Most cases of anterior epistaxis may be successfully treated by direct pressure on the site by compression of the nares continuously for 15 minutes (eFigure 8–4). Venous pressure is reduced in the sitting position, and slight leaning forward lessens the swallowing of blood. Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays), which act as vasoconstrictors, may also help. When the bleeding does not readily subside, the nose should be examined, using good illumination and suction, in an attempt to locate the bleeding site. Topical 4% cocaine applied either as a spray or on a cotton strip serves both as an anesthetic and a vasoconstrictor. If cocaine is unavailable, a topical decongestant (eg, oxymetazoline) and a topical anesthetic (eg, tetracaine or lidocaine) provide similar results. When visible, the bleeding site may be cauterized with silver nitrate, diathermy, or electrocautery. A supplemental patch of Surgicel or Gelfoam may be helpful with a moisture barrier, such as petroleum-based ointment, to prevent drying and crusting. Warfarin may be continued in the setting of controlled epistaxis, although resorbable packing may be preferable in these patients.
Anatomy of the nasal cavity, showing the location of the blood supply to the nasal septum. (Reproduced, with permission, from Chesnutt MS et al. Office & Bedside Procedures. Originally published by Appleton & Lange. Copyright © 1992 by The McGraw-Hill Companies, Inc.)
Occasionally, a site of bleeding may be inaccessible to direct control, or attempts at direct control may be unsuccessful. In such cases, there are a number of alternatives. When the site of bleeding is anterior, a hemostatic sealant, pneumatic or other nasal tamponade, or anterior packing may suffice as the latter may be accomplished with several feet of lubricated iodoform packing systematically placed in the floor of the nose and then the vault of the nose.
About 5% of nasal bleeding originates in the posterior nasal cavity, commonly associated with atherosclerotic disease and hypertension. In such cases, it may be necessary to consult an otolaryngologist for a pack to occlude the choana before placing a pack anteriorly (eFigure 8–5). In emergency settings, double balloon packs (Epistat) may facilitate rapid control of bleeding with little or no mucosal trauma. Because such packing is uncomfortable, bleeding may persist, and vasovagal syncope is possible, hospitalization for monitoring and stabilization is indicated. Posterior nasal packing is quite uncomfortable and may require an opioid analgesic for pain control.
Control of posterior epistaxis using rolled posterior pack. A: Flexible rubber catheter inserted and pack attached. B: Catheter removed and posterior pack drawn into position. C: Anterior pack installed "accordion-pleating" style and posterior pack tied in place over a bolster. (Reproduced, with permission, from Chesnutt MS et al. Office & Bedside Procedures. Originally published by Appleton & Lange. Copyright © 1992 by The McGraw-Hill Companies, Inc.)
Surgical management of epistaxis, through ligation of the nasal arterial supply (internal maxillary artery and ethmoid arteries) is indicated when direct pressure and nasal packing fail. The most common approach to surgical treatment is endoscopic sphenopalatine artery ligation. This method has a reported efficacy of 73–100% in studies; however, it may miss bleeds caused by the ethmoid arterial supply. Alternatively, endovascular epistaxis control is highly effective (75–92%) and can address all sources of intranasal bleeding except those from the anterior ethmoid artery. Its use may be reserved for when a surgical approach fails because it is associated with a 1.1–1.5% risk of stroke.
After control of epistaxis, the patient is advised to avoid straining and vigorous exercise for several days. Nasal saline should be applied to the packing frequently to keep the packing moist. Avoidance of hot or spicy foods and tobacco is also advisable, since these may cause nasal vasodilation. Avoiding nasal trauma, including nose picking, is an obvious necessity. Lubrication with petroleum jelly or bacitracin ointment and increased home humidity may also be useful ancillary measures. Finally, antistaphylococcal antibiotics (eg, cephalexin, 500 mg orally four times daily, or clindamycin, 150 mg orally four times daily) are indicated to reduce the risk of toxic shock syndrome developing while the packing remains in place (at least 5 days).