Nasal bleeding that does not stop with a topical vasoconstrictor and direct pressure applied by the patient (described below in the “Technique” section).

PROCEDURES

 Cauterization

    Anterior source bleeding that can be visualized

 Anterior Nasal Packing

    Anterior source bleeding that cannot be visualized

    Cauterization fails

 Posterior Nasal Packing or Balloon Tamponade

    Anterior source cannot be identified and

       Bleeding from both nares or

       Blood draining into the posterior pharynx

    Anterior packing of both nares fails to control bleeding

CONTRAINDICATIONS

 None

RISKS

 Nasal packing can cause pain or discomfort

 Risk of infection, septal damage, and ulceration

 Risk of balloon migration, airway obstruction, or aspiration with posterior packing

LANDMARKS

 The choice of procedure depends on the source of bleeding. The source can be identified by direct visualization, or with use of a nasal speculum (described in more detail in the “Technique” section).

 Nosebleeds are most commonly anterior (80% to 90%), originating from the Kiesselbach plexus in the septum

 Most posterior nosebleeds originate from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx. A posterior source is likely when an anterior source cannot be identified, when bleeding is from both nares, or when blood is draining into the posterior pharynx.

TECHNIQUE

 Patient Preparation

    Ask the patient to blow his or her nose, which decreases the effects of local fibrinolysis and removes clots (FIGURE 75.1)

    Ask the patient to lean forward and apply continuous pressure to the alae of both nares for 10 to 20 minutes. If this stops bleeding, consider sending patient home with follow-up to ear, nose, and throat (ENT) specialist or Primary Medical Doctor (PMD).

 Analgesia

    Apply a topical anesthetic and vasoconstrictor

       Soak cotton or gauze in 2% lidocaine with or without topical epinephrine or 4% topical cocaine. Place in the nasal cavity for 15 to 20 minutes.

       Alternatively, a topical anesthetic with a decongestant (2% lidocaine and 4% phenylephrine mixed 1:1) or oxymetazoline hydrochloride (Afrin) nasal spray may be used

    Because patients may be apprehensive and packing is uncomfortable, opiates or benzodiazepines may be given before the examination (strongly recommended in cases of posterior packing)

 Visualization

    Position the patient sitting upright, facing forward in the sniffing position

    Insert a nasal speculum so that one blade moves superiorly and the other inferiorly and spread the nares vertically. Suction all remaining clots and blood. This permits visualization of most anterior sources.

 Cauterization

    If an anterior source is visualized, cauterization should be attempted. To be effective, cautery should be performed after bleeding is controlled. Only cauterize one side of the septum at a time to prevent perforation or necrosis of the septum.

    Chemical cauterization can be performed using silver nitrate sticks. Apply the tip of a silver nitrate stick to the bleeding site until a white precipitate forms (usually a few seconds, rarely more than 10).

    If bleeding is vigorous, electrocauterization can be used. Apply the device to the bleeding site for up to 10 seconds or until a white precipitate forms.

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