Epistaxis management: which strategy to choose?

Dear Sirs, We read with great interest Supriya and colleagues’ article ‘Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome’, published recently in The Journal of Laryngology & Otology. Despite the our belief that management of the epistaxis depends on the departmental policy and experience of the clinician, Supriya and colleagues’ article generated some questions. The authors report successful nasal examination with a rigid nasal endoscope and identification of the bleeding site in 91 per cent of cases, even within 24 hours of Merocel nasal pack removal. However, in our experience such packing can lead to intranasal injuries and recurrent bleeding upon removal, especially when placed by a physician inexperienced in ENT emergency management. If there is a septal deviation, any packing may traumatise the nasal mucosa (septal and turbinate) and create more sites of bleeding. Traditionally, both sides of the nose are packed, and identification of the side of bleeding after packing removal is frequently a difficult problem. Septal deformation and hypertrophic turbinates often prevent visualisation of the bleeding regions. The article in question did not discuss these issues, nor the substantial number of patients with these common anatomical variations. In addition, Supriya et al. did not make clear whether their patients had continuous epistaxis at the moment of cauterisation. In our experience, we prefer to refer to severe and nonsevere epistaxis, rather than anterior and posterior epistaxis, in order to indicate the procedure most likely to result in successful management.