Background

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, andC 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 necessitateprocedural sedation. Ananterior 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, seeEpistaxis,Management of Acute Epistaxis, andAnterior Epistaxis Nasal Pack.

Relevant Anatomy

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]

Nasal vascular anatomy.

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For more information about the relevant anatomy, seeNasal Anatomy.

Indications

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 withatherosclerosis, 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.

Contraindications

Posterior nasal packing should not be performed in the presence of facial trauma that may include nasal bone and cribriform plate fractures. (SeeFacial 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.

Overview

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.

SeeEpistaxis for more information.

Topical Anesthesia and Vasoconstriction

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.

Double-Balloon Approach

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.

Foley Catheter Approach

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.

Posterior packing with 10F Foley catheter

Posterior packing with 10F Foley catheter.

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Anesthesia

Topical anesthetics include lidocaine (2% solution) (see the image below).

Lidocaine, 2%.

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For more information, seeTopical 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)

  Epinephrine 1:1000.

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  Epinephrine 1:10,000.

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Equipment

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)

  Medtronic Xomed double-balloon catheter.

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  Foley catheter, 10F.

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• 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)

Positioning

Place patient in the upright position (see the image below) unless hemodynamic instability prevents this positioning.

Proper positioning of patient.

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Postoperative Care

Antibiotics may be prescribed. Agents that coverStaphylococcus species (eg, cephalexin, amoxicillin, ampicillin) can preventsinusitis andtoxic 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.

Complications

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