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Three Part Question

In [adults with uncomplicated epistaxis] does [Naseptin cream] [prevent recurrence]

Clinical Scenario

A 44 year old male presents to the ED with primary epistaxis. It has spontaneously resolved. Should Naseptin cream be given on discharge to prevent recurrence?

Search Strategy

Using OVIDsp interface Medline 1946 to 18th August 2014 and Embase 1974 to 2014 August 15 was searched.
((epistaxis or nose bleed) and naseptin).af.

Search Outcome

35 papers found, of which 4 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ruddy J, Proops DW, Pearman K et al 1990 UK	48 patients age 3-14 years.	Randomised into two groups; Group 1 Naseptin cream twice daily both nostrils for 4 weeks. Group 2 Cautery with 75% silver nitrate stick to prominent vessels.	Complete Resolution	Naseptin Group 1 12 patients, Cautery Group 2 13	3 children lost to follow up. Unable to blind either clinician or patient. Small sample size. Study not powered.
			Partial Resolution	Naseptin Group 1 4 patients, Cautery Group 2 3 patients
			Failure	Naseptin Group 1 7 patients, Cautery Group 2 6 patients
			Chi-squared test	No statistically significant difference
Kubba H, Mac Andie C, Botma M et al May 2001 UK	GP referrals to Otolaryngology department for recurrent epistaxis in children aged 1 -16 years. 103 patients included. 52 to control, 51 to treatment.	Children randomly allocated to treatment group consisting of Naseptin cream to both nostrils twice daily for 4 weeks of no treatment group. Powered study analysed on intention to treat analysis. Doctor masked to patient group until after examination and data recorded.	Complete resolution in 4 weeks	Treatment group 26/47 (55%) had no bleeds, control group 12/41 (29%) p<0.05 47% relative risk reduction 95% confidence interval 9-69%	Comparison group received no treatment as no placebo could be identified that would provide no effect. Loss to follow up rate, although telephone contact attempted if patient failed to attend clinic.5 children in the treatment group id not receive the treatment as planned.
			Number needed to treat	3.8 (95% confidence interval 2.5-8.5)
Kara N, Spinou C, Gardiner Q Jan 2008 Uk	Survey to ENT clinicians regarding topical management of anterior epistaxis.	A questionnaire was posted out to all 105 ENT-UK registered trainees or Consultants within Scotland with a 95% response rate.	Most commonly used topical treatment	Naseptin used most commonly by 83% of Consultants and 92% of trainees.	Survey based on clinicians registered with ENT-UK. Possible some ENT clinicians missed from list.
			No topical treatment used	No topical agent in 4%.
			Frequency of Naseptin application	twice a day 46%, three times per day 35%
			Consultants advocated method of Naseptin application	Inserting nozzle of tube into nostril 57%, direct application with patients finger 32%
			Duration of treatment	Two weeks 45%, one week 17%, one month 17%
Murthy P, Nillsen EL, Rao S et al 1999 UK	Between 1994-1996 64 patients with recurrent epistaxis presenting to ENT outpatient clinic. Included children and adults, mean age 34 years.	Patients randomized to two groups. 22 patients in Group A Naseptin cream twice daily for two weeks, 28 patients in Group B cautery then Naseptin cream twice daily for two weeks. 50/64 (75%) of patients complied with Naseptin application and completing post treatment questionnaire.	Complete resolution	14 patients in Naseptin alone group versus 16 patients in cautery and Naseptin group. p=0.76, no statistical significance between two groups.	Study not powered. Randomisation process not detailed. Small sample size.

Comment(s)

There is a distinct lack of adult studies on this topic. Extrapolating the studies in childhood epistaxis with adult studies suggest Naseptin cream is well tolerated and prevents recurrent epistaxis. This is due to its moisturising effect which prevents drying and crusting of the nasal mucosa with dual antiseptic/antibiotic action. Kubba's study confirms the use of Naseptin is superior to no topical treatment to prevent recurrence.

Editor Comment

RB

Clinical Bottom Line

In adult patients with primary epistaxis Naseptin cream should be given for two weeks on discharge to prevent recurrence. However it is worth highlighting Naseptin contains Arachis oil (peanut oil) and is contraindicated in peanut allergy sufferers. Bactroban would be a suitable alternative in this case.

References

1. Ruddy J, Proops DW, Pearman K et al Management of epistaxis in children. International Journal of Pediatric Otorhinolaryngology Oct 1990; 139-142
2. Kubba H, MacAndie C, Botma M et al. A prospective, single-blind, randomised controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clinical Otolaryngology May 2001; 465-468
3. Kara N, Spinou C, Gardiner Q Topical management of anterior epistaxis: a national survey Journal of Otolaryngology Jan 2009; 91-5
4. Murthy P, Nillsen 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 Clinical Otolaryngology Allied Science 1999; 228-31