Abstract/Text: A large number of patients take complementary and alternative medicine (CAM) for a variety of reasons, but most do not inform their physicians. This has implications for safety, as many forms of herbal CAM are thought to have a variety of side-effects and may interact with conventional medicines with potentially adverse consequences. We present the case of an otherwise healthy 25-year-old man with difficult-to-control epistaxis. On further questioning, we learnt that he had recently started self-medicating with a combination of aspirin, garlic tablets and milk thistle. Garlic increases bleeding time and milk thistle alters the function of liver enzymes, both of which may have contributed to the difficulty in his management of epistaxis. This case highlights the importance of asking about CAM use when taking a patient's history, as it may have implications for management.

Abstract/Text: BACKGROUND: The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of the affected persons need medical care. In rare cases, severe bleeding calls for the rapid initiation of effective treatment.
METHODS: This review is based on pertinent articles that were retrieved by a selective search PubMed, and on the authors' clinical experience.
RESULTS: There are no German guidelines for the management of epistaxis. The available evidence consists mainly of retro spective analyses and expert opinions. 65-75% of the patients who require treatment can be adequately cared for by their primary care physician or by an emergency physician with baseline measures. If there is persistent anterior epistaxis, an otorhinolaryngologist can control the bleeding sastisfactorily in 78-88% of cases with chemical or electrical cauterization. Nasal packing is used if this treatment fails, or for posterior epistaxis. In a retrospective study, surgical treatment was found to be more effective than nasal packing in the treatment of posterior epistaxis (97% versus 62% treatment success). Percutaneous embolization is an alternative treatment for patients whom general anesthesia would put at high risk.
CONCLUSION: The treatment of severe or recurrent epistaxis requires the interdisciplinary collaboration of the primary care physician, the emergency physician, the practice-based otolaryngologist, and the hospital otolaryngology service. Uniform guidelines and epidemiological studies on this topic would be desirable.