Current practices in the management of post-operative epistaxis: a survey of Australian and New Zealand otolaryngologists

Introduction

Epistaxis is a distressing and potentially life-threatening complication of nasal and sinus procedures. The reported incidence of post-operative epistaxis ranges from 7.5% in inferior turbinate reductions (1), between 4.5% and 13.4% in septoplasties (2-4), 1.4% and 4.1% in endoscopic transsphenoidal surgeries (5-7), and between 2.3% and 6% in functional endoscopic sinus surgery (FESS), with 0.76% requiring a blood transfusion for post-operative epistaxis (8-10). In paediatric cases, post-operative epistaxis rates in turbinoplasty alone are between 0.3% and 1.3% (11,12).

The nose is highly vascular, receiving blood from several arteries. The anterior ethmoidal artery (AEA) and posterior ethmoidal artery supplies the superior septum, ethmoidal, frontal and sphenoid sinuses, lateral nasal wall, and superior turbinates. The sphenopalatine artery (SPA) enters the nasal cavity behind the middle turbinate and provides blood to the posterior septum and posterior lateral nasal wall, as well as the middle and inferior turbinates, through the posterior septal and posterior lateral arteries, respectively (13,14).

Kiesselbach’s plexus is a confluence of these arteries located in the anterior septum, which is the most common site of spontaneous epistaxis. However, in the post-operative patient the underlying pathophysiology of epistaxis differs, with the bleeding points arising from incision sites and traumatised mucosa and exposed vessels (15-17).

The literature is sparse when it comes to managing post-operative epistaxis. Clinical practice guidelines on the management of epistaxis, such as the one published by the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), often explicitly specify that the recommendations do not apply to post-operative patients (18). In practice, this leaves management reliant on individual clinician experiences, which contributes to variability in care and uncertainty regarding best practice. Given this paucity, understanding current practice is important to identify areas of consensus, differences in management, and discrepancies from the literature. This can aid in the development of future guidelines, protocols and ongoing research. This survey aims to establish existing management practices for post-operative epistaxis amongst Australian and New Zealand (ANZ) otolaryngologists, and is the first study to do so.

Methods

The study is reported according to the SURGE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-32/rc). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Sydney Children’s Hospital’s Human Research Ethics Committee (HREC2023/ETH02097) and informed consent was taken from all individual participants.

An anonymised, securely stored, electronic survey (see Appendix 1) was created, using Microsoft Forms, by the authors following a literature review on post-operative epistaxis and epistaxis guidelines (1,5,18-22). It was further refined following feedback from a research forum comprising of otolaryngologists and trainees. The final version was then sent by the respective secretaries to the electronic mailing list of both the New Zealand Society of Otolaryngology, Head and Neck Surgery (NZSOHNS) and the Australian Society of Otolaryngology, Head and Neck Surgery (ASOHNS) which contain member surgeons who have obtained a Fellowship with the Royal Australasian College of Surgeons (FRACS) in Otolaryngology. The survey was distributed and remained open for one month in each country; July to August 2024 in New Zealand, and September to October 2024 in Australia. Surgeons participated voluntarily in this survey without personal or financial incentive.

Data collected included demographic data pertaining to geographical location, whether they worked privately or publicly, number of years post FRACS, attainment of a rhinology fellowship, and experience and subjective confidence in managing post-operative epistaxis. Data regarding management included escalation choices, preferences for topical agents and nasal packing devices, use of systemic antibiotics and tranexamic acid (TXA), and use of procedural interventions.

Statistical analyses were performed using IBM SPSS Statistics (version 26, IBM Corp., Armonk, New York, USA). Descriptive statistics are presented. Associations between ordinal variables were assessed with Kendall’s τ-b correlation test. Chi-squared tests (or Fisher’s exact where appropriate) were used for group comparisons. Multinomial logistic regression analyses were used to evaluate predictors to management choices. Results are reported as odds ratios (ORs) with 95% confidence intervals (CIs), degrees of freedom (df) and P values, with a P value of <0.05 regarded to be statistically significant.

Results

A total of 146 responses were submitted. Twenty-five responded from NZSOHNS out of 140 members on the mailing list (17.9%) and 121 responded from ASOHNS out of 550 members on their mailing list (22%).

Characteristics of responders

The characteristics of respondents are detailed in Table 1, including workplace geographical location, public or private setting, fellowship training, annual sinonasal surgical volume, number of post-epistaxis cases managed, and confidence in management. The highest representation was from New South Wales (25.3%, n=37). Rhinology trained fellows represented 28.8% (n=42) of responders. Most respondents (78%, n=114) practiced in a combination of public and private settings. Higher confidence in managing post-operative epistaxis was associated with performing a greater number of sino-nasal operations annually (τ=0.424, P<0.001), and being fellowship trained (τ=0.194, P=0.016).

Systemic TXA use

The use of systemic TXA is reported in Table 2, with the majority of survey responders (86%, n=125) routinely administering systemic TXA to their post-operative epistaxis patients.

When comparing countries in a univariate analysis, there was no difference in TXA use between Australia and New Zealand (χ²=1.44, df =2, P=0.484). Victoria had the highest proportion of non-routine TXA use (25%, 8/32), and when compared against other Australian states this was a significant difference (P=0.012).

Correlation between TXA use and additional subspecialty rhinology training was not statistically significant on univariate analysis (OR =2.72, 95% CI: 0.76–9.78, P=0.113). However, when TXA use was collapsed into two categories (‘routine’ and ‘in select patients or never’) for binary logistic regression, rhinology fellowship became a significant predictor for routine TXA use when compared to those without the additional training (OR =6.91, 95% CI: 1.11–42.9, P=0.038). Subjective confidence, years post FRACS, annual operations, geographical location and management of epistaxis numbers did not significantly influence TXA use in this binomial model (Table 3).

Prophylactic antibiotics

Prophylactic antibiotics were routinely prescribed by 34% of surgeons (n=50) when managing a post-operative bleed. In a univariate analysis, number of years post-FRACS significantly influenced whether the responders gave prophylactic antibiotic (χ²=11.86, df =4, P=0.018), with surgeons 6–10 years post-FRACS less likely to prescribe antibiotics compared to those >20 years post-FRACS (OR =0.19, 95% CI: 0.05–0.70, P=0.013). In a multivariable binomial logistic regression analysis, this remained a significant predictor of antibiotic use [likelihood ratio χ²(4) =9.84]; however, this did not reach statistical significance at a group level. Geographical location, private or public practice settings, subjective confidence, fellowship status, annual operative and management of epistaxis volumes were not significant predictors (Table 4).

There was no significant difference between the rates of antibiotic usage between those who chose absorbable packing (33%) and those who did not (39%) (χ²=0.35, P=0.555, OR =0.78, 95% CI: 0.34–1.78).

Sinus rinses

Sinus rinses were recommended to resume within 72 hours following a bleed by 63% (n=92) of surgeons (Table 5). Using a multinomial logistic regression, there were no factors that influenced this.

Management

Figure 1 illustrates the preferred order of management options by otolaryngologists following the use of first aid, such as anterior nasal pressure. For first-line treatment, 82% (n=119) would trial topical agents and 16% (n=23) would trial silver nitrate cautery. Geographical location, private or public practice settings, post-FRACS years, rhinology fellowship and subjective confidence did not statistically influence choice.

Figure 1 Ranked preferences for management options following simple first-aid measures chosen amongst survey respondents. IR, interventional radiology; SPA, sphenopalatine artery.

Of all responders, 29 (19.9%) would not use silver nitrate and 23 (15.8%) would not use interventional embolisation (Figure 2). The reason cited for all those not pursuing silver nitrate cautery was that it would be ineffective in a post-operative bleed.

Figure 2 Management modalities surgeons indicated they would not pursue in the post-operative epistaxis setting. SPA, sphenopalatine artery.

The reasons cited for not pursing angiogram with interventional radiology (IR) guided embolisation include risk of complications such as cerebral vascular accidents and vision loss. Two responders stated they were limited due to not having the facilities and service available at their institution or area. Two others wrote that they found that post-operative bleeding is well managed with other options without need to progress to an angiogram, and another wrote that it is only a temporising measure.

Three responders wrote they were taking the patient to theatres they would proceed directly to an SPA ligation rather than pursuing endoscopic cautery first. Another wrote they would cauterise with bipolar under local first.

Choice of topical agents and nasal packing

The choice of topical agents and nasal packing also varied greatly between responders and are presented in Table 6. The most popular topical agent was Co-Phenylcaine-Forte (92.5%, n=135) and the RapidRhino was the most frequently reported packing device (78.8%, n=115).

Paediatric patients

Forty-two percent (n=61) of responders treat paediatric patients differently to their adult patients and 2 reported they don’t perform paediatric rhinology cases. When asked how their management differs, the most common response (32%, n=47) was having a lower threshold to taking the child back to theatres or taking them back to theatres sooner.

Responders also wrote that they would not, or at least avoid, packing the nose. If packing, they would avoid RapidRhinos with one responder writing they would use a topical agent with Gel-foam or Nasopore instead. Five respondents (3%) reported they would not undertake SPA or AEA ligation or embolisation in children, on the basis that post-operative paediatric bleeds rarely progress to requiring these.

One responder wrote that they are much more selective in choosing their paediatric patients for the reason of post-operative epistaxis, stating that if they would not tolerate an endoscopy or saline rinses, they would consider this a relative contraindication to surgery.

Discussion

In the ANZ context, a stepwise approach starting with non-invasive, conservative measures before escalating to operative or other invasive interventions is favoured in the management of post operative epistaxis. Systemic TXA was widely used, particularly amongst those with additional rhinology training while prophylactic antibiotics were prescribed less consistently. Overall, the responses to the survey illustrate management is led by clinician experience which often differs from the limited evidence base.

Packing is effective in 70% of posterior epistaxis cases (23) but non-absorbable packs can cause mucosal trauma and rebleeding rates of 11–15% (24,25). Absorbable agents achieve superior short-term haemostasis (26) and are more cost-effective (27), yet the RapidRhino remains the most commonly used, possibly due to familiarity in Emergency Departments (EDs). Upskilling initiatives may shift practice, for example, ED training in the use of TXA-soaked Nasopore reduced epistaxis admissions by 51% (28). The preference for packing among respondents contrasts with the evidence, which supports early surgical intervention or embolisation for spontaneous epistaxis (29-32), highlighting a significant discrepancy between current practice and the literature.

SPA ligation achieves higher haemostasis rates (87–90% vs. 48–70%) and is more cost-effective when compared to nasal packing in posterior bleeds, and embolisation is similarly effective at 88–90% success (23,33-37). Evidence directly comparing conservative and early surgical intervention in post-operative epistaxis is limited. A literature review identified only four observational studies with data that allowed indirect comparison, though this was not their primary research focus. In two retrospective case series, 45 of 46 post-FESS patients (21) and 57% of 56 post-turbinate reduction patients (1) required surgical intervention, however, the conservative and surgical management details were not presented. Among eight post-transsphenoidal cases, three settled with packing while five required electrocautery (5), and in a single-surgeon study all 15 post-septorhinoplasty patients with epistaxis were successfully managed conservatively with packing and intravenous TXA (22). Across these studies, 65.6% of patients with post-operative epistaxis required escalation to surgery. However, heterogeneity, the small sample sizes, and the lack of risk factor analyses limit the applicability of these findings. In contrast, respondents indicated a lower threshold for taking paediatric patients to theatre, aligning with evidence demonstrating reduced transfusion rates in children undergoing early ligation or embolisation (38). Practical factors also influenced management with limited access to neurointerventional radiology cited as a reason not to pursue embolisation. This highlights the need for post-operative epistaxis guidelines in the ANZ context to be developed by local governing bodies and hospital districts to ensure feasibility.

Another area of deviation was with the use of TXA. Although topical TXA has demonstrated superior efficacy in anterior bleeds when compared to co-phenylcaine and oxymetazoline (39-41), delays in preparation and limited ability for aerosolisation may explain its lower uptake with respondents. In its systemic use, a Cochrane Review in 2018 found only moderate-quality evidence that oral TXA reduced rebleeding risk (49% from 69%) (42), with no benefit in transfusion rates (43). Despite this, systemic TXA was widespread amongst ANZ respondents, contrasting with a United Kingdom (UK) National Epistaxis Audit where only 4.9% of patients received it for all epistaxis presentations (44). These variances suggests that ANZ respondents perceive a clinical benefit with systemic TXA not yet validated by objective data, underscoring the need for further robust trials in its use. Conversely, antibiotic use appeared to be more consistent with published evidence, which demonstrates no difference in infection rates between patients who did versus those who did not receive prophylactic doses with nasal packing (45,46). The choice of packing type did not influence prescribing by survey respondents. In comparison, an American study observed higher use, with 84% of clinicians prescribing antibiotics for non-dissolvable and 20% for dissolvable packing, citing toxic shock syndrome (47), despite its low incidence of 0.002–0.032% (48-50). It also found that antibiotic use was more common amongst senior surgeons, which this survey echoes. In the UK audit, only 6.4% of patients received antibiotics (44), suggesting a slower translation of evidence into practice for ANZ surgeons and the need for strategies to strengthen confidence in the evidence base, such as through local consensus forums, to reduce unnecessary prescribing.

Out of 690 members of ASOHNS and NZSOHNS contacted, 146 provided responses (21.2%), a rate observed in similar previous surveys, reflecting the typical level of organic engagement within these societies (51,52). Most of the respondents (92.4%) were comfortable or very confident in managing post operative epistaxis, which may indicate a response bias from those with greater expertise or familiarity with the topic, given 28.8% were rhinologists. Another limitation of the survey design, was that choice of management required sequential ranking of all options without the ability to omit those not used in practice, possibly inflating the position of less invasive measures, such as silver nitrate. Finally, the survey relied on the respondent’s recall of their practice rather than objective audit data and therefore may not be entirely accurate.

With no robust research available, recommendations must be informed by the practices reported in this survey and by adapting evidence from other epistaxis presentations. For small volume bleeds and given resource availability, it is reasonable to commence with conservative, non-invasive treatment. After initial first aid, an absorbable packing agent combined with an accessible topical agent should be used. Persistent or recurrent bleeding should prompt operative management such as electrocautery, with or without SPA ligation. In larger volume bleeds, or in anticoagulated patients, early escalation to theatres should be performed even if the bleeding initially settles, as the likelihood of requiring invasive management is high. Paediatric patients can be trialled with topical therapies, but if unsuccessful escalation to theatres is preferred and packing should be avoided. Antibiotics should not be routinely prescribed regardless of packing type, unless there are clinical signs of infection or the packing has been left in-situ for a prolonged period. While there is limited evidence for systemic TXA, its anecdotal benefit amongst survey respondents supports consideration for its use, particularly in large volume bleeds or in more vulnerable patients such as children or the elderly. Future research should prioritise post-operative epistaxis, with trials evaluating systemic TXA, multi-arm randomised studies comparing topical agents and packing devices, and comparative studies examining conservative and surgical interventions as first line management. Achieving adequate sample sizes, however, will be a major challenge. This will allow for standardised local protocols on post-operative management to be developed.

Conclusions

This survey of ANZ otolaryngologists reveals significant variability in the approach to post-operative epistaxis and highlights a lack of standardised, evidence-based pathways for post-operative epistaxis. Most of the literature investigating management of epistaxis does not explicitly examine post-operative patients, leading to a reliance on clinical experience and interpreting literature on spontaneous epistaxis to guide management. Large randomised controlled trials examining management options are required to establish best practice but is constrained by the multitude of treatment options, low sample sizes, and varying availability of services.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-32/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-32/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-32/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-32/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Sydney Children’s Hospital’s Human Research Ethics Committee (HREC2023/ETH02097) and informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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