What treatment is recommended for a patient with epistaxis (nose bleeding) for 1 hour, nasal septal pain, and no fever?

Management of Epistaxis with Nasal Septal Pain

For a patient with epistaxis and nasal septal pain without fever, antibiotics like co-amoxiclav are NOT indicated unless there is evidence of infection such as septal abscess, and NSAIDs like celecoxib should be avoided as they may worsen bleeding. 1

Immediate First-Line Treatment

Apply firm, sustained compression to the soft lower third of the nose for a minimum of 5 minutes without interruption, with the patient sitting upright and head tilted slightly forward to prevent blood from flowing into the airway. 2 Do not release pressure to "check" if bleeding has stopped, as this disrupts clot formation. 2

If bleeding persists after 5-10 minutes of compression, apply topical vasoconstrictors such as oxymetazoline (Afrin) directly to the bleeding site. 1 These agents achieve hemorrhage control in 65-75% of epistaxis cases through local vasoconstriction and should be left in place for 10-15 minutes while maintaining external pressure. 3, 1

Addressing the Nasal Septal Pain

The presence of nasal septal pain raises concern for potential complications:

• Nasal septal pain following epistaxis or cauterization warrants careful observation for septal hematoma or abscess, particularly if pain develops or worsens over days. 4
• A septal hematoma appears as a fluctuant, boggy swelling of the septum and requires urgent surgical drainage to prevent abscess formation and cartilage necrosis. 5
• Antibiotics are indicated ONLY if a septal abscess is suspected or confirmed (signs include fever, fluctuant septal mass, systemic toxicity), in which case clindamycin is recommended as initial therapy pending culture results. 5

When to Consider Cautery

If bleeding persists despite vasoconstrictors, nasal cautery can be performed after anesthetizing the bleeding site with topical lidocaine or tetracaine. 3, 1 The American Academy of Otolaryngology-Head and Neck Surgery recommends restricting cautery application only to the active or suspected site(s) of bleeding. 3

Critical pitfall: Avoid simultaneous cauterization of both sides of the septum to prevent septal perforation. 1

Why Co-Amoxiclav is NOT Indicated

Prophylactic antibiotics are not recommended for uncomplicated epistaxis, even with nasal septal pain, unless there is clinical evidence of infection. 5 The absence of fever in this patient argues against active infection. Routine antibiotic use for epistaxis is not supported by the American Academy of Otolaryngology-Head and Neck Surgery guidelines. 3

Why Celecoxib Should Be Avoided

NSAIDs like celecoxib can impair platelet function and potentially worsen or prolong bleeding. 1 For pain control in the setting of epistaxis, acetaminophen would be a safer alternative that does not affect hemostasis.

Appropriate Management Plan

The correct treatment approach is:

• Firm nasal compression for 5+ minutes 2
• Topical oxymetazoline if bleeding persists 1
• Nasal cautery with anesthesia if still bleeding 3, 1
• Acetaminophen (not NSAIDs) for pain control
• Close observation for development of septal hematoma/abscess given the septal pain 4
• Antibiotics ONLY if signs of infection develop 5

Red Flags Requiring Urgent Evaluation

Refer urgently if:

• Bleeding persists >30 minutes despite appropriate local measures 2
• Development of fluctuant septal swelling suggesting hematoma 5
• Fever or systemic signs of infection develop 5
• Signs of hemodynamic instability 2