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Look before you pack: key point in epistaxis management
  1. M K Aneeshkumar,
  2. E Osman,
  3. R Shahab,
  4. N J Roland
  1. Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Aintree, Lower Lane, Liverpool, UK
  1. Correspondence to:
 MrM K Aneeshkumar
 19 Farm Meadow Road, Orrell, Wigan WN5 8TE, UK;


We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term “epistaxis management ladder” for easy understanding of the treatment of epistaxis.

  • A&E, accident and emergency
  • Epistaxis management ladder
  • foreign body granuloma
  • nasal packing

Statistics from

Epistaxis is a common otolaryngology emergency, and is often managed by junior doctors. With the introduction of European working time directives and cross cover on calls, it has been argued that this common and potentially life threatening emergency may be managed by doctors with little training in its management. Nasal packing has been made simple by the introduction of packs such as Merocel and Rapid Rhino, and these can be used effectively to control bleeding by medical personnel without much otolaryngology experience. This case stresses the importance of examination of the nasal cavity before the insertion of the pack to find the site of bleeding and any foreign bodies inserted by the patient to control bleeding.


A 62 year old man presented to the accident and emergency (A&E) department with epistaxis. He was packed in the A&E department with Merocel and later with Vaseline gauze, which helped to stop the bleeding. The patient was admitted for observation. The nasal packs were removed after 48 hours and he was sent home with an outpatient appointment to examine the nose. On review, he did not have any further bleeds, but on fibreoptic endoscopy, some crusts were noted in the right nostril, which were difficult to remove. The patient was given saline douches and reviewed again. On this visit, two cottonwool balls were seen in the right nostril. One was removed in the clinic and the other had to be removed under general anaesthetic. Examination under general anaesthesia showed granulation tissue formation near the foreign body, which was confirmed as foreign body granuloma on histology.


Nasal packing is a common method to control epistaxis. With the introduction of cross cover on call between specialties to achieve the European time directive targets, nasal packing is more frequently performed by trainee staff with less ENT experience. Patients presenting with epistaxis should have a thorough examination using a Thudicum speculum and an endoscope to identify the bleeding point, and if possible, the bleeding vessel should be cauterized. If the bleeding cannot be stopped or recurs, then the nose should be packed.1 This is not possible without proper training. To ensure good quality service in the management of epistaxis in the National Health Service, all the doctors in the accident and emergency department and all surgical Senior House Officers who cover the ear, nose, and throat department during their on call duty should be adequately trained in management of this common condition.

It is a natural tendency to control bleeding by applying pressure. Our patient tried it with cotton wool. When an inexperienced trainee is packing the nose in such patients, it is possible to push these foreign bodies further into the nose. Along with other routine history taking for epistaxis, it is important to ask the patient about any temporary pack used before attending the hospital.

After removing the packs, it may be difficult to get a good view inside the nose because of blood clots, which the doctor may be reluctant to move as doing so may precipitate bleeding that may require repacking. In these situations, it is important to review these patients later in the outpatient department to examine the nose thoroughly.

To our knowledge, only three cases of pyogenic granulomas have been reported as a complication of nasal packing.2–4 Only two cases of foreign body granulomas of the nose have been reported in the literature.5,6

To avoid these potential complications and for an easy understanding of the management of epistaxis, we propose the term “epistaxis management ladder”(table 1).

Table 1

 Steps of the epistaxis management ladder

Epistaxis Management Ladder

Intiially, the doctor should check pulse and blood pressure, and using a large bore intravenous cannula, take a blood sample, to be sent for full blood count, clotting screen (international normalised ratio if patient is on warfarin) and blood group. Resuscitation becomes the paramount consideration in the elderly patient with epistaxis.1

First step

A thorough examination of the nose should be carried out. Examination will be made difficult in presence of active bleeding. Pinching the nose at the cartilaginous area often stops bleeding, facilitating examination. Every attempt should then be made to identify the bleeding point. Cocaine is widely used as a local anaesthetic in the nose; however, it is potentially toxic, a known drug of addiction, and its spray delivery devices can theoretically transfer infection. Cophenylcaine (5% lidocaine and 0.5% phenylephrine) is an excellent alternative to cocaine nasal spray. The common site of bleeding is the Little’s area,7 which is easily visualised with a Thudicum speculum and head light.

For doctors working in A&E with limited equipment, step 1 will often be all that is required to stop the bleeding.

Second step

If a bleeding point cannot be identified, second step in the management is by anterior nasal packing. This can be done with packing materials such as Merocel, Rapid Rhino, Vaseline gauze, or bismuth iodine paraffin paste.

Third step

The third step of the ladder is postnasal packing, performed if the patient continues to bleed after the first two steps. Postnasal packing can be performed using Foley’s catheter, or Brighton, Simpson, or Bivona balloon.

Fourth step

If the bleeding is not controlled with the first three steps, the patient will need general anaesthetic and the following procedures may need to be performed:1 (a) examination of the nose and cautery of bleeding vessel; (b) tight nasal and postnasal packing; (c) ligation of the sphenopalatine artery and/or anterior ethmoidal artery ligation or external carotid artery or internal maxillary artery; (d) angiography and embolisation; and (e) submucous resection of the septum.


Before packing the nose, it is important to ask the patient about any temporary pack they have used in the nose before presentation, and to look for and remove it before inserting a proper pack. The importance of examination of the nose before inserting the pack cannot be overstressed. We propose the term “epistaxis management ladder” for a better understanding of the different levels of control of nosebleed.



  • Competing interests: none declared

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