Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- severe/persistent epistaxis
- foreign body for example button batteries **urgent review**
- trauma
- periorbital cellulitis
- with or without swelling
- with or without sinusitis
- septal haematoma
- usually subsequent to trauma
- often indicated by intense nasal pain and obstruction
- usually subsequent to trauma
Please contact the on-call registrar to discuss your concerns prior to referral.
For clinical advice, please telephone the relevant specialty service.
If clinical advice is required urgently or out of hours, please contact Flinders Medical Centre or the Women’s and Children’s Hospital.
Northern Adelaide Local Health Network
- Lyell McEwin Hospital (08) 8182 9000
Southern Adelaide Local Health Network
- Flinders Medical Centre (08) 8204 5511
Women's and Children's Health Network
- Women’s and Children’s Hospital (08) 8161 7000
Category 1 (appointment clinically indicated within 30 days)
- suspected malignancy with epistaxis symptoms may include:
- facial deformity/pain
- proptosis (bulging eyeballs)
- visual change
Category 2 (appointment clinically indicated within 90 days)
- juvenile nasopharyngeal angiofibroma (JNA) - especially for posterior bleeding
- unilateral epistaxis in adolescent male
Category 3 (appointment clinically indicated within 365 days)
- epistaxis with any of the following:
- recurrent symptoms
- unresponsive to first-line management (6 to 8 weeks)
Essential referral information
Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
- age
- past medical/surgical/family history specifically of bleeding disorder
- onset, duration, and progression of symptoms including:
- unilateral or bilateral bleeding
- anterior or posterior bleeding
- management history including treatments trialled or implemented
- nasopharyngeal/sinus examination
- if suspected bleeding disorder:
- complete blood examination (CBE)
- prothrombin time (PT)
- activated partial thromboplastin time (APTT)
- Von Willebrand screening (vWF)
- relevant diagnostic/imaging reports including location of company and accession number
Additional information to assist triage categorisation
- paranasal sinus high-resolution computed tomography (CT) – suspected juvenile nasopharyngeal angiofibroma (JNA)
Clinical management advice
Epistaxis in children is usually from Little's area, which is on the septal wall anteriorly. The bleeding is usually venous, is of brief duration and is often recurrent. The two most important factors in childhood epistaxis are:
- minor trauma - from nose picking, rubbing, sneezing, coughing or straining
- friable nasal mucosa - from upper respiratory tract infection, drying of mucosa, intranasal steroids
Rarer causes include foreign bodies, nasal polyps, bleeding diatheses, vascular malformations, and nasopharyngeal tumours.
Refer to Royal Children’s Hospital Melbourne Clinical Guidelines for management options.
Please utilise the relevant Aboriginal Liaison Units (ALU) to provide support to Aboriginal families.
Clinical resources
- Royal Children's Hospital Melbourne — Clinical Practice Guidelines: Epistaxis
- SA Health – South Australian Paediatric Clinical Practice Guidelines: Ingested foreign bodies (including button batteries) (PDF 254KB)
- Women's and Children's Hospital Aboriginal Liaison Unit / Taikurrinthi
- Flinders Medical Centre Aboriginal Hospital Liaison Unit / Karpa Ngarrattendi
- Alternative ear health services and resources for Aboriginal children in South Australia
Consumer resources
- Health Direct - Nosebleed
- Royal Children’s Hospital Melbourne - Nosebleeds fact sheet
-
Alternative ear health services and resources for Aboriginal children in South Australia
Reason for request
- to establish a diagnosis
- for treatment or intervention
- for advice and management
- for specialist to take over management
- for a specified test/investigation the General Practitioner cannot order
- for other reason (e.g. rapidly accelerating disease progression)
- transfer of care from another tertiary service
- clinical judgement indicates a referral for specialist review is necessary.
Patient demographic details
- full name, including aliases
- date of birth
- residential and postal address
- telephone contact number/s – home, mobile and alternative
- Medicare number, where eligible
- name of the parent or caregiver, if appropriate
- preferred language and interpreter requirements
- identifies as Aboriginal and/or Torres Strait Islander
Clinical modifiers
- impact on employment
- impact on education
- impact on home
- impact on activities of daily living
- impact on ability to care for others
- impact on personal frailty or safety
- identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery, where surgery is a likely intervention.
- Choice to be treated as a public or private patient.
- Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
- Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
- Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
- Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
- All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.