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Three Part Question

In [adult patients with spontaneous epistaxis and no underlying disease] is [cautery or packing] more effective at [stopping bleeding].

Clinical Scenario

An adult patient 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 packing or cautery is the best method of obtaining haemostasis.

Search Strategy

Medline 1966-10/98 using the OVID interface.
([exp epistaxis OR epistaxis.ti,ab,rw,sh OR nose bleed$.ti,ab,rw,sh] OR {[exp hemorrhage OR hemorrhage$.ti,ab,rw,sh OR haemorrhage$.ti,ab,rw,sh OR bleed$.ti,ab,rw,sh] AND [exp nose OR exp nasal mucosa OR nose.ti,ab,rw,sh OR nasal.ti,ab,rw,sh OR nares.ti,ab,rw,sh]}) AND [pack$.ti,ab,rw,sh OR exp cautery OR cauter$.ti,ab,rw,sh] AND maximally sensitive RCT filter LIMIT to human and english language.

Search Outcome

103 papers found of which 80 irrelevant and 16 of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Toner JG and Walby AP 1990 UK	97 consecutive patients with anterior epistaxis attending the Emergency Department Randomised to either electro-cautery or cautery with silver nitrate	PRCT	Number having further epistaxis	No statistical difference	Low power study.
			Complications	No significant difference
Nicolaides A et al 1991 UK	30 consecutive patients with acute epistaxis in the control vs 33 consecutive patients in the intervention group. Intervention group had visualisation using the operating microscope and hot wire cautery.	Controlled clinical trial	Complete control of bleeding by cautery	82% vs 23%	Not randomised.
			Need for subsequent packing	18% vs 77% (P < 0.001)
			Need for admission for longer than 24h.	27% vs 76%
McGlashan JA et al 1992 UK	40 consecutive adult (> 16y) patients with significant epistaxis of at least 2h duration. Kalostat vs xeroform packs	PRCT	Discomfort of insertion	ns	No power calculation
			Rebleed rate	ns
Quine SM et al 1994 UK	100 consecutive adult (> 16y) patients with acute epistaxis All hot wire cauterised	Observational	Patients sent home immediately	80%	Uncontrolled
Pringle MB et al 1996 UK	83 patients packed with merocel out of 149 patients with epistaxis presenting over 1 year.	Observational	Control of epistaxis	91.5%	Uncontrolled.
			Discomfort of insertion (n=34)	low VAS scores (median 3)

Comment(s)

There is a paucity of good evidence in this area. No head to head trials have been carried out. Hot wire cautery using an operating microscope requires skills unlikely to be found in the emergency department, while nasal packing is easier for the relatively unskilled to perform but is less comfortable for patients.

Clinical Bottom Line

Both cautery and packing can be effective. In the absence of better comparative studies the operator should use the technique with which they are most familiar.

References

1. Toner JG, Walby AP. Comparison of electro and chemical cautery in the treatment of anterior epistaxis. J Laryngol Otol 1990;104:617-618.
2. Nicolaides A, Gray R, Pfleiderer A. A new approach to the management of acute epistaxis. Clin Otolaryngol 1991;16:59-61.
3. McGlashan JA, Walsh MB, Dauod A et al. A comparative study of calcium sodium alginate (Kalostat) and bismuthtribromophenate (xeroform) packing in the management of epistaxis J Laryngol Otol 1992;106:1067-1071.
4. Quine S, Gray RF, Rudd M et al. Microscope and hot wire cautery management of 100 consecutive patients with acute epistaxis - a superior method to traditional packing. J Laryngol Otol 1994;108:845-848.
5. Pringle MB, Beasley P, Brightwell AP. The use of Merocel nasal packs in the treatment of epistaxis. J Laryngol Otol; 1996:543-546.