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Three Part Question

[In patients with anterior epistaxis] does [the use of local ice or other cooling method rather than pressure alone to the nose] give [decrease in blood loss]?

Clinical Scenario

A 24 year old office worker attends the Primary Care Emergency Centre with a spontaneous epistaxis. He explains this occurred suddenly whilst sitting at his desk this morning and it has not responded to simply pinching the nose. You wonder whether cooling the nose would help? Two methods are suggested for people who have no underlying causes, namely sucking ice cubes, or placing an ice pack on the nape of the neck. There is evidence to suggest that both produce reflex vasoconstriction in the nasal mucosa, and hence may help to achieve haemostasis.

Search Strategy

Medline 1966- week 3/09/04 using the Ovid interface.
[exp EPISTAXIS/ OR epistaxis.af OR nosebleed.af OR (nasal adj haemorrhage).af OR (nose adj5 bleed$).af OR (nasal adj5 bleed$).af OR (nasal adj hemorrhage).af] AND [exp ice OR ice.af OR exp cold OR cold.af OR cool$.af OR freez$.af OR exp temperature OR temperature.af OR thermal.af] LIMIT to human.

Search Outcome

Altogether 68 papers were found of which one addressed the three-part question, another two are mentioned in the discussion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Conolly WB et al, 1972, Australia	28 patients with epistaxis Cryogel packs at 30F applied to forehead	Clinical Trial	Cessation of bleeding	22/28 stopped bleeding, other 6 required packing and admission	No control group Small numbers Cessation bleeding only measure , no time factor considered No mention if pressure applied

Comment(s)

This study is difficult to interpret as there is no control group. We cannot know how many of the bleeds would have stopped spontaneously. The additional benefit from the cold packs is therefore unknown. Porter (2) in 1971 showed that sucking ice cubes caused reflex vasconstriction of nasal vessels. Dost and Polyzoidis in 1992 showed that a reduction in blood flow to nasal mucosa when ice packs were applied to the neck (1). These support the theory that the use of cooling the nasal mucosa by local or near-local methods would reduce blood flow and epistaxis.

Clinical Bottom Line

There is little evidence to support the use of ice packs in clinical studies of patients with epistaxis.

References

1. Dost P, Polyzoidis T. Benefit of the ice pack in the treatment of nosebleed. [German]. HNO 1992;40(1):25-7.
2. Porter MJ. A comparison between the effect of ice packs on the forehead and ice cubes in the mouth on nasal submucosal temperature. Rhinology 1991;29(1):11-5.
3. Conolly WB, Paltos N, Tooth RM. Cold Therapy- An improved method Med J Aust 1972;2(8):424-5.