Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may be treated by pinching the nares closed for 10 full minutes. If pinching is unsuccessful and the bleeding site is visible and localized, the next step is to control anterior epistaxis using cautery How To Treat Epistaxis With Cautery Epistaxis (nasal hemorrhage) can often be stopped with cautery (sealing off a blood vessel using current or chemicals). Epistaxis may be due to bleeding from the anterior or posterior nasal... read more , followed by tamponade if cautery is unsuccessful or not indicated. Posterior epistaxis How To Treat Posterior Epistaxis With a Balloon Posterior epistaxis (nasal hemorrhage) can often be controlled with balloon tamponade. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much... read more is managed quite differently so identifying the site of bleeding is critical.
If a bleeding site that is accessible can be localized, cautery may be preferred because it avoids some disadvantages (eg, risk of infection, migration of packing material) and the discomfort of tamponade.
(See also Epistaxis Epistaxis Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage. Most nasal bleeding is anterior... read more .)
Anterior nasal bleeding from a site that is not clearly visible
Failure of cautery to stop nasal bleeding
Possible or identified skull base fracture
Significant maxillofacial or nasal bone trauma
Uncontrolled airway or hemodynamic instability
Procedures described here are intended for epistaxis that is spontaneous or resulting from minor trauma. Epistaxis in patients with significant facial trauma should be managed by a specialist.
Severe nasal septal deviation toward bleeding side (makes it difficult to insert tamponade material)
Injury to the nasal mucosa including pressure necrosis with possible septal perforation, particularly with bilateral nasal packing
Migration of anterior nasal packing to the posterior nasopharyngeal area or aspiration into the airway
Infections such as sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more or rarely toxic shock syndrome Toxic Shock Syndrome (TSS) Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which... read more
Rebleeding when pack is removed
Gloves, mask, and gown
Gown or drapes for patient
Suction source and Frazier-tip and/or other suction-tip catheters
Tamponade device or material*
Chair with headrest or an ear, nose, and throat (ENT) specialist's chair
Light source and head mirror or headlamp with adjustable narrow beam
Scissors for cutting nasal gauze or tampons
Antibiotic ointment (bacitracin)
5-mL sterile saline solution
Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)
Cotton swabs or pledgets
* There are several types of tamponade material/devices:
Compressed polyvinyl acetate nasal tampon (sometimes with an internal airway tube), ideally with removal strings that can be secured to the patient's cheek to prevent aspiration and aid removal
High-volume, low-pressure inflatable ballon tampon with an air passage and a carboxymethylcellulose (platelet aggregating) covering
1.25 cm (½-inch) petrolatum gauze strip, 180 cm (72") long
Nasal tampons are highly compressed for ease of insertion; they expand and become soft when hydrated. Tampons are much easier to insert and more comfortable than packing gauze and are preferred when available.
Insertion of a petrolatum gauze strip is uncomfortable and often requires some analgesia and/or mild sedation (however, not enough to risk airway compromise). Thus, this procedure should be done only when other methods fail or are not available.
Ask about use of anticoagulant or antiplatelet drugs.
Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or the patient has severe or recurrent epistaxis.
Kiesselbach's plexus is a vascular watershed area on the anterior nasal septum that is the most common site of anterior epistaxis.
The patient should sit upright in the sniffing position with the head extended, preferably in a specialized ENT chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should be level with the physician's eyes.
The patient should hold the emesis basin to collect any continued bleeding or emesis of swallowed blood.
Step-by-Step Description of Procedure
Have the patient gently blow the nose to remove clots, or suction the nasal passageway carefully.
Insert a nasal speculum with your index finger resting against the patient's nose or cheek and the handle parallel to the floor (so the blades open vertically).
Slowly open the speculum and examine the nose using a bright headlamp or head mirror, which leaves one hand free to manipulate suction or an instrument.
Use a Frazier-tip suction catheter to remove any blood and clots obscuring the view.
Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose.
Apply a topical vasoconstrictor/anesthetic mixture: Place about 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in a small medicine cup and soak 2 or 3 cotton pledgets with the solution and insert them into the nose, stacked vertically (or spray in a topical vasoconstrictor such as oxymetazoline and place pledgets containing only topical anesthetic).
Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.
To insert a compressed (expandable) nasal tampon:
Coat the tampon with a topical antibiotic ointment, such as bacitracin or mupirocin.
Trim the length and width of the tampon to fit the nose. A typical 8-cm commercial nasal tampon can fit into an adult nasal cavity without modification.
Insert the tampon perpendicular to the face and advance it parallel to the floor of the nasal cavity in a single, smooth movement to limit discomfort.
After the tampon has been properly inserted, expand the tampon by injecting 5 to 10 mL of saline or local anesthetic onto the tampon using an 18- to 22-gauge angiocatheter.
Tie the drawstring (if present) around a piece of gauze to prevent displacement posteriorly, or tape the string to the cheek.
If necessary, insert a second tampon to fill the nasal cavity. Be sure that the tips of both tampons are at the level of the nares or protrude slightly.
Observe the patient for 10 minutes after tampon insertion to ascertain control of bleeding.
To insert an inflatable tampon:
Soak the device in sterile water for up to 30 seconds (do not soak in saline).
Insert the device perpendicular to the face and advance it parallel to the floor of the nasal cavity until the plastic ring is within the nasal cavity.
Inflate the device with air using a 20-mL syringe until the pilot cuff becomes rounded and firm. Do not inflate with water or saline and do not apply lubricants or antibiotic ointments to the device.
Secure the inflation port to the patient's face using tape or a transparent dressing.
To insert petrolatum gauze packing:
For patients who appear unlikely to tolerate the procedure, consider giving a low dose of IV analgesic (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg and potentially lower in those older than 65 years of age).
Grasp the petrolatum gauze with bayonet forceps about 10 cm from the end (this determines how deeply the gauze will be placed). Advance the strip of petrolatum gauze posteriorly into the nasal cavity parallel to the nasal floor until the end of the gauze strip is just outside the opening of the naris.
Grasp another 8 to 10 cm of strip gauze and place this on top of the prior layer in an accordion fashion, being sure that it is inserted parallel to the nasal floor and extends the full length of the nasal cavity.
Be sure to grasp a long enough piece each time to allow insertion to the back of the nose in a single motion.
Place each layer slightly anterior to the previous layer to prevent the packing from slipping posteriorly.
Press down on the packing with the bayonet forceps to pack it tighter after placement of every several layers.
Continue to add layers of strip gauze until the nasal cavity is packed. The full length of strip gauze—typically, 72 inches (180 cm)—may be required.
Advise patient not to take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days after treatment of epistaxis.
Anterior packs are usually left in place for 3 to 5 days.
Nasal tampons should be moistened 3 times a day with water or saline.
Consider treating with a course of antibiotics because of the small risk of sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more and rare toxic shock syndrome Toxic Shock Syndrome (TSS) Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which... read more .
Warnings and Common Errors
Do not open the nasal speculum laterally or use in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)
Insert the tampon straight back, parallel to the floor of the nasal cavity, not angled upward parallel to the contour of the nose.
Avoid bunching gauze in the anterior nasal passage; if nearly the full 180 cm (72 inches) of prepackaged gauze could not be inserted, it was probably not inserted deeply enough.
When using inflatable tamponade devices, avoid excessive inflation (particularly of bilateral devices) because this can cause pressure necrosis of the septum.
When removing an inflatable tamponade device, be sure to deflate it completely before removal.
Tips and Tricks
Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.
If necessary, packing the contralateral nasal cavity can improve tamponade and prevent septal deviation.
Compressed nasal tampons can be wrapped in a layer of oxidized regenerated cellulose material prior to insertion to facilitate hemostasis.