Supplement
Otolaryngology–
Head and Neck Surgery
Clinical Practice Guideline: Nosebleed 2020, Vol. 162(1S) S1–S38
Ó American Academy of
Otolaryngology–Head and Neck
(Epistaxis) Surgery Foundation 2020
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DOI: 10.1177/0194599819890327
http://otojournal.org
David E. Tunkel, MD1, Samantha Anne, MD, MS2,
Spencer C. Payne, MD3, Stacey L. Ishman, MD, MPH4,
Richard M. Rosenfeld, MD, MPH, MBA5, Peter J. Abramson, MD6,
Jacqueline D. Alikhaani7, Margo McKenna Benoit, MD8,
Rachel S. Bercovitz, MD, MS9, Michael D. Brown, MD, MSc10,
Boris Chernobilsky, MD11, David A. Feldstein, MD12,
Jesse M. Hackell, MD13, Eric H. Holbrook, MD14,
Sarah M. Holdsworth, MSN, APRN15, Kenneth W. Lin, MD, MPH16,
Meredith Merz Lind, MD17, David M. Poetker, MD, MA18,
Charles A. Riley, MD19, John S. Schneider, MD, MA20,
Michael D. Seidman, MD21,22,23, Venu Vadlamudi, MD24,
Tulio A. Valdez, MD25, Lorraine C. Nnacheta, MPH, DrPH26,
and Taskin M. Monjur26
Sponsorships or competing interests that may be relevant to content are dis- minimize the potential harms of nosebleeds or interventions
closed at the end of this article. to treat nosebleeds.
The target patient for the guideline is any individual aged 3
Abstract years with a nosebleed or history of nosebleed who needs
Objective. Nosebleed, also known as epistaxis, is a common medical treatment or seeks medical advice. The target audi-
problem that occurs at some point in at least 60% of people ence of this guideline is clinicians who evaluate and treat
in the United States. While the majority of nosebleeds are patients with nosebleed. This includes primary care provi-
limited in severity and duration, about 6% of people who ders such as family medicine physicians, internists, pediatri-
experience nosebleeds will seek medical attention. For the cians, physician assistants, and nurse practitioners. It also
purposes of this guideline, we define the target patient with includes specialists such as emergency medicine providers,
a nosebleed as a patient with bleeding from the nostril, nasal otolaryngologists, interventional radiologists/neuroradiolo-
cavity, or nasopharynx that is sufficient to warrant medical advice gists and neurointerventionalists, hematologists, and cardiol-
or care. This includes bleeding that is severe, persistent, and/or ogists. The setting for this guideline includes any site of
recurrent, as well as bleeding that impacts a patient’s quality of evaluation and treatment for a patient with nosebleed,
life. Interventions for nosebleeds range from self-treatment including ambulatory medical sites, the emergency depart-
and home remedies to more intensive procedural interven- ment, the inpatient hospital, and even remote outpatient
tions in medical offices, emergency departments, hospitals, encounters with phone calls and telemedicine. Outcomes to
and operating rooms. Epistaxis has been estimated to be considered for patients with nosebleed include control
account for 0.5% of all emergency department visits and up of acute bleeding, prevention of recurrent episodes of nasal
to one-third of all otolaryngology-related emergency bleeding, complications of treatment modalities, and accu-
department encounters. Inpatient hospitalization for aggres- racy of diagnostic measures.
sive treatment of severe nosebleeds has been reported in
0.2% of patients with nosebleeds. This guideline addresses the diagnosis, treatment, and pre-
vention of nosebleed. It focuses on nosebleeds that com-
Purpose. The primary purpose of this multidisciplinary guide- monly present to clinicians via phone calls, office visits, and
line is to identify quality improvement opportunities in the emergency room encounters. This guideline discusses first-
management of nosebleeds and to create clear and action- line treatments such as nasal compression, application of
able recommendations to implement these opportunities in vasoconstrictors, nasal packing, and nasal cautery. It also
clinical practice. Specific goals of this guideline are to pro- addresses more complex epistaxis management, which
mote best practices, reduce unjustified variations in care of includes the use of endoscopic arterial ligation and interven-
patients with nosebleeds, improve health outcomes, and tional radiology procedures. Management options for 2
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S2 Otolaryngology–Head and Neck Surgery 162(1S)
special groups of patients—patients with hereditary hemor- should perform, or should refer to a clinician who can per-
rhagic telangiectasia syndrome and patients taking medica- form, nasal endoscopy to identify the site of bleeding and
tions that inhibit coagulation and/or platelet function—are guide further management in patients with recurrent nasal
included in this guideline. bleeding, despite prior treatment with packing or cautery,
or with recurrent unilateral nasal bleeding. (8) The clinician
This guideline is intended to focus on evidence-based quality
should treat patients with an identified site of bleeding with
improvement opportunities judged most important by the
an appropriate intervention, which may include one or
guideline development group. It is not intended to be a
more of the following: topical vasoconstrictors, nasal cau-
comprehensive, general guide for managing patients with
tery, and moisturizing or lubricating agents. (9) When nasal
nosebleed. In this context, the purpose is to define useful
cautery is chosen for treatment, the clinician should
actions for clinicians, generalists, and specialists from a vari-
anesthetize the bleeding site and restrict application of cau-
ety of disciplines to improve quality of care. Conversely, the
tery only to the active or suspected site(s) of bleeding. (10)
statements in this guideline are not intended to limit or
The clinician should evaluate, or refer to a clinician who can
restrict care provided by clinicians based on their experi-
evaluate, candidacy for surgical arterial ligation or endovas-
ence and assessment of individual patients.
cular embolization for patients with persistent or recurrent
Action Statements. The guideline development group made bleeding not controlled by packing or nasal cauterization.
recommendations for the following key action statements: (1) (11) In the absence of life-threatening bleeding, the clinician
At the time of initial contact, the clinician should distinguish should initiate first-line treatments prior to transfusion,
the nosebleed patient who requires prompt management reversal of anticoagulation, or withdrawal of anticoagulation/
from the patient who does not. (2) The clinician should antiplatelet medications for patients using these medications.
treat active bleeding for patients in need of prompt manage- (12) The clinician should assess, or refer to a specialist who
ment with firm sustained compression to the lower third of can assess, the presence of nasal telangiectasias and/or oral
the nose, with or without the assistance of the patient or mucosal telangiectasias in patients who have a history of
caregiver, for 5 minutes or longer. (3a) For patients in recurrent bilateral nosebleeds or a family history of recur-
whom bleeding precludes identification of a bleeding site rent nosebleeds to diagnose hereditary hemorrhagic telan-
despite nasal compression, the clinician should treat ongoing giectasia syndrome. (13) The clinician should educate
active bleeding with nasal packing. (3b) The clinician should patients with nosebleeds and their caregivers about preven-
use resorbable packing for patients with a suspected bleed- tive measures for nosebleeds, home treatment for noseble-
ing disorder or for patients who are using anticoagulation or eds, and indications to seek additional medical care. (14)
antiplatelet medications. (4) The clinician should educate the The clinician or designee should document the outcome of
patient who undergoes nasal packing about the type of pack- intervention within 30 days or document transition of care
ing placed, timing of and plan for removal of packing (if not in patients who had a nosebleed treated with nonresorbable
resorbable), postprocedure care, and any signs or symptoms packing, surgery, or arterial ligation/embolization.
that would warrant prompt reassessment. (5) The clinician
should document factors that increase the frequency or The policy level for the following recommendation, about
severity of bleeding for any patient with a nosebleed, includ- examination of the nasal cavity and nasopharynx using nasal
ing personal or family history of bleeding disorders, use of endoscopy, was an option: (7b) The clinician may perform, or
anticoagulant or antiplatelet medications, or intranasal drug may refer to a clinician who can perform, nasal endoscopy to
use. (6) The clinician should perform anterior rhinoscopy to examine the nasal cavity and nasopharynx in patients with
identify a source of bleeding after removal of any blood clot epistaxis that is difficult to control or when there is concern
(if present) for patients with nosebleeds. (7a) The clinician for unrecognized pathology contributing to epistaxis.
1
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; 2Cleveland Clinic,
Cleveland, Ohio, USA; 3University of Virginia School of Medicine, Charlottesville, Virginia, USA; 4Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio, USA; 5SUNY Downstate Medical Center, Brooklyn, New York, USA; 6Ear Nose Throat of Georgia, Atlanta, Georgia, USA; 7Consumers United for
Evidence-Based Healthcare, Baltimore, Maryland, USA; 8University of Rochester, Rochester, New York, USA; 9Ann & Robert H. Lurie Children’s Hospital of
Chicago, Chicago, Illinois, USA; 10Michigan State University, Grand Rapids, Michigan, USA; 11NYU Langone Health, New York, New York, USA; 12University
of Wisconsin, Madison, Wisconsin, USA; 13Pomona Pediatrics, Boston Children’s Health Physicians, Pomona, New York, USA; 14Massachusetts Eye and Ear,
Boston, Massachusetts, USA; 15Emory University Hospital Midtown, Atlanta, Georgia, USA; 16Georgetown University, Washington, DC, USA; 17Nationwide
Children’s Hospital/The Ohio State University, Columbus, Ohio, USA; 18Medical College of Wisconsin, Milwaukee, Wisconsin, USA; 19Weill Cornell Medical
College, New York, New York, USA; 20Washington University School of Medicine, St Louis, Missouri, USA; 21AdventHealth Medical Group, Celebration,
Florida, USA; 22University of Central Florida, Orlando, Florida, USA; 23University of South Florida, Tampa, Florida, USA; 24Inova Alexandria Hospital,
Alexandria, Virginia, USA; 25Stanford University, Palo Alto, California, USA; 26American Academy of Otolaryngology–Head and Neck Surgery Foundation,
Alexandria, Virginia, USA.
Corresponding Author:
David E. Tunkel, MD, Johns Hopkins School of Medicine, 601 N Caroline St, Rm 6161B, Baltimore, MD, 21287, USA.
Email: dtunkel@jhmi.edu
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Tunkel et al S3
Keywords promote best practices, reduce unjustified variations in the
epistaxis, nosebleed, nasal packing, nasal cautery, hereditary care of patients with nosebleeds, improve health outcomes,
hemorrhagic telangiectasia (HHT) and minimize the potential harms of nosebleeds and/or
interventions to treat nosebleeds.
Received June 10, 2019; accepted November 4, 2019. The target patient for the guideline is any individual
aged 3 years with a nosebleed or history of nosebleed.
Children aged \3 years are excluded, as the guideline
development group (GDG) felt that very young, otherwise
Introduction healthy children rarely required evaluation for nosebleeds.
The group also recognized that literature informing treat-
Nosebleed, also known as epistaxis, is a common problem ment of nosebleeds in infants and toddlers was scant.
that occurs at some point in at least 60% of people in the Additionally, while bleeding from the nose may occur sec-
United States.1 While the majority of nosebleeds are limited ondary to a variety of systemic diseases and head and neck
in severity and duration, about 6% of people who experi- disorders, this guideline does not apply to patients who have
ence nosebleeds will seek medical attention.2 For the pur- a diagnosed bleeding disorder, tumors of the nose or naso-
poses of this guideline, we define the target patient with a pharynx, vascular malformations of the head and neck, a
nosebleed as a patient with bleeding from the nostril, nasal history of recent facial trauma, or who have undergone nasal
cavity, or nasopharynx that is sufficient to warrant medical and/or sinus surgery in the past 30 days. The management of
advice or care. This includes bleeding that is severe, persis- nosebleeds in such excluded patients centers on the treatment
tent, and/or recurrent, as well as bleeding that impacts a of these causative factors, and the recommendations within
patient’s quality of life (QOL). this guideline may not consistently apply in such cases.
Interventions for nosebleeds range from self-treatment Patients with intranasal telangiectasias associated with HHT
and home remedies to more intensive procedural interven- are not excluded, as the GDG noted opportunity for improved
tions in medical offices, emergency departments, hospitals, care of these patients with specific recommendations based
and operating rooms. Epistaxis has been estimated to on studies of patients with HHT and epistaxis.
account for 0.5% of all emergency department visits and up The target audience of this guideline is clinicians who
to one-third of all otolaryngology-related emergency depart- evaluate and treat patients with nosebleed. This includes pri-
ment encounters.1,3,4 Inpatient hospitalization for aggressive mary care providers, such as family medicine physicians,
treatment of severe nosebleeds has been reported in 6% of internists, pediatricians, physician assistants, and nurse prac-
patients treated for nosebleeds in emergency departments.4 titioners. It also includes specialists, such as emergency
The comprehensive management of nosebleeds was medicine providers, otolaryngologists, interventional radiol-
recently addressed in 2 sets of publications: a series of ogists/neuroradiologists and neurointerventionalists, hema-
guidelines on aspects of epistaxis management in France tologists, and cardiologists. A plain language summary
and an ‘‘audit’’ of epistaxis management from the United accompanies this clinical practice guideline for the use of
Kingdom. These 2 sets of publications addressed the initial patients and nonclinicians. The setting for this guideline
evaluation of patients with nosebleeds, the use of packing includes any site of evaluation and treatment for a patient
and cautery as initial treatments, the care of nosebleeds in with nosebleed, including ambulatory medical sites, the
patients who are taking medication that impair clotting, the emergency department, the inpatient hospital, and even out-
use of surgical and endovascular procedures for refractory patient remote encounters with phone calls and telemedicine
epistaxis, and the management of nosebleeds in patients (Table 1). Outcomes to be considered for patients with
with comorbid conditions, such as hypertension or heredi- epistaxis include control of acute bleeding, prevention of
tary hemorrhagic telangiectasia (HHT) syndrome.5-12 This recurrent episodes of nasal bleeding, complications of treat-
multidisciplinary clinical practice guideline has been devel- ment modalities, and accuracy of diagnostic measures.
oped with the guideline development process of the Other considerations are cost, time, and efficiency of diag-
American Academy of Otolaryngology–Head and Neck nostic and treatment measures in patients with nosebleed.
Surgery Foundation (AAO-HNSF) to create evidence-based This guideline addresses the diagnosis, treatment, and
recommendations to improve quality and reduce variations prevention of nosebleed. It focuses on nosebleeds that com-
in the care of patients with nosebleeds.13 monly present to clinicians through phone calls, office
visits, and emergency room encounters. This guideline dis-
Guideline Scope and Purpose cusses first-line treatments, such as nasal compression,
The purpose of this multidisciplinary guideline is to identify application of vasoconstrictors, nasal packing, and nasal
quality improvement opportunities in the management of cautery. It also addresses more complex epistaxis manage-
nosebleeds and to create clear and actionable recommenda- ment, which includes the use of endoscopic arterial ligation
tions to implement these opportunities in clinical practice. and interventional radiology procedures. Management
Expert consensus to fill evidence gaps, when used, is expli- options for 2 special groups of patients, patients with HHT
citly stated and supported with a detailed evidence profile and patients taking medications that inhibit coagulation and/
for transparency. Specific goals of this guideline are to or platelet function, are included in this guideline.
, 10976817, 2020, S1, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599819890327 by EBMG ACCESS - ETHIOPIA, Wiley Online Library on [16/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
S4 Otolaryngology–Head and Neck Surgery 162(1S)
Table 1. Applying the Nosebleed Clinical Practice Guideline: Target Patient and Practice Settings.
Target Patient Exclusions Practice Settings/Encounter Type
Age 3 years Age \3 years Outpatient office or clinic
Nosebleed that is severe, persistent, or Nasal or nasopharyngeal tumor Emergency department
recurrent or affects quality of life Vascular malformation of the head and Hospital (wards, radiology suites, operating
neck rooms)
Diagnosed bleeding disorder Phone call encounters
Recent facial trauma Emails/texts
Recent sinus and/or nasal surgery Telemedicine
This guideline is intended to focus on evidence-based between ages 70 and 79 years.4 A review of Medicare
quality improvement opportunities judged most important claims data showed an increase in emergency department
by the working group. It is not intended to be a comprehen- visits for epistaxis with advanced age, with patients aged 66
sive, general guide for managing patients with nosebleed. In to 75 years 1.36 times more likely, patients aged 76 to 85
this context, the purpose is to define useful actions for clini- years 2.37 times more likely, and patients aged .85 years
cians, generalists, and specialists from a variety of disciplines 3.24 times more likely to present to the emergency room
to improve quality of care. Conversely, the statements in this than patients \65 years old.1 Although some studies report
guideline are not intended to limit or restrict care provided a higher incidence of nosebleeds in male patients,4,19 other
by clinicians based on their experience and assessment of studies have not demonstrated any gender preponderance.20
individual patients. Nosebleeds are very common in childhood, with 3 out of
4 children experiencing at least 1 episode of epistaxis
according to 1 recent report.5 Nosebleeds in otherwise
Health Care Burden
healthy children most often are limited bleeds from the
Epidemiology anterior nasal septum and can be caused or aggravated by
As noted previously, nearly 60% of the population experi- digital trauma, crusting from nasal inflammation, or nasal
ence a nosebleed at least once. One-tenth of these patients foreign bodies. Persistent or recurrent nasal bleeding in ado-
eventually seek medical advice/intervention, and 0.16% will lescent males, particularly unilateral nosebleed in the pres-
need hospitalization.14 Many people with nosebleed experi- ence of nasal obstruction, could suggest the diagnosis of
ence recurrent minor bleeding episodes and may not present juvenile nasopharyngeal angiofibroma, an uncommon histo-
for medical attention; instead, they may use home treat- logically benign but locally invasive vascular tumor.21 A
ments or simply observe without need for intervention. One recent study of emergency department databases in 4 states
survey has shown that nearly one-third of households have showed that children who presented with epistaxis had a
1 household members who experience these minor recur- mean age of 7.5 years and 57.4% were male.22 Procedures
rent nosebleeds.15 to control epistaxis were required in 6.9% of these children,
A recent study based on data from the Nationwide with 93.5% of these procedures coded as simple anterior
Emergency Department Sample (NEDS) from 2009 to 2011 epistaxis control (limited cautery and/or packing).22
identified 1.2 million emergency department visits for About 5% to 10% of nosebleeds are from posterior sites on
epistaxis in the United States, thus representing 0.32% of the lateral nasal wall or nasal septum not visible by anterior
all emergency department encounters.16 The mean age of rhinoscopy, known as posterior epistaxis. Posterior epistaxis is
patients treated for epistaxis in the emergency department more common in older patients and often more difficult to
was 53.4 years, and 52.7% were male. In the audit of epis- control.2 One series demonstrated that posterior epistaxis
taxis cases managed in the United Kingdom during accounted for 5% of all patients with nosebleed treated in the
November 2016, 13.9% of patients treated for epistaxis pre- emergency department or admitted to the hospital.23
sented again for treatment within 30 days.17 These investi- While epistaxis is usually spontaneous without obvious
gators also found a 30-day all-cause mortality rate of 3.4% cause, some nosebleeds can be associated with systemic
in these patients. hematologic, hepatic, renal, genetic, or cardiovascular dis-
Nosebleeds seem to affect the population in a bimodal eases. Forty-five percent of patients hospitalized for epis-
age distribution, with more nosebleeds seen in children and taxis had systemic illnesses that likely contributed to the
the elderly.18 A review of the National Hospital Ambulatory nosebleeds.24 In the NEDS study of patients with epistaxis,
Medical Care Survey from 1992 to 2001 demonstrated this 15% of patients were on long-term anticoagulation; 33%
bimodal age distribution of patients presenting to emergency had a history of hypertension; and 0.9% had an underlying
departments for treatment of epistaxis, with peak frequency coagulation disorder.16 The often-assumed causal relation-
of bleeding in children \10 years of age and in adults ship between epistaxis and hypertension is not well
