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Is staph the cause of recurrent epistaxis?

QI have been told to treat all children with recurrent epistaxis with Naseptin for two weeks before referral for cautery. Is there good evidence that staph infection is the cause?

AEpistaxis is extremely common between the ages of three and eight. Recurrent epistaxis can be both socially disabling and a cause for significant parental concern. First-line treatment typically involves the use of an antiseptic cream such as a chlorhexidine/neomycin (Naseptin) and nasal cautery is often performed.

The aetiology of epistaxis is often multifactorial, and coagulopathy should always be considered as a rare but potentially serious cause.

But there is little doubt inflammation, often as a result of upper respiratory tract infection, plays an important role.

This may lead to crusting and local trauma from nose rubbing and picking, which often causes bleeding of the hyperaemic mucosa directly, and may predispose to secondary bacterial infection and vestibulitis. A vicious circle can develop of crusting, picking, and bleeding, leading to further crusting.

It has been shown Naseptin is significantly more effective than no treatment (relative risk reduction 47 per cent). Naseptin alone has also been shown to be as effective as silver nitrate cautery alone. Naseptin is known to reduce nasal staphylococcal carriage, although not as effectively as mupirocin.

What is not clear, however, is whether Naseptin works by a specific antibacterial effect or by reducing crusting and acting as a barrier cream.

Until more is known, we would recommend its continued use as a first-line treatment in the management of recurrent epistaxis for all children, unless they are known to be allergic to the peanut oil that forms part of its base.

Mr Nicholas Saunders is specialist registrar and Mr Theo Joseph is ENT consultant at The Royal National Throat, Nose and Ear Hospital, London

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