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Protection from blood aerosol contamination when managing epistaxis: a study of the effectiveness of a patient mouth mask.


The danger to healthcare personnel of acquiring a bloodborne infection accidentally transmitted by a patient is well known. Such an infection can have serious and career-altering implications. Epistaxis, which is the most common emergency seen in ENT practice, poses a great risk of contaminated blood being spattered on the face of the attending medical provider. Areas of possible contamination include the mucosa of the nasal passages, oral cavity, and conjunctiva. Various strategies to prevent contamination have been described in the literature, most of which involve the wearing of protective equipment by the healthcare provider. We conducted a prospective, randomized study of 60 epistaxis patients to determine if a simple surgical mask warn by the patient over his or her mouth would protect the treating physician from aerosolized blood contamination. We found evidence of significant blood splashes on the physician in 8 of the 30 cases (26.7%) in which the patient did not wear a mask, compared with only 4 cases (13.3%) when the mouth mask was worn. We therefore conclude that a patient mouth mask is a simple, inexpensive, and effective way to minimize the risk of aerosolized blood contamination during the treatment of epistaxis.


Epistaxis is the most common emergency seen in ENT practice. In an epistaxis emergency, active and sometimes brisk bleeding from the nose may also involve the oral cavity. It has been reported that aerosolized blood can be transmitted to the treating healthcare provider in as many as as 18% of cases. (1) This is a serious issue in view of the risk that a healthcare provider might contract a potentially life-threatening or career-altering blood-borne infection as a result of blood aerosol contamination.

Various measures of preventing such contamination have been described in the literature. These methods generally involve the healthcare provider's wearing protective equipment. In this article, we describe our study of a patient-worn protective mask as a means of preventing blood contamination.

Patients and methods

We conducted a prospective study of 60 consecutively presenting patients who were treated for epistaxis at our tertiary hospital. These patients were randomly and evenly divided into two groups. The patients in one group--16 men and 14 women, aged 17 to 80 years--were treated while they wore a surgical mask that covered their mouth (Classic Surgical Mask; Kimberly-Clark; Dallas). The control group--18 men and 12 women, aged 19 to 79 years--wore no such protection. The two groups were similar in terms of age, sex, severity of epistaxis, and the specific type of treatment modality (table 1).

All patients were treated by a single physician (S.B.) to avoid physician variability. In all cases, the physician wore a disposable three-ply polypropylene face mask with a plastic protective eye shield that included side flaps (Fluidshield Surgical Face Mask with wraparound Splashguard Visor; Kimberley-Clark).

Immediately at the end of each treatment procedure, the physician removed his gloves first and then his face mask. This was done to avoid any contamination or transfer of blood from the gloves to the mask. The physician then carefully examined the face mask and counted the visible blood spatters on the eye shield.


After treatment, the physician counted 4 spatters from the mouth mask group (13.3%) and 8 spatters from the control group (26.7%) (table 1). All of the patients who transmitted aerosolized blood delivered at least 3 spatters each. The most risky procedure by far was anterior nasal packing (table 2).


Blood-borne viral infections such as those caused by human immunodeficiency virus (HIV) and hepatitis B and C virus (HBV, HCV) can be transmitted to healthcare personnel in a variety of clinical interactions with patients. By 2003, the Centers for Disease Control and Prevention (CDC) in the United States had received reports of 57 documented cases and 138 possible cases of occupationally acquired HIV infection among healthcare personnel since 1985. (2) The CDC also estimated that the risk of HIV infection after exposure of the eye, nose, or mouth to HIV-infected blood was 0.1% (1 in 1,000 cases). (2)

Since inoculation with HBV vaccine became mandatory for U.S. healthcare workers in 1982, the incidence of occupationally acquired HBV infections decreased from more than 100,000 cases in 1983 to fewer than 400 in 2001. (2) The number of healthcare workers infected with HCV is unknown. (2) The drop in HBV transmission may be encouraging, but this should not lead to complacency.

During examination, a patient with epistaxis may spit, sneeze, or cough up blood from the nasal or oral cavities. While the incidence of contamination of gloves and gowns is considerably higher than contamination of the face, (3) the danger of the latter is obviously much greater. The chance that blood may contaminate a healthcare provider's respiratory tract lining or the mucous membranes of the lips, mouth, nose, or conjunctiva is very high. (4) The incidence of blood contamination of a physicians face mask and visor has been reported to range between 14%3 and 18%. (1) Gioannini et al reported a case of HIV infection that was acquired by a healthcare worker via conjunctival contamination. (5) While all surgical procedures carry a risk of aerosol blood contamination, (6,7) the risk is much higher during ENT procedures. (8)

In its guidance to healthcare employees on ways to prevent blood-borne viral infections, the U.K. Department of Health has strongly recommended the use of facial protection equipment when the spattering of bodily fluids is a possibility. (9) However, despite the well-known dangers, a study of epistaxis treatment by Ho et al found that 60 to 90% of treating physicians did not wear eye protection or a face mask. (10)

A variety of preventive measures for physicians have been studied, including face masks with and without an eye shield and an innovative device called "the double bag," which was described by Ku et al. (11) Our search of the literature found only a few reports describing the use of protection worn by patients. Hassan and Trotter studied the use of a patient mouth mask in 18 cases and reported no instance of contamination of the physicians face mask, visor, gown, or apron. (12) This is in contrast to our findings in 30 patients, where the contamination rate of patients who wore a mouth mask was 13.3%. Our high rate might be explained by two factors: (1) since our series was larger, there was a greater chance of contamination and/or (2) as long as the nasal area of a patient is uncovered during treatment, the chance of completely avoiding contamination of the physician is low.

Stimpson and Collard reported an additional advantage of patient mouth masks. (13) In their opinion, the use of a mouth mask caused all the blood from the patient s mouth to be funneled by the mask into a bowl. This prevented patients from seeing a large amount of their own blood, which might have worsened their anxiety in an already frightening situation.

Our prospective study showed quite clearly that protection limited only to physician--worn equipment is inadequate. Our simple, inexpensive, readily available, and easily applicable mouth mask reduced the number of incidents of blood contamination by half. It is both practical and logical to prevent contamination at its source, which is why a mouth mask is so useful.

One possible drawback of our study is that we used a visual method of assessing the blood spatter on the protective eye shield. In a comprehensive multicenter study of blood splashes on 600 facial shields, Endo et al found that visual examination alone detected blood spatters on 50.5% of all facial shields; however, when leucomalachite green, a triphenylmethane dye used for detecting blood in criminal forensic science, was used to detect spatters, the detection rate rose to 66%. (14) It can be argued that if we had we used a similar substance, the incidence of facial spatter would have been much higher, which further reinforces our argument that a mouth mask is an effective protection from blood aerosol contamination during the management of epistaxis.


(1.) Wallace HC, Harries PG. Epistaxis and conjunctival contamination--are our ENT trainees at risk? Ann R Coll Surg Engl 2002;84(5):302-3.

(2.) Exposure to blood: What healthcare personnel need to know. Centers for Disease Control and Prevention Web site, HAI/pdfs/bbp/Exp_to_Blood.pdf. Updated July 2003. Accessed May 11.2015.

(3.) Carney AS, Wier J. Baldwin DL. Contamination with blood during management of epistaxis. BMJ 1995;311 (7012): 1064.

(4.) Rowe-Jones JM, Pringle MB. Prevention of occupational transmission of HIV in the ENT clinic. Ann R Coll Surg Engl 1992;74(1):5-8.

(5.) Gioannini P. Sinnico A, Carti G, et al. HIV infection acquired by a nurse. Eur J Epidemiol 1988;4(1):119-20.

(6.) Porteus MJ. Hazards of bloodsplashes [letter], BMJ 1990;300(6722):466.

(7.) Brearley S. Buist LJ. Blood splashes: An underestimated hazard to surgeons. BMJ 1989:299(6711): 1315.

(8.) Hinton AE, Herdman RC. Timms MS. Incidence and prevention of conjunctival contamination with blood during hazardous surgical procedures. Ann R Coll Surg Engl 1991;73(4):239-41; discussion 241-2.

(9.) Blood-borne viruses in the workplace. Guidance for employers and employees. Health and Safety Executive Leaflet INDG342, 2008. Department of Health U.K. Web site, indg342.pdf. Updated September 2011. Accessed May 11, 2015.

(10.) Ho EC, Patiar S, Corbridge R. How we do it: Blood contamination during management of epistaxis--awareness, utilization and availability of barrier protection. Clin Otolaryngol 2005;30(1):71-2.

(11.) Ku PK, Marshall JN, van Hasselt CA. The 'double bag': A device for protection against blood spray in the management of epistaxis. J Laryngol Otol 2001; 115(6) :479-81.

(12.) Hassan MS, Trotter MI. Protection from epistaxis blood aerosol contamination: A novel use of a surgical facemask. Eur Arch Otorhinolaryngol 2003;260(5):242-3.

(13.) Stimpson P, Collard B. Use of face mask in the management of epistaxis [letter], Clin Otolaryngol 2007;32(2): 146.

(14.) Endo S, Kanemitsu K, Ishii H, et al. Risk of facial splashes in four major surgical specialties in a multicentre study. J Hosp Infect 2007;67(1):56-61.

Salman Baig, FRCSI; Tahir Rashid, FCPS, FEB(ORL-HNS); Muhammad Saleem, FRCS

From the Department of Otolaryngology, Dr. Ziauddin University and Hospital, Clifton Campus, Karachi, Pakistan (Dr. Baig); and the Department of Otolaryngology-Head and Neck Surgery and Communication Sciences, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia (Dr. Rashid and Dr. Saleem). The study described in this article was conducted when all authors were affiliated with the King Faisal Specialist Hospital and Research Centre.

Corresponding author: Dr. Salman Baig, Department of Otolaryngology, Ziauddin University and Hospital, Clifton Campus, 4/B, Shahrah Ghalib, Block-6, Clifton, Karachi, Pakistan. Email: drsalmanbaig@
Table 1. Distribution of patients in the two groups

                                 Mouth mask group   Control group
Variable                             (n = 30)         (n = 30)

Age, yr                              17 to 80         19 to 79
Sex, M/F                              16/14             18/12
Treatment, n
  Cautery                               21               23
  Anterior nasal packing                8                 6
  Anterior/posterior packing            1                 1
Blood spatters on physician's        4(13.3)          8 (26.7)
  eye shield, n (%)

Table 2. Frequency of blood spatters on physician's
eye shield according to the type of treatment

Treatment                             Spatters, n (%)

Cautery (n = 44)                          2 (4.5)
Anterior nasal packing (n = 14)          9 (64.3)
Anterior/posterior packing (n = 2)       1 (50.0)
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Comment:Protection from blood aerosol contamination when managing epistaxis: a study of the effectiveness of a patient mouth mask.(ORIGINAL ARTICLE)
Author:Baig, Salman; Rashid, Tahir; Saleem, Muhammad
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:9PAKI
Date:Sep 1, 2015
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