxis at first presentation and children with recurrent epitaxis. The final outcome being the same - stopping any further bleeds.

Clinical Bottom Line

Cautery and naseptin are equally effective. Given the ease of application naseptin is the treatment of choice.

References

1. Ruddy J, Proops DW, Pearman K, et al. Management of epistaxis in children. Int J of Pediatr Otorhinolaryngol 1991;21(2):139-42.
2. Murthy P, Nilssen EL, Rao S, et al. A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Otolaryngol Allied Sci 1999;24(3):228-31.