Posterior Epistaxis Nasal Pack
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Epistaxis is a common problem in the emergency department (ED). Although it usually is relatively benign, it can produce serious, life-threatening situations. Up to 60% of the population is estimated to have had at least 1 episode of epistaxis at some point in their lives. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization. [1]
A patient with epistaxis must be evaluated expediently. [2, 3, 4] All patients with epistaxis require a thorough examination and control of the bleeding. Epistaxis that has resolved still requires management to prevent rebleeding. [5]
Ten percent of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral. Posterior epistaxis may present in ways that suggest a more inferiorly located site of bleeding from the aerodigestive tract (eg, hemoptysis, melena, anemia, or just nausea). A posterior source of the bleeding must be sought when epistaxis is bilateral, brisk, and not controlled with anterior nasal packing.
Posterior epistaxis is usually treated by an otolaryngologist, but an emergency practitioner may be called upon to treat this condition in a medical environment with few support services.
A focused history aids the clinician in managing the acutely bleeding patient. This history should include some or all of the following questions:
Which side is bleeding?
Which side was bleeding initially?
What is the estimated amount of blood loss?
Is it recurrent?
Is it in the pharynx?
Has any trauma recently occurred?
Are symptoms of hypovolemia present?
What are the patient’s past medical history and current medications (eg, aspirin, warfarin)? [6]
As with any unstable patient, initial management begins by assessing the ABCs (A irway, B reathing, and C irculation). Next, the source of the bleed should be identified by a thorough examination of the nasopharynx.
A posterior pack is placed to occlude the choanal arch and, in conjunction with an anterior nasal pack, provide hemostasis. Posterior packing can be accomplished with gauze, a Foley catheter, a nasal sponge/tampon, or an inflatable nasal balloon catheter. Posterior packing is very uncomfortable and may necessitate procedural sedation. An anterior nasal pack is always required on the side of a posterior pack, and a contralateral nasal pack is strongly encouraged to maintain the septum midline. [5]
For more information, see Epistaxis, Management of Acute Epistaxis, and Anterior Epistaxis Nasal Pack.
The nose, like the rest of the face, has an abundant blood supply. The arterial supply to the nose may be principally divided into (1) branches from the internal carotid, namely the branches of the anterior and posterior ethmoid arteries from the ophthalmic artery, and (2) branches from the external carotid, namely the sphenopalatine, greater palatine, superior labial, and angular arteries.
The bleeding site of a posterior epistaxis is either posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity. Branches of the sphenopalatine artery supply the blood for such an epistaxis (see the image below). The vast majority of posterior bleeding sites originate from the septum. [7]
For more information about the relevant anatomy, see Nasal Anatomy.
Indications for posterior nasal packing include the following:
Failure of anterior packing
Reliable or high suspicion of posterior bleeding (patient spitting out blood, older patient with atherosclerosis, no visible anterior bleeding site)
Patient with bleeding diathesis (hereditary hemorrhagic telangiectasia, [8] von Willebrand disease, hemophilia, anticoagulation, antiplatelet therapy) – Each of these states makes hemostatic control much more difficult, and each has its set of additional specific targeted therapies.
Temporizing measures until more definitive therapies are obtained include endoscopic ligation by an otolaryngologist or endovascular ligation by an interventional radiologist.
Posterior nasal packing should not be performed in the presence of facial trauma that may include nasal bone and cribriform plate fractures. (See Facial Fractures.)
If the patient is in shock, has altered mental status, or is otherwise not protecting the airway, the airway must be controlled before any nasal packing is attempted.
Good lighting is paramount. A head lamp is optimal, but a reasonable alternative is an overhead lamp.
Have the patient blow his or her nose to expel any clot. Perform a thorough anterior nasal examination to rule out an anterior bleeding source. A brisk posterior bleed may have some anterior flow but predominantly manifests with posterior oropharyngeal blood flow.
See Epistaxis for more information.
Have the patient nasally insufflate a topical vasoconstrictor, such as oxymetazoline or phenylephrine. To provide anesthesia, add 2% lidocaine solution to the vasoconstrictor first, and then have the patient inhale the combination.
Apply mupirocin (Bactroban) nasal ointment 2% to the double-balloon catheter, and advance the device completely into the nostril. Inflate the posterior balloon with up to 7-10 mL of sterile water. Withdraw the catheter until posterior balloon seats. The balloon stops at the posterior nasal cavity. Inflate the anterior balloon with up to 15-30 mL of sterile water.
Apply padding (eg, Xeroform wrap, iodoform strips) to prevent alar necrosis. Leave the balloons in place for 3-5 days, until coagulopathy and hypertension have been controlled.
Apply mupirocin nasal ointment 2% to the Foley catheter, and insert the device into the nostril. Visualize the catheter tip in the back of the throat. Inflate the balloon with up to 10 mL of sterile water. (Do not inflate the balloon to its full 30-mL capacity.) Withdraw the balloon gently until it seats posteriorly.
Pack the anterior nasal cavity with a balloon device, nasal tampon (eg, Rhino Rocket), or layered ribbon gauze. Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep the balloon from dislodging.
Topical anesthetics include lidocaine (2% solution) (see the image below).
For more information, see Topical Anesthesia.
Vasoconstrictors include the following:
Epinephrine (1:1000 or 1:10,000) (see the images below)
Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)
Equipment includes the following:
Gloves
Tape
Tongue depressors
Nasal speculum
Posterior packing (balloon methods) – Commercially produced double-balloon tampon (see the first image below); Foley catheter, 10-14 French with a 30-mL balloon (see the second image below)
Posterior packing (gauze method) – Silk suture material, 0 gauge; gauze squares, 4 × 4; catheter (Foley or some other type; not to be inflated); hemostats
Commercially produced anterior nasal tampon
Absorbable gelatin (Gelfoam)
Oxidized cellulose (Surgicel)
Place patient in the upright position (see the image below) unless hemodynamic instability prevents this positioning.
Antibiotics may be prescribed. Agents that cover Staphylococcus species (eg, cephalexin, amoxicillin, ampicillin) can prevent sinusitis and toxic shock syndrome.
Admit all patients with posterior packing to the hospital for observation. Reflex bradydysrhythmia can develop because of stimulation of the deep posterior oropharynx by the packing. Airway compromise may develop. Posterior packing should be removed in 72-96 hours.
Potential complications include the following:
Sinusitis
Nasal septal pressure necrosis
Abscesses
Neurogenic syncope
Toxic shock syndrome
Persistent bleeding and restart of bleeding, in spite of above interventions
Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006 Mar. 64(3):511-8. [Medline].
Frazee TA, Hauser MS. Nonsurgical management of epistaxis. J Oral Maxillofac Surg. 2000 Apr. 58(4):419-24. [Medline].
Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope. 1987 Dec. 97(12):1392-6. [Medline].
Tintinalli JE, Ruiz E, Krome RL, eds. Nasal emergencies and sinusitis. Emergency Medicine: A Comprehensive Study Guide. 4th. New York: McGraw-Hill, Health Professions Division; 1996. 1083-93.
Reichman E, et al. Emergency Medicine Procedures. McGraw Hill; 2004.
Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. 2005 Jul. 22(7):470-2. [Medline].
Chiu TW, McGarry GW. Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis. Otolaryngol Head Neck Surg. 2007 Sep. 137(3):390-3. [Medline].
Saba HI, Morelli GA, Logrono LA. Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med. 1994 Jun 23. 330(25):1789-90. [Medline].
Eric Goralnick, MD Instructor in Medicine, Brigham and Women’s Hospital
Eric Goralnick, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Prajoy P Kadkade, MD Assistant Professor of Otolaryngology, Albert Einstein College of Medicine; Attending Physician, Department of Otolaryngology and Communicative Disorders, Director of Otolaryngology, North Shore University Hospital, North Shore-Long Island Jewish Hospital System
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Medical Society of the State of New York
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Scott Bailey, MD, to the development and writing of the source article.
Posterior Epistaxis Nasal Pack
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