How is posterior epistaxis treated using balloon tamponade. What are the indications and contraindications for this procedure. What equipment is needed for balloon tamponade of posterior nosebleeds. How is the balloon insertion technique performed to stop severe nasal bleeding.

Understanding Posterior Epistaxis: Causes and Challenges

Posterior epistaxis, or bleeding from the back of the nasal passage, presents a significant medical challenge compared to its anterior counterpart. While less common, posterior nosebleeds are often more severe and difficult to manage. But what exactly causes this type of nasal hemorrhage?

Posterior epistaxis can result from various factors, including:

• Trauma to the back of the nasal cavity
• High blood pressure
• Blood thinning medications
• Vascular abnormalities
• Tumors in the nasal or sinus region

The location of the bleeding source makes it particularly challenging to access and treat directly. This is why specialized techniques like balloon tamponade have become crucial in managing these cases.

Why is posterior epistaxis more dangerous?

Posterior nosebleeds pose a greater risk due to several factors:

1. Higher blood flow in the posterior nasal region
2. Difficulty in directly visualizing and accessing the bleeding site
3. Increased risk of airway compromise
4. Potential for significant blood loss before effective intervention

These factors underscore the importance of prompt and effective treatment, often necessitating more advanced techniques like balloon tamponade.

Balloon Tamponade: A Modern Approach to Posterior Epistaxis Control

Balloon tamponade has emerged as a preferred method for managing posterior epistaxis, offering several advantages over traditional gauze packing. This technique involves inserting a specially designed balloon catheter into the nasal cavity to apply pressure directly to the bleeding site.

Advantages of balloon tamponade over gauze packing

• Easier insertion procedure
• More comfortable for the patient
• Better distribution of pressure
• Reduced risk of mucosal injury
• Easier removal process

Some advanced balloon systems can simultaneously occlude both the anterior and posterior nasal cavity, providing comprehensive hemorrhage control. This dual-action approach can be particularly effective in cases of diffuse or hard-to-localize bleeding sources.

Indications and Contraindications for Balloon Tamponade in Posterior Epistaxis

While balloon tamponade is a valuable tool in managing posterior epistaxis, it’s crucial to understand when it’s appropriate to use this technique and when other interventions may be necessary.

When is balloon tamponade indicated?

Balloon tamponade is typically indicated in the following scenarios:

• Persistent posterior epistaxis unresponsive to topical vasoconstrictors
• Cases where the bleeding source cannot be visualized or accessed directly
• As a temporary measure to stabilize a patient before definitive treatment
• In situations where more invasive interventions are not immediately available or appropriate

Absolute contraindications for balloon tamponade

There are several situations where balloon tamponade should not be attempted:

1. Suspected or confirmed skull base fracture
2. Significant maxillofacial or nasal bone trauma
3. Uncontrolled airway or hemodynamic instability

In these cases, the risks of the procedure outweigh its potential benefits, and alternative management strategies should be pursued.

Relative contraindications and potential complications

While not absolute, the following factors should be carefully considered before proceeding with balloon tamponade:

• Risk of pressure necrosis to nasal tissues
• Potential for balloon migration and airway compromise
• Increased risk of sinusitis or otitis media
• Rare cases of toxic shock syndrome associated with nasal packing
• Theoretical risk of catheter penetration into the skull base (in cases of pre-existing trauma)

These relative contraindications highlight the importance of careful patient selection and close monitoring during and after the procedure.

Essential Equipment for Balloon Tamponade in Posterior Epistaxis

Proper preparation and equipment are crucial for the successful implementation of balloon tamponade in managing posterior epistaxis. Having the right tools at hand can make the difference between a smooth procedure and potential complications.

Personal protective equipment (PPE)

Ensuring proper protection for both the healthcare provider and the patient is paramount. Essential PPE includes:

• Sterile gloves
• Surgical mask
• Protective gown
• Patient drapes

Monitoring equipment

Given the potential for complications, continuous monitoring of the patient’s vital signs is crucial. Key monitoring equipment includes:

• Cardiac monitor
• Pulse oximeter

Intravenous access and fluid management

Establishing reliable IV access is essential for fluid management and potential medication administration. Required items include:

• 18-gauge (or larger) angiocatheter
• 1 L isotonic crystalloid solution (e.g., 0.9% saline)

Medication for sedation and analgesia

Posterior nasal packing can be uncomfortable, often necessitating sedation and pain management. Commonly used medications include:

• Fentanyl (0.5 to 1.0 mcg/kg, maximum dose 100 mcg)
• Note: Lower doses may be appropriate for patients over 65 years old

Balloon catheter and associated equipment

The core components for the tamponade procedure include:

• Appropriate balloon catheter system (specific to posterior or combined anterior/posterior use)
• Sterile gauze sponges
• Emesis basin
• Suction source with Frazier-tip attachment

Having all these elements prepared before initiating the procedure ensures a smoother, more efficient process and potentially better outcomes for the patient.

Step-by-Step Technique for Balloon Tamponade Insertion

Proper insertion of the balloon catheter is crucial for effective control of posterior epistaxis. This step-by-step guide outlines the key stages of the procedure.

Patient preparation

1. Position the patient in a slightly reclined position with the head elevated at about 30 degrees.
2. Apply topical anesthetic and vasoconstrictor to the nasal cavity if not already done.
3. Ensure IV access is established and monitoring equipment is in place.
4. Administer sedation and analgesia as needed, titrating to effect.

Catheter insertion

1. Lubricate the deflated balloon catheter with water-soluble lubricant.
2. Gently insert the catheter along the floor of the nasal cavity, aiming towards the back of the throat.
3. Advance the catheter until resistance is felt or the desired depth is reached (typically when the catheter is visible in the oropharynx).

Balloon inflation

1. Slowly inflate the posterior balloon with sterile saline or water, following manufacturer guidelines for volume.
2. Gently pull the catheter forward to seat the balloon against the posterior choana.
3. If using a combination anterior/posterior balloon, inflate the anterior balloon next.
4. Secure the catheter to prevent migration, typically by taping to the cheek or using a specially designed securing device.

Confirming proper placement

1. Visually inspect the oropharynx to ensure the posterior balloon is properly seated.
2. Check for ongoing bleeding from the nares or posterior pharynx.
3. Assess the patient’s comfort level and ability to breathe through the unaffected nostril.

Remember, the exact technique may vary slightly depending on the specific balloon system used. Always refer to the manufacturer’s instructions for device-specific guidance.

Post-Insertion Care and Monitoring

After successful insertion of the balloon tamponade, careful monitoring and follow-up care are essential to ensure effective bleeding control and minimize complications.

Immediate post-procedure care

• Continue cardiac monitoring and pulse oximetry for at least 2 hours post-insertion.
• Administer supplemental oxygen if needed to maintain adequate saturation.
• Provide appropriate analgesia to manage discomfort.
• Elevate the head of the bed to 30-45 degrees to reduce venous pressure.

Ongoing monitoring

Regular assessments should include:

1. Vital signs, including blood pressure and heart rate
2. Signs of ongoing bleeding (oral or nasal)
3. Balloon integrity and position
4. Patient comfort and ability to breathe
5. Hydration status and urine output

Potential complications to watch for

Be vigilant for signs of the following complications:

• Pressure necrosis of nasal tissues
• Sinusitis or otitis media
• Balloon migration or displacement
• Toxic shock syndrome (rare but serious)
• Cardiovascular complications (e.g., vagal response, arrhythmias)

Duration of tamponade

The optimal duration for balloon tamponade can vary based on individual circumstances, but general guidelines include:

• Minimum of 48-72 hours for most cases
• Up to 5-7 days in severe or recurrent cases
• Gradual deflation and removal under medical supervision

Always consult with an otolaryngologist or appropriate specialist for guidance on timing of removal and further management.

Alternative and Adjunctive Treatments for Posterior Epistaxis

While balloon tamponade is an effective method for managing posterior epistaxis, it’s important to be aware of alternative and complementary approaches that may be used in conjunction with or instead of balloon tamponade.

Topical treatments

• Vasoconstrictor sprays (e.g., oxymetazoline, phenylephrine)
• Topical tranexamic acid
• Hemostatic agents (e.g., gelatin-thrombin matrix)

Systemic interventions

In some cases, systemic treatments may be necessary to address underlying causes or support local measures:

• Correction of coagulopathies (e.g., vitamin K, fresh frozen plasma)
• Antifibrinolytic agents (e.g., tranexamic acid)
• Blood pressure management in hypertensive patients

Surgical and interventional approaches

When conservative measures fail or in cases of severe, recurrent bleeding, more invasive interventions may be required:

1. Endoscopic cauterization of bleeding vessels
2. Arterial ligation (e.g., sphenopalatine artery ligation)
3. Endovascular embolization

Combination therapies

Often, a multimodal approach yields the best results. This might include:

• Balloon tamponade combined with topical hemostatic agents
• Systemic antifibrinolytics alongside local measures
• Staged approach, starting with conservative methods and escalating as needed

The choice of treatment should be tailored to the individual patient, considering factors such as the severity of bleeding, underlying causes, and available resources.

Long-Term Management and Prevention of Recurrent Posterior Epistaxis

While acute management of posterior epistaxis is crucial, addressing underlying causes and implementing preventive strategies are equally important for long-term patient care.

Identifying and treating underlying causes

Common contributors to recurrent epistaxis include:

• Hypertension
• Coagulation disorders
• Vascular anomalies
• Nasal tumors or polyps
• Chronic sinusitis

A thorough workup and appropriate specialist referrals may be necessary to address these underlying issues.

Lifestyle modifications

Patients can take several steps to reduce the risk of recurrent epistaxis:

1. Maintain proper nasal hygiene and hydration
2. Use a humidifier in dry environments
3. Avoid nasal irritants (e.g., smoking, excessive alcohol consumption)
4. Practice gentle nose-blowing techniques

Medication management

Adjusting medications that may contribute to bleeding risk is often necessary:

• Optimizing anticoagulant and antiplatelet therapy
• Managing hypertension effectively
• Considering prophylactic use of topical treatments (e.g., saline sprays, moisturizing gels)

Follow-up care

Regular follow-up is essential for patients with a history of severe epistaxis:

• Scheduled check-ups with primary care or ENT specialists
• Nasal endoscopy to assess for recurrent bleeding sources or structural abnormalities
• Patient education on early recognition and first-aid measures for nosebleeds

By implementing a comprehensive long-term management plan, the frequency and severity of epistaxis episodes can often be significantly reduced, improving patient quality of life and reducing the need for emergency interventions.

How To Treat Posterior Epistaxis With a Balloon – Ear, Nose, and Throat Disorders

By

Waleed M Abuzeid

, BSc, MBBS, University of Washington

Reviewed/Revised Nov 2020 | Modified Sep 2022

View Patient Education

Topic Resources

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 more common, but posterior bleeding is more dangerous and is managed differently; thus, identifying the site of bleeding is critical. Epistaxis that persists without an evident anterior nasal source is most often caused by a posterior bleeding site.

Posterior bleeding is sometimes controlled using topical vasoconstrictors. If not, it usually requires treatment with tamponade. Historically, gauze packing was used but balloon tamponade is easier to do and more comfortable to the patient and thus is usually preferred. Some balloons can occlude both the anterior and posterior nasal cavity simultaneously.

Posterior nasal packing is very uncomfortable. Intravenous sedation and analgesia are often needed and hospitalization is often required. Applying a cardiac monitor and pulse oximetry Pulse Oximetry Gas exchange is measured through several means, including Diffusing capacity for carbon monoxide Pulse oximetry Arterial blood gas sampling The diffusing capacity for carbon monoxide (DLCO)… read more is strongly recommended.

(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 , How To Treat Epistaxis With 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 and How To Treat Anterior Epistaxis With Tamponade How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may… read more .)

Absolute contraindications

• Possible or identified skull base fracture

• Significant maxillofacial or nasal bone trauma

• Uncontrolled airway or hemodynamic instability

Procedures described here are intended for spontaneous posterior epistaxis. Epistaxis in patients with significant facial trauma should be managed by a specialist.

Relative contraindications

• Injury (eg, pressure necrosis)

• Migration of the nasal packing and aspiration into the airway or airway compromise

• 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 , otitis media Introduction to Middle Ear and Tympanic Membrane Disorders Middle ear disorders may be secondary to infection, eustachian tube obstruction, or trauma. Information about objects placed in the ear and symptoms such as rhinorrhea, nasal obstruction, sore… 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

• Penetration of the catheter through the skull base and into the brain parenchyma, though this is unlikely in the absence of preexisting skull base trauma

• Dysphagia

• Otitis media secondary to eustachian tube obstruction

• Necrosis of the nasal ala

• Sometimes hypoxemia, particularly if patients are also sedated

• Activation of the trigemino-cardiac reflex leading to cardiac arrhythmia and even cardiac arrest*

* Such cardiac complications have been reported in the literature, although this remains controversial.

• Gloves, mask, and gown

• Gown or drapes for patient

• Cardiac monitor, pulse oximeter

• IV setup: 18-gauge (or larger) angiocatheter and 1 L isotonic crystalloid solution (eg, 0.9% saline)

• Drugs for sedation/analgesia if needed (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect)

• Sterile gauze sponges

• Emesis basin

• Suction source and Frazier-tip suction catheter

• Chair with headrest or ear, nose, and throat (ENT) specialist’s chair

• Light source and head mirror or headlamp with adjustable narrow beam

• Nasal speculum

• Tongue depressors

• Bayonet forceps

• 12 to 16 French inflatable balloon (eg, Foley) catheter or commercial epistaxis balloon (single or dual-balloon)

• 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)

• Water-soluble lubricant or anesthetic jelly (eg, viscous lidocaine)

• Cotton pledgets or swabs

• Sometimes supplies and equipment for anterior nasal packing How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may… read more using a gauze strip

• Initiate treatment for any hypovolemia or shock before treating epistaxis.

• 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 patient has severe or recurrent epistaxis.

If posterior packing fails to control nasal hemorrhage, invasive methods done by specialists may be needed:

• Sphenopalatine artery (SPA) ligation, typically done using a transnasal endoscopic approach; success rates exceed 85% (1 References 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 )

• Endovascular SPA embolization; reported success rate 88% (2 References 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 ).

Endoscopic SPA ligation is done by an otolaryngologist and has a lower risk of major complications (eg, stroke, blindness) than endovascular SPA embolization and may be more appropriate for patients who can safely tolerate general anesthesia or if the embolization procedure is not readily available.

Endovascular SPA embolization is done by an interventional radiologist under local anesthesia and may be better for patients with multiple comorbidities that preclude safe general anesthesia, for those on anticoagulant therapy, and for patients who present with bleeding after previously having had endoscopic SPA ligation.

• The patient should sit upright in the sniffing position with head extended, preferably in an ENT specialist’s 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 an emesis basin to collect any continued bleeding or emesis of swallowed blood.

Initial steps:

• Start IV and send any laboratory studies needed.

• Place patient on cardiac monitor and pulse oximeter.

• Have the patient blow the nose to remove clots, or suction the nasal passageway gently.

• To help identify the bleeding site (and possibly stop the bleeding), apply a 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.

• 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.

• If no bleeding site is visible in the anterior nose, use a tongue depressor and look into the oropharynx. Continued bleeding suggests a posterior source.

Place balloon catheter to tamponade active posterior bleeding:

• Give IV analgesia (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect).

• Insert the balloon catheter into the nose, and gently advance it parallel to the floor of the nasal cavity. Advance the catheter until the tip can be seen in the oropharynx when looking through the mouth.

• Follow inflation instructions for any commercial epistaxis balloon. If using a Foley catheter, partially inflate the balloon with 5 to 7 mL of water. Gently pull the catheter anteriorly until it is firmly seated in the posterior nasal cavity. Then slowly add another 5 to 7 mL of water.

• If pain or inferior displacement of the soft palate occurs, deflate the balloon until the pain resolves or the soft palate is no longer displaced.

• While maintaining traction on the catheter, place anterior nasal packing How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may… read more of layered petrolatum gauze.

• Consider packing the contralateral anterior nasal cavity to avoid septal deviation.

• Wrap a piece of gauze around the catheter at the naris to protect the nasal ala and place a clamp on the catheter to prevent the balloon from sliding back out of the posterior nasal cavity.

• If using a dual-balloon catheter, first inflate the posterior balloon, using the same general technique as for the single balloon catheter. Then inflate the anterior balloon (typically with 30 mL). Anterior nasal packing with layered gauze is unnecessary when using a dual-balloon catheter.

VIDEO

• Admit all patients with posterior balloon packing. Manage hypoxemia as required.

• Avoid use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days post-treatment.

• Give an antibiotic (eg, amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) to prevent 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 otitis media Introduction to Middle Ear and Tympanic Membrane Disorders Middle ear disorders may be secondary to infection, eustachian tube obstruction, or trauma. Information about objects placed in the ear and symptoms such as rhinorrhea, nasal obstruction, sore… read more .

• Deflate the balloon and remove the catheter after 48 to 72 hours.

• Elevating the patient’s chair to eye height is easier on the practitioner’s back than bending down.

• Always consult an otolaryngologist after placement of a posterior nasal pack to ensure follow-up.

• After placement of the posterior pack, look through the mouth to make sure that there is no further bleeding down the throat. If there is bleeding, put more fluid into the catheter balloon. If this fails to control bleeding, consult an otolaryngologist immediately.

• 1. Rudmik L, Smith TL: Management of intractable spontaneous epistaxis. Am J Rhinol Allergy 26(1):55-60, 2012.

• 2. Christensen NP, Smith DS, Barnwell SL, et al: Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg 133:748-753, 2005. doi: 10.1016/j.otohns.2005.07.041

Drug Name	Select Trade
fentanyl	ABSTRAL, Actiq, Duragesic, Fentora, IONSYS, Lazanda, Onsolis, Sublimaze, SUBSYS
cocaine	GOPRELTO, NUMBRINO
tetracaine	AK-T Caine, Pontocaine, Pontocaine in Dextrose, Pontocaine Niphanoid, Tetcaine, TetraVisc, TetraVisc Forte, Viractin
lidocaine	7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, Gold Bond, LidaMantle, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido
oxymetazoline	12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children’s Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, Rhinase D, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L. R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
aspirin	Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children’s Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
amoxicillin	Amoxil, Dispermox, Moxatag, Moxilin , Sumox, Trimox

NOTE:


This is the Professional Version.


CONSUMERS:



View Consumer Version

Copyright © 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

Test your knowledge

Take a Quiz! 

Management of Epistaxis | AAFP

CORRY J. KUCIK, LT, MC, USN, AND TIMOTHY CLENNEY, CDR, MC, USN

Family physicians frequently encounter patients with epistaxis (nasal bleeding). In rare cases, this condition may lead to massive bleeding and even death. Although epistaxis can have an anterior or posterior source, it most often originates in the anterior nasal cavity. A directed history and physical examination generally determine the cause of the bleeding. Both local and systemic processes can play a role in epistaxis. Nasal bleeding usually responds to first-aid measures such as compression. When epistaxis does not respond to simple measures, the source of the bleeding should be located and treated appropriately. Treatments to be considered include topical vasoconstriction, chemical cautery, electrocautery, nasal packing (nasal tampon or gauze impregnated with petroleum jelly), posterior gauze packing, use of a balloon system (including a modified Foley catheter), and arterial ligation or embolization. Topical or systemic antibiotics should be used in selected patients. Hospital admission should be considered for patients with significant comorbid conditions or complications of blood loss. Referral to an otolaryngologist is appropriate when bleeding is refractory, complications are present, or specialized treatment (balloon placement, arterial ligation, angiographic arterial embolization) is required.

Epistaxis, or nasal bleeding, has been reported to occur in up to 60 percent of the general population.^1–3 The condition has a bimodal distribution, with incidence peaks at ages younger than 10 years and older than 50 years. Epistaxis appears to occur more often in males than in females.^1,4

Epistaxis is common, and affected persons usually do not seek medical attention, particularly if the bleeding is minor or self-limited. In rare cases, however, massive nasal bleeding can lead to death.^5–7

Key clinical recommendation	Label	References
If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed from posterior to anterior with ribbon gauze impregnated with petroleum jelly or antibiotic ointment.	C	5,9
Based on one study, chemical cautery (silver nitrate sticks) can be used for simple anterior epistaxis because it has efficacy and complication rates similar to electrocautery.	C	14
Because of the possibility of toxic shock syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended.	C	10,12
Either ribbon gauze packing or nasal tampons can be used for packing; one study found no significant difference in patient comfort or efficacy.	B	15

Anatomy

The rich vascular supply of the nose originates from the ethmoid branches of the internal carotid arteries and the facial and internal maxillary divisions of the external carotid arteries. ⁵ Although nasal circulation is complex (Figure 1), epistaxis usually is described as either anterior or posterior bleeding. This simple distinction provides a useful basis for management.

Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach’s plexus). Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries.⁸ Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity.

In most cases, anterior bleeding is clinically obvious. In contrast, posterior bleeding may be asymptomatic or may present insidiously as nausea, hematemesis, anemia, hemoptysis, or melena. Infrequently, larger vessels are involved in posterior epistaxis and can result in sudden, massive bleeding.

Etiology

Most causes of nasal bleeding can be identified readily through a directed history and physical examination. The patient should be asked about the initial presentation of the bleeding, previous bleeding episodes and their treatment, comorbid conditions, and current medications, including over-the-counter medicines and herbal and home remedies. Although the differential diagnosis should include both local and systemic causes (Table 1),^1,5,9 environmental factors such as humidity and allergens also must be considered.^5,10 Often, no cause for the bleeding is identified.

Local causes

Chronic sinusitis

Epistaxis digitorum (nose picking)

Foreign bodies

Intranasal neoplasm or polyps

Irritants (e.g., cigarette smoke)

Medications (e.g., topical corticosteroids)

Rhinitis

Septal deviation

Septal perforation

Trauma

Vascular malformation or telangiectasia

Systemic causes

Hemophilia

Hypertension

Leukemia

Liver disease (e. g., cirrhosis)

Medications (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs)

Platelet dysfunction

Thrombocytopenia

Management

GENERAL APPROACH

Initial management includes compression of the nostrils (application of direct pressure to the septal area) and plugging of the affected nostril with gauze or cotton that has been soaked in a topical decongestant. Direct pressure should be applied continuously for at least five minutes, and for up to 20 minutes. Tilting the head forward prevents blood from pooling in the posterior pharynx, thereby avoiding nausea and airway obstruction. Hemodynamic stability and airway patency should be confirmed. Fluid resuscitation should be initiated if volume depletion is suspected.

Every attempt should be made to locate the source of bleeding that does not respond to simple compression and nasal plugging. The examination should be performed in a well-lighted room, with the patient seated and clothing protected by a sheet or gown. The physician should wear gloves and other appropriate protective equipment (e.g., surgical mask, safety glasses). A headlamp or head mirror and a nasal speculum should be used for optimal visualization.

An epistaxis tray can be created using common supplies and a few specialized instruments (Figure 2). Clots and foreign bodies in the anterior nasal cavity can be removed with a small (Frazier) suction tip, irrigation, forceps, and cotton-tipped applicators.

When posterior bleeding is suspected, the general location of the source should be determined. This step is important because different arteries supply the floor and roof of the posterior nasal cavity; therefore, selective ligation may be required.^5,11

Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic process such as hypertension, anticoagulation, or coagulopathy. In such cases, a hematologic evaluation should be performed. Appropriate tests include a complete blood count, anticoagulant levels, a prothrombin time, a partial thromboplastin time, a platelet count and, if indicated, blood typing and crossmatching.^9,12

Although most patients with epistaxis can be treated as outpatients, hospital admission and close observation should be considered for elderly patients and patients with posterior bleeding or coagulopathy. Admission also may be prudent for patients with complicating comorbid conditions such as coronary artery disease, severe hypertension, or significant anemia.

ANTERIOR EPISTAXIS

If a single anterior bleeding site is found, vasoconstriction should be attempted with topical application of a 4 percent cocaine solution or an oxymetazoline or phenylephrine solution. For bleeding that is likely to require more aggressive treatment, a local anesthetic, such as a 4 percent cocaine solution or tetracaine or lidocaine (Xylocaine) solution, should be used. Adequate anesthesia should be obtained before treatment proceeds.

Intravenous access should be obtained in difficult cases, especially when anxiolytic medications are to be used.

Cotton pledgets soaked in vasoconstrictor and anesthetic should be placed in the anterior nasal cavity, and direct pressure should be applied at both sides of the nose for at least five minutes. Then the pledgets can be removed for reinspection of the bleeding site. If this measure is unsuccessful, chemical cautery can be attempted using a silver nitrate stick applied directly to the bleeding site for approximately 30 seconds.⁵ Other treatment options include hemostatic packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel). Use of desmopressin spray (DDAVP) may be considered in a patient with a known bleeding disorder.^5,13

Larger vessels generally respond more readily to electrocautery. However, electrocautery must be performed cautiously to avoid excessive destruction of healthy surrounding tissues. Note that use of electrocautery on both sides of the septum may increase the risk of septal perforation.⁹ Interestingly, at least one study¹⁴ found no difference in efficacy or complication rate between chemical cautery (silver nitrate stick) and electrocautery.

If local treatments fail to stop anterior bleeding, the anterior nasal cavity should be packed, from posterior to anterior, with ribbon gauze impregnated with petroleum jelly or polymyxin B-bacitracin zinc-neomycin (Neosporin) ointment. Nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate (Xeroform) also works well for this purpose.^5,9 Bayonet forceps and a nasal speculum are used to approximate the accordion-folded layers of the gauze, which should extend as far back into the nose as possible. Each layer should be pressed down firmly before the next layer is inserted (Figure 3). Once the cavity has been packed as completely as possible, a gauze “drip pad” may be taped over the nostrils and changed periodically.

Alternatively, a preformed nasal tampon (Merocel or Doyle sponge) may be used.¹² The tampon is inserted carefully along the floor of the nasal cavity, where it expands on contact with blood or other liquid. Application of lubricant jelly to the tip of the tampon facilitates placement. After the nasal tampon has been inserted, wetting it with a small amount of topical vasoconstrictor may hasten effectiveness. It may be necessary to drip saline into the nostril to achieve full expansion of the tampon if the bleeding has decreased at the time of insertion. Although one study¹⁵ found no significant difference in patient comfort or efficacy with nasal tampons or ribbon gauze packing, simplicity of placement makes the tampons highly useful in primary care settings. When applied in the outpatient setting, nasal packing may be left in place for three to five days to ensure formation of an adequate clot.¹²

Complications of nasal packing procedures include septal hematomas and abscesses from traumatic packing, sinusitis, neurogenic syncope during packing, and pressure necrosis secondary to excessively tight packing. Because of the possibility of toxic shock syndrome with prolonged nasal packing, use of a topical antistaphylococcal antibiotic ointment on the packing materials has been recommended.^10,12

POSTERIOR EPISTAXIS

Posterior bleeding is much less common than anterior bleeding¹⁶ and usually is treated by an otolaryngologist. Posterior packing may be accomplished by passing a catheter through one nostril (or both nostrils), through the nasopharynx, and out the mouth (Figure 4). A gauze pack then is secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior choana, sealing the posterior nasal passage and applying pressure to the site of the posterior bleeding.⁵ Although this procedure is not outside the scope of family practice, it requires special training and usually is performed by an otolaryngologist.

Various balloon systems are effective for managing posterior bleeding and are less complicated than the packing procedure. The double-balloon device (Figure 2) is passed into the affected nostril under topical anesthesia until it reaches the nasopharynx. The posterior balloon then is inflated with 7 to 10 mL of saline, and the catheter extending out of the nostril is withdrawn carefully so that the balloon seats in the posterior nasal cavity to tamponade the bleeding source. Next, the anterior balloon is inflated with roughly 15 to 30 mL of saline in the anterior nasal cavity to prevent retrograde travel of the posterior balloon and subsequent airway obstruction. An umbilical clamp or other device can be placed across the stalk of the balloon adjacent to the nostril to further prevent dislodgement; the clamp should be padded to prevent pressure necrosis of the nasal skin. Balloon packs generally are left in place for two to five days. As with anterior packing, tissue necrosis can occur if a posterior pack is inserted improperly or balloons are overinflated.

If a specialized balloon device is not available, a Foley catheter (10 to 14 French) with a 30-mL balloon may be used. The catheter is inserted through the bleeding nostril and visualized in the oropharynx before inflation of the balloon.¹⁸ The balloon then is inflated with approximately 10 mL of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and forward. The balloon should seat in the posterior nasal cavity and tamponade a posterior bleed. With traction maintained on the catheter, the anterior nasal cavity then is packed as previously described. Traction is maintained by placing an umbilical clamp on the catheter beyond the nostrils, which should be padded to prevent soft tissue damage. As with anterior epistaxis, topical antistaphylococcal antibiotic ointment may be used to prevent toxic shock syndrome. However, use of oral or intravenous antibiotics for posterior nasal packing most likely is unnecessary.¹⁹

PERSISTENT BLEEDING

Patients with anterior or posterior bleeding that continues despite packing or balloon procedures may require treatment by an otolaryngologist. Endoscopy may be used to locate the exact site of bleeding for direct cauterization.

Hot water irrigation, a technique described more than 100 years ago, has been reexamined recently. This technique has shown promise in reducing discomfort and length of hospitalization in patients with posterior epistaxis.^20,21 More invasive alternatives include arterial ligation and angiographic arterial embolization.

Postoperative hemostasis in intranasal surgery | Kryukov A.I., Tsarapkin G.Yu., Lavrova A.S., Artemiev M.E.

Endonasal operations occupy a leading place in the structure of surgical treatment of ENT pathology [7]. Intraoperative epistaxis is characterized by predictability, while the achievement of reliable hemostasis is the main condition for the completion of surgical intervention.

Features of the anatomical structure of the nasal cavity limit the otorhinolaryngologist in choosing ways to stop postoperative nosebleeds, which determines the acuteness of the issue of preventing its recurrence in the early and delayed periods after treatment. The fundamental points in reducing the likelihood of resumption of postoperative nosebleeds are the combination of minimally invasive ENT surgery, rational prevention of bacterial invasion and low traumatization of the nasal mucosa in the postoperative period.
The sparing attitude to the mucous membrane of the nasal septum is reflected in the use of septal splints, which make it possible to exclude mucoperichondrial injury during postoperative care [2]. The combination of the nasal septal stenting method with “bloodless” radio wave disintegration allows the surgeon to carry out the postoperative period without tampons in patients with nasal septal curvature, combined with vasomotor dysfunction of the inferior turbinates [3,4]. The method of tampon-free management of patients undergoing septoplasty, described by A.I. Kryukov et al. (2008), not only improves the patient’s quality of life in the early postoperative period, but also eliminates long-term compression injury of the nasal mucosa during tamponade.
However, deformity of the nasal septum is quite often combined with chronic hypertrophic rhinitis, and, therefore, together with septoplasty, the patient undergoes a sparing excision of the altered areas of the nasal concha, which is accompanied by profuse nosebleeds. Regardless of the etiology of epistaxis, initial therapeutic measures should be aimed at stopping it and correcting hypovolemia [1,5].
Ways to stop bleeding of any localization, depending on the nature of the methods used, are divided into mechanical, physical, chemical and biological [6]. Mechanical methods of stopping bleeding are the most reliable, but, given the anatomical features of the nasal cavity, the most common method is plugging. Carrying out this manipulation requires certain skills from the doctor. But the difficulties that arise due to the impossibility of targeting the bleeding areas of the middle and posterior parts of the nasal cavity often do not lead to a positive result, which leads to an increase in the traumatic component in the total volume of the operation [1,11,12]. A significant disadvantage of all types of nasal tampons, with the exception of pneumatic ones, is the impossibility of controlling intranasal tampon pressure, which should not exceed 42 mm Hg, since excessive compression load on the mucous membrane of the nasal septum leads to its ischemia [10].
Physical methods to stop nosebleeds, which are based on the temperature effect on the bleeding vessels of the nasal cavity (local hypo- and hyperthermia), are characterized by short-term clinical effectiveness [12,14]. Local hypothermia is justified only for anterior nosebleeds, while local hyperthermia is effective for bleeding from the posterior parts of the nasal cavity [12,14]. The positive hemostatic effect of thermal effects on the vessels of the nasal cavity is due both to the structural features of the vascular wall and to the response pathophysiological processes in the mucous membrane.
It is known that the vessels of Woodruff’s venous plexus lack a muscular layer [9]. When irrigating the posterior sections of the nasal cavity with hot water (HWI – hot water irrigation), the temperature of which is in the range from 46 to 52ºС, hemostasis is achieved by increasing the speed of the cascade of the blood coagulation system, pronounced edema of the stroma without necrotic damage to the tissues of the nasal cavity [13]. But, despite the low-impact HWI-method of stopping posterior nosebleeds, in almost more than 1/3 of cases (37%) there is a recurrence of bleeding [12].
Therefore, the development of an anatomical intranasal tampon, which allows us to combine several types of impact on the bleeding area with a reasonable reduction in the compression load on the nasal mucosa, seems to us to be an extremely urgent task.
In this regard, we, together with CJSC MedSil (Mytishchi, Moscow region), developed an original intranasal balloon made of two silicone rubber plates hermetically welded together along the edge. The shape of the tampon (plates) was determined based on the vector analysis of CT-reformations of the septum and the lateral wall of the nasal cavity and corresponded to the most significant areas of intranasal surgery and loci of the main blood supply to the nasal cavity. Taking into account the peculiarities of the blood supply to the nasal cavity, the syntopy of the main main vessels and vasal plexuses, the general cavity of the original tampon was divided by suture-soldering into two compartments, which correspond to the posterior and anterior-middle loci of postoperative bleeding.
As a result, we received two balloons located in a single tampon block with separate channels for filling (Fig. 1). The sectional nature of the tampon made it possible to independently mechanically act on the posterior and anterior-middle parts of the nasal cavity. When choosing a tampon filler, we preferred liquid (saline). This choice is dictated by the fact that a liquid is incompressible and it is easier for it to set the required temperature than for a gas.
We compared the original sectional hydrotampon developed by us in terms of its clinical effectiveness in stopping intraoperative nosebleeds both with its closest analogue, a hydroballoon (Epistat, UK), and with a combined effect on the vessels of the posterior parts of the nasal cavity through local hyperthermia.
Under our supervision, there were 78 patients who were examined and treated in the otorhinolaryngological department of the Moscow Scientific and Practical Center for Otorhinolaryngology of the Department of Health of Moscow and the ENT departments of the GKB. S.P. Botkin in the period from 2007 to 2009. about the curvature of the nasal septum and hypertrophic rhinitis. The diagnosis was made on the basis of the patient’s complaints, medical history, examination of the ENT organs and the results of endoscopic examination of the nasal cavity in combination with diagnostic anemization of the mucous membrane of the inferior turbinates. Among the patients there were 32 women and 46 men aged 19up to 55 years old. The inclusion criteria for the study were: the presence of deformity of the nasal septum, combined with hypertrophy of the inferior and/or bullous enlargement of the middle turbinate; the absence of gross deformity of the external nose, affecting nasal breathing and requiring surgical correction.
All patients of the clinical group underwent septoplasty and sparing excision of hypertrophied areas of the turbinates according to the generally accepted method. At the same time, the nasal septum was shielded with septal splints for 7 days. according to the method described by A.I. Kryukov et al. (2008) when its complete immobilization is achieved with two transseptal sutures. Local and general drug therapy in all patients was identical.
Evaluation of the clinical efficacy of different types of balloon tamponade, which was used at the final stage of surgical treatment, was carried out separately for each half of the nose. Thus, our work was represented by 156 study units (nose halves). Depending on the type of hydrotamponade of the nasal cavity, we have identified three groups:
Group I (52 study units) – hemostasis in the nasal cavity was carried out with a hydroballoon;
Group II (52 study units) – hemostasis in the nasal cavity was carried out with a sectional hydrotampon;
Group III (52 study units) – hemostasis in the nasal cavity was performed with a sectional hydrotampon with selective hyperthermia.
Depending on the manifestations of hypertrophic lesions of the turbinates in each clinical group, we identified two subgroups:
A-subgroup (78 study units) – a combination of bullous hypertrophy of the middle turbinate and an increase in the anterior end and middle sections of the inferior turbinate;
B-subgroup (78 study units) – limited hypertrophy of the posterior sections of the inferior turbinate.
The period of hydrotamponade of the nasal cavity was 24 hours, while the temperature of the physiological solution injected into the hydrotampon in patients of groups I, II and in the anterior compartment of group III corresponded to room temperature (19–21oC). The choanal compartment in group III patients was filled with a solution heated to 50–51°C (selective hyperthermia). The choice of the site of selective hyperthermic exposure, which increases the rate of the cascade of the blood coagulation system without necrotic tissue damage [13], was determined by the structural features of the vascular wall of Woodruff’s plexus [9]. Quantitative assessment of the viability of intranasal hydrotamponade was performed by measuring the volume of injected filler (in ml) and intranasal tampon compression created (in mm Hg), sufficient to achieve postoperative hemostasis. The qualitative component of the viability of hydrotamponade of the nasal cavity was assessed using a visual analogue scale (VAS).
Assessing the quality of the performed tamponade, we noted that hydroballoon (group I), sectional hydrotampon (group II) and sectional hydrotampon with selective hyperthermia (group III) showed a fairly high efficiency in achieving postoperative hemostasis during endonasal surgical interventions: VAS values ​​ranged from 0 .87±0.02 to 0.92±0.03 points, p<0.01. However, comparing quantitative values ​​(tampon volume - in ml and intranasal tampon pressure - in mmHg), we revealed the advantage of a sectional hydrotampon with selective hyperthermia over a hydroballoon and a sectional hydrotampon. The results of a quantitative assessment of the consistency of postoperative hemostasis in patients undergoing septoplasty with sparing conchotomy are presented in Table 1.
Comparing the values ​​of the volume index, we recorded that in order to stop intraoperative nosebleeds in subgroups III-A, a smaller volume of the tampon is needed than that in subgroups I-A and II-A (5,20, 9.71 and 5. 75 ml, respectively), while the difference in the obtained values ​​corresponds to a decrease of 46.4 and 9.6%. Correlating the total volume index of III-B subgroup (5.29 ml) with the results obtained in I-B (12.29 ml) and II-B (6.11 ml) subgroups, we noted a decrease in volume value by 57 and 13, 4% respectively. Comparing the volume values ​​in the anterior and posterior compartments of hydrotampons of groups II and III, we obtained results that clearly indicate that selective hyperthermia leads to a decrease in the volume index in both sections of the tampon: in the III-A subgroup, the volume of injected saline in the anterior compartment decreases by 0.22 ml, in the choanal – by 0.33 ml, which, respectively, is 8.5 and 10.5% lower than the compared values ​​in the II-A subgroup; in the III-B subgroup, the decrease in the volume index in the tampon sections was 10.8% (0.25 ml) and 15.0% (0.57 ml), respectively. Our results of studying the volumetric index of nasal hydrotamponade in the compared subgroups are statistically significant (p<0. 05).
We compared the compression component of hydrotamponade between clinical groups, while the results were correlated with the critical value of tampon pressure (42 mm Hg), above which blood circulation in the mucous membrane of the nasal septum stops [10]. It was noted that during the installation of hydroballoons (clinical group I), postoperative hemostasis in subgroup I–A is achieved at a tampon pressure of 45.8±0.05 mm Hg, which is 9.0% higher than the critical one; in subgroup I–B, the manometric indicator is 48.4±0.02 mm Hg, while there is an excess of the critical value by 15.2% (p<0.05). The results obtained by us in the II clinical group (48.2±0.12 mm Hg) testified to the excess of the critical value (by 14.8%), which was recorded only in the choanal compartments of the B-subgroups (p<0.05 ), while in other cases, the tampon pressure was below the "dangerous" level.
Correlating the results of manometric measurement in group III with the critical level, we noted that selective hyperthermia makes it possible to reduce tampon pressure on the nasal mucosa with a minimum difference of 13. 6%, which was noted in the choanal compartment of subgroup III–B. In the course of the study, it was also found that selective hyperthermia (group III) can significantly reduce the compression load on the mucous membrane of the nasal cavity from both the choanal and anterior compartments of the hydrotampon. In the III–A subgroup, the pressure in the posterior compartment of the hydrotampon was 35.7±0.03 mm Hg. At the same time, comparing this indicator with the II-A subgroup, we obtained a decrease in the compression load on the nasal mucosa by 10.3% (4.1 mm Hg).
A decrease in the studied indicator by 6.0% (2.1 mm Hg) was noted in the anterior compartment of the subgroup III-A hydrotampon, while the manometric value was 32.7±0.02 mm Hg. Art. (p<0.05). In the III-B subgroup, the pressure in the posterior compartment of the hydrotampon was fixed at 36.3±0.02 mm Hg. Art. At the same time, comparing this indicator with subgroup II–B, we obtained a decrease in the compression load on the nasal mucosa by 24. 7% (11.9 mm Hg). Also, a decrease in tampon pressure by 9.3% (2.9 mm Hg) was noted in the anterior compartment of hydrotampon III-B subgroup, while the manometric value was 28.4±0.03 mm Hg. (p<0.05).
Thus, the following conclusions can be drawn:
1. The anatomical shape of the sectional hydrotampon allows, with a smaller volume of injected filler, to provide reliable hemostasis in postoperative nosebleeds. A decrease in the volume index by 40.8–50.3% indicates a targeted mechanical effect on the loci of nasal bleeding.
2. The presence of two independent cylinders located in a single block of a sectional hydrotampon allows differential mechanical action on the anterior-middle and posterior regions of the nasal cavity, excluding an unreasonable increase in the tampon pressure on areas that are “uninterested” in this (pressure distribution gradient between the compartments of the hydrotampon in II -A subgroup is 5.0 mm Hg, in II-B subgroup – 16.9 mm Hg).
3. The combination of a mechanical method for stopping postoperative nosebleeds with selective hyperthermia in the posterior areas of nasal bleeding can reduce the compression load on the mucous membrane of the nasal cavity (in the choanal compartment of the tampon – by 10. 3–24.7%; in the anterior compartment – by 6.0 -9.3%).

Literature
1. Volkov A.G., Boyko N.V., Kiselev V.V. Nosebleeds. – M.: APP “Dzhangar”, 2002. – S. 276.
2. Kryukov A.I., Tsarapkin G.Yu., Turovsky A.B. An original method for determining the shape and fixation of septal stents. Bulletin of Otorhinolaryngology. – 2008. – No. 3. – P. 42–45.
3. Kryukov A.I., Tsarapkin G.Yu., Turovsky A.B., Kirilenko E.G. Septal stents – the prospect of tamponade-free management of patients undergoing septoplasty. Bulletin of Otorhinolaryngology. – 2008. – No. 3. – P. 45–47.
4. Leizerman M.G., Starosvetsky A.B. Radio wave surgery in otorhinolaryngology. – M.: Galeria, 2003. – S. 128.
5. Palchun V.T., Kunelskaya N.A., Kislova N.M. Emergency pathology of the nose and paranasal sinuses. Bulletin of Otorhinolaryngology. – 1998. – No. 3. – P. 4–12.
6. Petrov S.V. General Surgery: A Textbook (2nd ed.). – St. Petersburg: Peter, 2002. – S. 213.
7. Piskunov S.Z., Piskunov G.Z. Clinical rhinology. – M.: Miklosh, 2002. – S. 390.
8. Soldatov I.B. Guide to otorhinolaryngology. 2nd ed. – M.: Medicine. – 1997. – S. 608.
9. Chiu T.W., Shaw-Dunn J., McGarry G.W. Woodruff’s plexus // J Laryngol. Otol. – 2008. – No. 21. – R. 1-4.
10. Klinger M., Siegert R. Microcirculation of the nasal mucosa during use of balloon tamponade // Journal Laryngorhinootologie. – 1997. – Vol. 76. – No. 3. – P. 127-130.
11. McCarry, Aitken D. Intransal balloon catheters: how do they work // Clinical Otolar. – 1991. – Vol. 16, No. 4. – P. 388 – 392.
12. Stangerup S.E., Dommerby H., Lau T. Hot–water irrigation as a treatment of posterior epistaxis // Rhinology. – 1996. – No. 34. – R. 18–20.
13. Stangerup S.E., Thomsen H.K. Histological changes in the nasal mucosa after “hot-water-irrigation”: an animal study // Rhinology. – 1996. – No. 34. – R. 14-17.
14. Teymoortash A., Sesterhenn A., Kress R., Sapundzhiev N., Werner J. A. Efficacy of ice packs in the management of epistaxis // Clin Otolaryngol Allied Sci. – 2003. – Vol. 28. No. 6. – R. 545-547.

Treatment of epistaxis

Treatment for frequent nosebleeds

Stop nose bleeding.

Medical treatment of epistaxis

The most common cause of nosebleeds in adults is hypertension. Epistaxis most often occurs against the background of a hypertensive crisis, which requires the appointment of antihypertensive therapy.

Recurrent nosebleeds against the background of hypertension occur due to the presence of chronic DIC and a relative lack of plasma coagulation factors due to erythrocytosis – polycythemia (i.e. lack of coagulation factors per unit of blood cells), which leads to the formation of loose erythrocyte thrombi. easily rejected when removing tampons from the nasal cavity. To correct these disorders, intravenous drip administration of antiplatelet agents and agents that provide hemodilution is necessary: ​​actovegin (400 mg per 200 ml 0. 9% sodium chloride solution or 250 ml solution for infusion), pentoxifylline {100 mg per 200 ml of 0.9% sodium chloride solution), rheomacrodex (200 ml). For persistent, recurrent nosebleeds, a transfusion of fresh frozen plasma and coagulation factor VIII can be given. The introduction of a 5% solution of aminocaproic acid is contraindicated in this group of patients.

The main treatment for hemophilic hemorrhage is substitution therapy. It should be noted that factor VIII is labile and practically does not remain in preserved blood and native plasma. In this regard, only blood preparations prepared under such conditions are suitable for replacement therapy, under which the safety of VIII is ensured.

The drug of choice for the treatment of massive bleeding in patients with hemophilia is eptacog alfa activated – recombinant coagulation factor VIIa.

This drug in pharmacological doses binds to a large amount of tissue factor, forming an eptacog-tissue factor complex, which enhances the initial activation of factor X. In addition, eptacog alfa in the presence of calcium ions and anionic phospholipids is able to activate factor X on the surface of activated platelets, bypassing the coagulation cascade system, which makes it a universal hemostatic agent. Eptacog alfa acts only in the focus of bleeding and does not cause systemic activation of the blood coagulation process. Produced in the form of powder for solution for injection. After dilution, the drug is administered intravenously over 2-5 minutes as a bolus injection. The dose of the drug is 3-6 KED / kg of body weight. The drug is administered every 2 hours until the onset of the clinical effect. Side effects: chills, headache, nausea, vomiting, weakness, changes in blood pressure, redness, itching. Contraindications hypersensitivity to proteins of cows, mice, hamsters. During pregnancy, the appointment is for health reasons. Cases of overdose and drug interactions are not indicated.

Treatment of thrombocytopenia should be strictly pathogenetic, among acquired thrombocytopenia, immune lesions are most common, requiring the appointment of glucocorticoids. The daily dose of prednisolone is 1 mg/kg of body weight: it is divided into 3 doses. After normalization of the platelet count, the dose of glucocorticoids begins to be reduced up to the complete abolition of hormones.

Replacement therapy for thrombocytopenic hemorrhagic syndrome involves platelet transfusion. Indications for platelet transfusion are determined by the doctor based on the dynamics of the clinical picture. In the absence of spontaneous bleeding and the prospect of planned surgical interventions, a low, even critical, level of platelets (less than 30×109/l) does not serve as an indication for the appointment of platelet transfusion. If bleeding from the nose on the background of thrombocytopenia cannot be stopped within 1 hour, it is necessary to transfuse 15-20 doses of platelet mass (the first dose of platelet mass contains 108 platelets), regardless of the number of platelets in the analysis.

Aminocaproic acid in relatively small doses (0.2 g / kg or 8-12 g per adult patient per day) reduces bleeding in many disaggregation thrombocytopathies, enhances the release of intraplasmic factors, and reduces the time of capillary bleeding. The hemostatic effect of aminocaproic acid is explained not only by its stimulating effect on platelet function and inhibitory effect on fibrinolysis, but also by other effects – a normalizing effect on capillary permeability and resistance, inhibition of the Hageman factor and the kallikrein bridge between XII and VII factors. This, apparently, explains the fact that aminocaproic acid reduces bleeding not only with qualitative platelet defects, but also with thrombocytopenia. Treatment with this drug is not indicated in the presence of macrohematuria and DIC. The drug is prescribed intravenously by drip, 100 ml of a 5-6% solution.

Cyclic amino acids have similar pharmacotherapeutic effects to aminocaproic acid: aminomethylbenzoic acid, tranexamic acid. These drugs significantly reduce microcirculatory type bleeding (nasal, uterine bleeding). Tranexamic acid is the most widely used. It is prescribed orally at 500-1000 mg 4 times a day. In case of massive bleeding, 1000-2000 mg of the drug, diluted in 0. 9% sodium chloride solution, is injected intravenously. In the future, the dose and route of administration of the drug are determined by the clinical situation and laboratory parameters of the blood coagulation process.

With thrombocytopenic and thrombocytopenic bleeding, ztamzilat is used. The drug has practically no effect on the number and function of platelets, but increases the resistance of the endotheliocyte membrane, thereby correcting secondary vasopathy against the background of violations of the platelet hemostasis. Usually ztamzilat is administered orally at 0.5 g 3-4 times a day; with massive nosebleeds, an intravenous jet injection of a 12.5% ​​solution of 2 ml 2 times a day is prescribed, it is also possible to increase the dose to 4 ml (3-4 times a day).

With nosebleeds caused by liver damage (including alcohol), it is necessary to compensate for the lack of vitamin K. Deficiency of K-vitamin-dependent factors requires intensive therapy due to the rapid progression of the disease. A good affect is achieved by transfusion of donor plasma or intravenous administration of a concentrate of K-vitamin-dependent factors. At the same time, the administration of menadione sodium bisulfite at a dose of 1-3 mg is prescribed. Treatment with this drug alone is not enough, since its effect on the level of K-vitamin-dependent factors begins after 10 hours, and their noticeable increase occurs after 16-24 hours, and the improvement in prothrombin test values ​​only 48-72 hours after the start of treatment. Therefore, ongoing bleeding always requires transfusion therapy.

With massive bleeding caused by taking indirect anticoagulants, plasma transfusions are performed in large quantities (up to 1.0-1.5 liters per day, 2-3 doses.), The dose of menadione sodium bisulfite is increased to 20-30 mg per day (in severe cases – up to 60 mg). The action of menadione sodium bisulfite is potentiated by prednisolone (up to 40 mg per day). Vitamin P, ascorbic acid and calcium preparations are not effective in these cases.

In case of bleeding caused by an overdose of heparin sodium, it is necessary to reduce the dose of the latter or skip 1-2 injections, and then cancel it, gradually reducing the dose. Along with this, you can assign the introduction of a 1% solution of protamine sulfate intravenously at a dose of 0.5-1 mg for every 100 IU of sodium heparin.

In the treatment of streptokinase or urokinase, nosebleeds may occur with a rapid drop in the content of fibrinogen in the blood below 0.5-1.0 g / l. In these cases, with the abolition of streptokinase, it is necessary to prescribe sodium heparin and infusion with a substitution purpose of fresh frozen plasma, which contains a significant amount of plasminogen and antithrombin III. Such therapy requires daily monitoring of blood levels of antithrombin III.

Calcium preparations are also used to improve hemostasis, since the presence of Ca2+ ions is necessary for the conversion of prothrombin to thrombin, fibrin polymerization, and platelet aggregation and adhesion. However, calcium is present in the blood in sufficient quantities for blood clotting. Even with hypocalcemic seizures, blood clotting and platelet aggregation are not disturbed. In this regard, the introduction of calcium salts does not affect the coagulation properties of the blood, but reduces the permeability of the vascular wall.

Stopping nosebleeds

First of all, it is necessary to calm the patient and free him from all the objects that tighten his neck and torso (tie, belt, tight clothing), give him a half-sitting position. Then put a bubble with ice or cold water on the back of his nose, and a heating pad to his feet. With minor nosebleeds from the anterior sections of the nasal septum of one of the halves of the nose, a cotton swab with a 3% solution of hydrogen peroxide is injected into it and the wings of the nose are squeezed with fingers for several minutes. If the localization of the bleeding vessel is accurately established (according to the point pulsating “fountain”), then after application anesthesia with a 3-5% solution of dicaine mixed with a few drops of adrenaline (1: 1000), this vessel is cauterized (cauterization) with the so-called lyapis “pearl”, electrocautery or YAG-niodymium laser; it is also possible to use the method of cryodestruction. A “pearl” is made as follows: crystals of silver nitrate are collected on the tip of an aluminum wire and carefully heated on the flame of an alcohol lamp until melted and a rounded bead is formed, which is tightly melted to the end of the aluminum wire. Cauterization is carried out only on the side of the bleeding vessel, however, if this procedure is necessary and, on the other hand, to prevent the formation of perforation of the nasal septum, it is carried out no earlier than 5-8 days after the first cauterization. After cauterization, the patient should not strain, blow his nose and independently exert mechanical influences on the crusts formed on the nasal septum. After cauterization, cotton swabs soaked in vaseline oil, carotoline or sea buckthorn oil are inserted into the nasal cavity 2-3 times a day.

If a curvature of the nasal septum or its crest serves as an obstacle to stopping nosebleeds, then a preliminary resection of its deformed part is possible. Often, for a radical stop of nasal bleeding, they resort to detachment of the mucous membrane with the perichondrium and transection of the vessels of the nasal septum. If the presence of a bleeding polyp of the nasal septum is established, then it is removed along with the underlying cartilage.

To stop nosebleeds, they often resort to anterior, posterior, or combined nasal tamponade.

Anterior nasal tamponade is used in cases where the localization of the source of bleeding is obvious (anterior sections of the nasal septum) and stopping nosebleeds by simple methods is ineffective.

There are several ways of anterior nasal tamponade. For its implementation, gauze swabs 1-2 cm wide of different lengths (from 20 cm to 1 m), nasal mirrors of different lengths, nasal or ear forceps, solution of cocaine (10%) or dicaine (5 %) mixed with a few drops of adrenaline chloride (1:1000) for topical anesthesia.

Mikulich method

A tampon 70-80 cm long is inserted into the nasal cavity in the direction of the choana and tightly laid in the form of loops. The front end of the tampon is wound around a ball of cotton, forming an “anchor”. A sling-like bandage is applied over the top. When soaking the bandage with blood, it is replaced without removing the tampon. The disadvantage of this type of tamponade is that the back end of the tampon can penetrate the pharynx and cause a gag reflex, and if it enters the larynx, signs of its obstruction.

Lawrence-Likhachev method

It is an improved method of Mikulich. A thread is tied to the inner end of the tampon, which remains outside along with the front end of the tampon and is attached to the anchor, thereby preventing the back end of the tampon from slipping into the throat. A.G. Likhachev improved Lawrence’s method by suggesting pulling the posterior end of the tampon into the posterior sections of the nose and thereby not only prevent it from falling into the nasopharynx, but also seal the tamponade of the nose in its posterior sections.

V.I. Voyachek method

A loop swab is inserted into one of the halves of the nose to its entire depth, the ends of which remain outside. Short (insert) tampons are sequentially introduced into the resulting loop to the entire depth of the nasal cavity, without collecting them in folds. Thus, several insertion tampons are placed in the cavity, expanding the loop tampon and exerting pressure on the tissues of the inner nose. This method can be attributed to the most sparing, since the subsequent removal of insertion tampons is not associated with their “separation” from the tissues of the nose, but occurs in the environment of other tampons. Before removing the loop swab, its inner surface is irrigated with an anesthetic and a 3% hydrogen peroxide solution, as a result of which, after some exposure, it is easily removed by traction at the lateral end.

With anterior nasal tamponade, the tampons are kept for 2-3 days, after which they are removed, if necessary, the tamponade is repeated. It is also possible to partially remove the tampon (or tampons with the Woyachek method) to loosen them and make subsequent removal more painless.

Seiffert method. R. Seiffert (R. Seiffert), and later other authors, proposed a more gentle method of anterior nasal tamponade, which consists in inflating a rubber balloon in the bleeding half of it (for example, a finger from a surgical glove tied to a metal or rubber tube with a locking device), which filled all the nasal passages and squeezed the bleeding vessels. After 1-2 days, the air from the balloon was released, and if the bleeding did not resume, it was removed.

If the anterior nasal tamponade is ineffective, a posterior nasal tamponade is performed.

Posterior nasal packing

Often, posterior nasal tamponade is carried out in an emergency setting for a patient with heavy bleeding from the mouth and both halves of the nose, so the procedure requires certain skills from the doctor. The method was developed by J.Bcllock (1732-1870), a major French surgeon, who proposed a special curved tube for posterior nasal tamponade, inside which there is a long flexible mandrin with a button at the end. A tube with a mandrin is inserted through the nose to the choanae, and the mandrin is pushed into the mouth. Then, the threads of the tampon are tied to the mandrel button and the tube, together with the mandrel, is removed from the nose along with the threads; when pulling the threads, the swab is inserted into the nasopharynx. Currently, the Nelaton rubber urological catheter is used instead of the Belloc tube. This method, in a modified form, has survived to this day.

For posterior nasal tamponade, a Nelaton rubber catheter No. 16 and a special nasopharyngeal tampon made of densely packed gauze in the form of a parallelepiped are required, tied crosswise with two strong thick silk threads 60 cm long, forming 4 ends after the tampon is made. The average size of a tampon for men is 2×3.7×4.4 cm, for women and adolescents 1.7x3x3.6 cm. The individual size of a tampon corresponds to two distal phalanges of the first fingers folded together. The nasopharyngeal swab is impregnated with vaseline oil, and after squeezing the latter, it is additionally impregnated with an antibiotic solution.

After application anesthesia of the mucous membrane of the corresponding half of the nasal cavity, the catheter is inserted into it until its end appears in the pharynx due to the soft palate. The end of the catheter is pulled out with a forceps from the oral cavity, and two tampon threads are firmly tied to it, which are brought out through the nose with the help of a catheter. By lightly pulling on the threads, a swab is inserted into the oral cavity. With the help of the second finger of the left hand, the tampon is inserted behind the soft palate, and at the same time it is pulled with the right hand by the threads to the choanae. In this case, it is necessary to ensure that when the tampon is inserted along with it, the soft palate is not wrapped in the nasopharynx, otherwise its necrosis may occur. After the nasopharyngeal tampon is tightly fixed to the choanal openings, the assistant holds the threads in a taut position, and the doctor performs an anterior tamponade of the nose but to V. I. Voyachek. However, anterior nasal tamponade may be omitted. In this case, the threads are fixed with three knots on a gauze anchor tightly fixed to the nostrils. Two other threads coming out of the oral cavity (or one, if the second one is cut off), in an unstretched position, are fixed with an adhesive plaster to the zygomatic region. These threads will later serve to remove the tampon, which is usually carried out after 1-3 days. If necessary, the tampon can be kept in the nasopharynx for another 2-3 days under the “cover” of antibiotics, however, in this case, the risk of complications from the slough tube and middle ear increases.

The tampon is removed as follows. First, the anchor is removed by cutting the threads that fix it. Then the insertion swabs are removed from the nasal cavity, irrigating it with a 3% hydrogen peroxide solution. After their removal, the loop swab is abundantly soaked from the inside with hydrogen peroxide and kept for some time to soak it and weaken the connection with the nasal mucosa. Then, with a dry thin gauze swab, the cavity of the insertion swab is dried and irrigated with a 5% solution of dicaine and a few drops of a solution of adrenaline hydrochloride (1: 1000). After 5 minutes, continuing to soak the loop swab with hydrogen peroxide, carefully remove it. After making sure that the bleeding has not resumed (with minor bleeding, it is stopped with hydrogen peroxide, adrenaline solution, etc.), they begin to remove the nasopharyngeal swab. In no case should you pull hard on the threads coming out of the oral cavity, as you can injure the soft palate. It is necessary, under visual control, to firmly grasp the thread hanging from the nasopharynx, and pull it down with a downward movement, pull the tampon into the pharynx and quickly remove it.

In hemopathy of various etiologies, nasal plugging and cautery of bleeding vessels are often ineffective. In these cases, some authors recommend soaking swabs with horse or diphtheria serum, inserting gauze bags with a hemostatic sponge or fibrin film into the nasal cavity in combination with x-ray irradiation of the nose and spleen, once every three days, 3 times in total.