Epistaxis

Department of the Navy
Bureau of Medicine and Surgery

The key to obtaining hemostasis in the bleeding nose is to understand the anatomical etiology of the bleeding source and to exclude concomitant factors, which would inhibit natural hemostatic capability.

Tributaries of the external carotid system (facial, internal maxillary) supply the anterior nasal cavity whereas the posterior nasal cavity is supplied by the internal carotid system (ethmoid arteries). The area of the anterior nasal septum (Kiesselbach's plexus) is where a plexus of anastomotic vessels can be found. This area is the source for nearly 90 percent of all cases of nasal bleeding. These bleeding episodes are usually incited by local intranasal factors such as deviated nasal septum with crusting, drying, and subsequent ulceration. Posterior bleeding is more troublesome, difficult to identify, and more challenging to control.

When confronted with a patient with a bleeding nose, first consider the following possibilities:

Collect and arrange the following items:

Use of the head mirror frees up both hands so you can get exposure with the nasal speculum and locate the source of bleeding. Initially, have the patient blow all of the clotted blood from their nose. This will most likely aggravate the bleeding so be ready with the suction and nasal speculum. After a first quick look, place a cotton pledgett soaked with a vasoconstrictor in both sides of the nose and leave for 5-10 minutes. The second look will usually lead to identification of the bleeding source. If the source is identified, cauterize by holding a silver nitrate (AgN03) applicator firmly over the bleeding source for 15- 30 seconds. Repeat 2-3 times as needed. Other techniques of mechanical hemostasis include a through and through septal stitch, electrocautery, injection with adrenaline containing local anesthetic, or packing.

If all attempts to stop bleeding have failed, pack the nose. Use Vaseline gauze, Nu-Gauze with bacitracin ointment, rolled telfa, or packing sponge. An alternative is to squeeze a tube of bacitracin into the nasal cavity and place a drip pad. If bleeding continues despite appropriate anterior nasal packing, then a posterior nasal bleed may be the source. The easiest posterior pack to place is a lubricated #14 French Foley catheter into the nasopharynx. Inflate the balloon with 10-15cc of saline and pull forward and secure at the nostril with an umbilical clamp or hemostat. Take care not to cause pressure necrosis of the columella.

• For any nasal pack left in place over 24 hours an anti-staphylococcal antibiotic should be used to prevent staphylococcal overgrowth and possible toxic shock syndrome (although rare). For posterior packs, sedate and manage your patient under observation. Humidified oxygen and hydration will make the patient comfortable while the packs are in place. Valium can help reduce anxiety.

• The anterior packs should be left in place for 24-48 hours and the posterior packs longer,

usually 48-72 hours. After pack removal, keep the patient on a local vasoconstrictor (Afrin) for an additional 72 hours and use saline nasal spray for moisture. Follow-up is important to assure a thorough exam after resolution of the bleeding. Rule out polyps, tumors, or intranasal deformities and refer to an otolaryngologist as needed for definitive management.

1. Deweese and Saunders, Textbook of Otolaryngology, 1994.