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Three Part Question

In [patients presenting to the Emergency Department with anterior epistaxis] does [the use of anti-septic nasal cream with or without silver nitrate cautery] reduce [recurrence of epistaxis or infective complications]?

Clinical Scenario

A 32 year old woman presents to the Emergency Department with epistaxis which she cannot stop herself. First aid measures in triage cause haemostasis. She is haemodynamically stable, her observations are within normal limits and she is not taking any anti-coagulation or anti-platelet medications. This is her first episode of epistaxis. The Ear, Nose and Throat specialist advises you to prescribe anti-septic nasal cream for one week “to prevent recurrence or complications.” You are unsure whether this treatment will reduce the risk of recurrent epistaxis or infective complications.

Search Strategy

The EMBASE and MedLine databases were searched via the Ovid interface. Search terms were as follows:
"naseptin".m_titl OR "Chlorhexidine with neomycin".m_titl. OR "Chlorhexidine and neomycin".m_titl. OR "antiseptic".m_titl. OR "anti-septic".m_titl. AND "epistaxis".m_titl. OR "nose bleed".m_titl. OR "nosebleed".m_titl.

A search of the BestBET and Cochrane databases was also conducted.

Search Outcome

A total of 9 papers, one BestBET and one Cochrane review were found. After review of the abstracts and full texts, including cross referencing the bibliographies of potentially relevant papers, 7 were deemed relevant and of suitable quality for inclusion. Of these, one was a randomised, controlled trial, five were prospective, randomised studies and one was a retrospective case review.

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. 1991 United Kingdom	48 paediatric patients with epistaxis	Prospective, randomised trial with treatment options of naseptin cream twice daily for 4 weeks or silver nitrate nasal cautery.	No bleeding during study period 50% reduction in epistaxis <50% reduction in epistaxis	12/24 naseptin v 13/24 cautery 4/24 naseptin v 3/25 cautery 7/24 naseptin v 6/24 cautery	3 patients lost to follow up
Murthy P, Nilssen EL, Rao S, et al. 1999 United Kingdom	50 adult and paediatric patients with recurrent epistaxis	Prospective, randomised trial with treatments of naseptin cream only for 2 weeks or silver nitrate cautery followed by Naseptin cream for 2 weeks	Epistaxis recurrence prevented Decrease in epistaxis frequency Improvement in symptoms	14/22 naseptin only v 16/28 naseptin & cautery 6/22 naseptin only v 9/28 naseptin & cautery 91% naseptin only v 89% naseptin & cautery p= 0.7569 with no statistically significant difference between age groups p=1	Patients with acute epistaxis were excluded from the study. No blinding for participants or researchers. Poor compliance with study protocol leading to 14/64 recruited patients excluded from the study.
Kubba H, MacAndie C, Botma M, et al. 2001 United Kingdom	103 paediatric patients with recurrent epistaxis	Prospective, randomised trial, allocated to treatments of naseptin cream for 4 weeks to both nostrils or no treatment	Proportion of patients with no epistaxis in 4 weeks	55% naseptin v 29% no treatment p<0.05. Relative risk reduction of 47% (95% confidence interval 9-69%). Absolute risk reduction 26% (95% confidence interval 12-40%). NNT 3.8 (95% confidence interval 2.5-8.5).	No true blinding. Only 83 participants were analysed on a treatment received analysis, meaning the study is underpowered.
Robertson S, Kubba H. 2008 United Kingdom	60 paediatric patients with recurrent epistaxis	Retrospective case review of patients who were randomised 5 years prior to the study to naseptin cream for 4 weeks or no treatment.	Ongoing, recurrent epistaxis Emergency Department attendance Referral back to ENT clinic	66% Naseptin cream v 64% no treatment 5 children treated with Naseptin followed by cautery in ENT clinic 8 children overall	28 of the originally recruited 88 patients were not contactable for this follow up study. Bleeding frequency was assessed from patient memory retrospectively, rather than prospectively recorded.
Calder N, Kang S, Fraser L, et al. 2009 United Kingdom	109 patients with epistaxis and visible anterior septal vessels	Double-blind randomised control trial, with patients randomised to receive either ‘treatment’ silver nitrate cautery followed by antiseptic cream for 4 weeks, or ‘control’ sham cautery followed by antiseptic cream for 4 weeks.	Primary outcome: no reported bleeding in the 4 weeks before follow up	21/46 (45.7%) in treatment group had complete resolution of symptoms. 14/47 (29.8%) in control group had complete resolution of symptoms.	Results available for only 93 of the 109 patients (85%) as 16 patients were lost to follow up with equal numbers in the treatment and control group. Some inaccuracy with timing of follow up as some patients were followed up later than 2 months, which could lead to inaccuracy regarding symptom resolution/recurrence.
			Secondary outcome: subjective reduction in symptoms.	42/46 (91.%) in treatment group had improvement in symptoms. 33/47 (70.2%) in control group had improvement in symptoms. NNT 4.7
Zhang J, Qiu R 2012 China	82 consecutive patients with recurrent anterior epistaxis	Prospective, randomised study, with patients randomly assigned to receive either liquid paraffin plus antiseptic cream ‘Group 1 (Nasal cream)’, or Nd:YAG laser photocoagulation ‘Group 2 (Laser photocoagulation)’.	Bleeding intensity and frequency 4 weeks after treatment		Data for 2 patients was lost.
			Bleeding intensity 12 weeks after treatment
			Bleeding frequency 12 weeks after treatment	No reported bleeding at 12 weeks: Nasal cream 40% v Laser photocoagulation 85%
			Outcome scores (no bleeding; reduced bleeding; same bleeding; worse bleeding) 4 weeks after treatment	Outcome score at 4 weeks showed no statistically significant difference between groups.
			Outcome scores (no bleeding; reduced bleeding; same bleeding; worse bleeding) 12 weeks after treatment	Outcome score at 12 weeks showed a statistically significant difference between the groups. Rank outcome score after 12 weeks: Nasal cream 49.6 v Laser photocoagulation 31.4 P=<0.01
			Participant’s perception of discomfort during the management	Level of pain associated with procedure/ management for both groups was tolerated.
			Complications	No complications reported for either group.
Zhang J, Qiu R 2015 China	80 consecutive patients with recurrent anterior epistaxis.	Prospective, randomised, single-blinded study, with patients randomly allocated to either: Group 1 - liquid paraffin + antiseptic cream (containing 0.5% neomycin and 0.1% chlorhexidine) for 4 weeks, or Group 2 - Nd:YAG laser photocoagulation once, with no other additional agents.	Intensity of bleeding		Data for one patient from group 2 was lost. One patient from group 1 died (cause not mentioned).
			Number of applications of liquid paraffin or Nd:YAG laser
			Frequency of nasal bleeding	No reported bleeding at 2 years: Nd:YAG laser therapy group 86% v control group (nasal cream) 31%. Outcome score at 2 years shows a significant difference between the two groups: Mean rank nasal cream = 45.03 Mean rank Nd:YAG laser therapy = 25.97
			Pain experienced during haemostasis
			Complications	Both groups had no complications.

Comment(s)

Epistaxis is a common problem for both paediatric and adult patients, although most bleeding is minor and self-limiting. A cohort of patients suffer from more severe and/or repeated epistaxis, resulting in their presentation to the Emergency Department (ED). The cause of epistaxis is usually idiopathic, but it can occur as a result of localised trauma (including digital trauma), telangiectatic vessels, nasal vestibulitis or coagulopathy. Once the acute bleeding is stopped, treatment options include conservative management, localised application of antiseptic nasal cream (often sold under the brand name ‘Naseptin’), and silver nitrate cautery or electrocautery. Conservative management reduces cost, patient attendance and required procedures, although this may not be an acceptable treatment regimen to patients. Kubba, MacAndie and Botma demonstrate that conservative management is inferior to treatment with nasal cream.3 Antiseptic nasal cream reduces crusting and nasal vestibulitis, whilst also eliminating nasal Staphylococcus aureus, which has been shown to cause inflammation and new vessel formation, leading to epistaxis.3 However, treatment can fail as a result of antiseptic nasal cream having little effect on telangiectatic vessels, or due to it failing to relieve vestibulitis as a result of habitual nose picking and recolonisation by bacteria.1 Cautery causes sclerosis of cauterised vessels, replacing them with scar tissue, whilst also leading to nasal mucosa thickening.1 The use of cautery risks perforation of the nasal septum and therefore requires clinicians to be trained in performing this procedure. It is an uncomfortable and sometimes painful procedure, which can be mitigated by the use of local anaesthesia. Cautery can fail due to revascularisation at the margins of the cauterised area and from the resulting vestibulitis as the cauterised area heals.1 Although the articles reviewed in this study focus on the management of epistaxis in the outpatient setting, the results and principles of treatment can be applied to clinical practice in the ED. With most cases of epistaxis resolving spontaneously or from simple first aid measures, the majority (63.6%)8 of patients presenting to the ED with epistaxis are seen and discharged by ED clinicians directly, without the need for specialist review. Understanding treatment principles, including reducing recurrence, is therefore imperative for ED clinicians. Prevention of re-bleeding is one of the treatment goals for both patients and clinicians. Treatment with antiseptic nasal cream has been shown to be more effective than no treatment at all,3 whereas Qureishi and Burton’s 2012 Cochrane review showed that there is no clear evidence that the addition of cautery to anti-septic nasal cream reduces the chance of further episodes of epistaxis.9 Despite this, although cautery is a potentially painful procedure, it is generally well tolerated by paediatric and adult patients,6 especially when 75% silver nitrate is used in preference to 95% silver nitrate.9 Cautery requires a trained clinician to perform the procedure as there are risks associated with this, including perforation of the nasal septum, crusting and vestibulitis which can potentiate the re-bleeding risk. Calder et al. demonstrate that where there are visible anterior nasal septal vessels there is a small, but statistically significant benefit of using cautery alongside anti-septic nasal cream with a NNT of 3.2.5 With antiseptic nasal cream containing active antimicrobial medication, there is a theoretical possibility of a reduction in infective complications. None of the papers reviewed assessed this risk.

Clinical Bottom Line

For patients attending the ED with minor epistaxis which stops in the department, anti-septic nasal cream is an effective treatment to reduce the risk of re-bleeding. The addition of cautery should be used selectively in cases where anterior nasal septal vessels are visible and a trained clinician can perform the procedure with 75% silver nitrate. The benefit of anti-septic nasal cream, with or without silver nitrate cautery, in reducing infective complications cannot be established based on this review.

References

1. Ruddy J, Proops DW, Pearman K, et al. Management of epistaxis in children. Int J Pediatr Otorhinolaryngol 1991;21:139-42
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;24:228-31
3. Kubba H, MacAndie C, Botma M, et al. A prospective single-blind randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol 2001;26:465-8
4. Robertson S, Kubba H. Long term effectiveness of antiseptic cream for recurrent epistaxis in childhood: five-year follow up of a randomised, controlled trial. J Laryngol Otol 2008;122:1084-87
5. Calder N, Kang S, Fraser L, et al. A double-blind randomized controlled trial of management of recurrent nosebleeds in children. Otolaryngology – Head and Neck Surgery 2009; 140, 670-674
6. Zhang J, Qiu R A prospective randomised controlled trial of Nd:YAG laser photocoagulation versus liquid paraffin plus antiseptic cream in the treatment of recurrent epistaxis. Clin Otolaryngol 2012; 37(4):271-275
7. Zhang J, Qiu R Long-term efficacy of Nd:YAG laser photocoagulation vs. liquid paraffin plus antiseptic cream in the treatment of recurrent epistaxis. Eur Arch Otorhinolaryngol 2015; 272:3721-3725
8. Eze N, Lo S, Toma A. Advice given to patients with epistaxis by A&E doctors Emerg Med J 2005; 22:724-725
9. Qureishi A, Burton MJ Interventions for recurrent idiopathic epistaxis (nosebleeds) in children (Review). Cochrane Database of Systematic Reviews 2012, Issue 9. Art.No.:CD004461.