How is posterior epistaxis different from anterior epistaxis. What are the main treatment options for posterior nosebleeds. Why is balloon tamponade preferred over gauze packing. What are the potential risks and complications of posterior nasal packing.

Understanding Posterior Epistaxis: Causes and Characteristics

Posterior epistaxis, or nasal hemorrhage originating from the back of the nasal passage, is a less common but potentially more dangerous form of nosebleed compared to its anterior counterpart. While anterior epistaxis accounts for the majority of cases, posterior bleeding poses unique challenges in terms of management and control.

What distinguishes posterior epistaxis from anterior bleeding? Posterior epistaxis typically:

• Originates from deeper within the nasal cavity
• Is more difficult to visualize and access
• Often results in more significant blood loss
• Requires different treatment approaches

Can posterior epistaxis resolve on its own? Unlike some cases of anterior bleeding, posterior epistaxis rarely stops without intervention. The location and severity of the bleed often necessitate more aggressive treatment measures to achieve hemostasis.

Diagnostic Approaches for Identifying Posterior Epistaxis

Accurate diagnosis is crucial for effective management of posterior epistaxis. Healthcare providers employ several techniques to differentiate between anterior and posterior bleeding sources:

1. Visual inspection: Careful examination of the nasal cavity using appropriate lighting and instrumentation
2. Nasal endoscopy: Provides a more detailed view of the posterior nasal structures
3. Persistence of bleeding: Continued bleeding despite attempts to control anterior sources may indicate a posterior origin
4. Blood flow patterns: Observation of blood trickling down the back of the throat suggests a posterior source

How do medical professionals confirm a posterior bleed? In many cases, the diagnosis is presumptive based on the clinical presentation and the inability to visualize an anterior bleeding source. Definitive confirmation often occurs during the treatment process.

Initial Management Strategies for Posterior Epistaxis

Before proceeding to more invasive interventions, healthcare providers may attempt less aggressive measures to control posterior epistaxis:

• Application of topical vasoconstrictors to reduce blood flow
• Positioning the patient to minimize blood aspiration
• Clearing the nasal cavity of clots to improve visualization
• Applying direct pressure to accessible areas

Are these initial measures usually sufficient? While these steps can be helpful in some cases, posterior epistaxis often requires more definitive treatment, such as balloon tamponade or surgical intervention.

The Role of Topical Vasoconstrictors

Topical vasoconstrictors play a crucial role in the initial management of posterior epistaxis. These medications work by constricting blood vessels, potentially reducing blood flow to the affected area. Common vasoconstrictors used include:

• Oxymetazoline
• Phenylephrine
• Epinephrine (in some cases)

How are vasoconstrictors applied in posterior epistaxis? Typically, cotton pledgets soaked in the vasoconstrictor solution are carefully inserted into the nasal cavity, targeting the posterior region. This technique allows for localized drug delivery and may help in temporarily controlling the bleed.

Balloon Tamponade: A Preferred Method for Posterior Epistaxis Control

Balloon tamponade has emerged as the treatment of choice for many cases of posterior epistaxis. This technique involves inserting a specialized balloon catheter into the nasal cavity and inflating it to apply pressure to the bleeding site.

Why is balloon tamponade preferred over traditional gauze packing?

• Easier to insert and remove
• More comfortable for the patient
• Allows for adjustable pressure
• Reduced risk of mucosal injury
• Can simultaneously occlude both anterior and posterior nasal cavities

Types of Balloon Catheters for Posterior Epistaxis

Several types of balloon catheters are available for managing posterior epistaxis:

1. Foley catheter: A standard urinary catheter repurposed for nasal use
2. Epistat: Designed specifically for epistaxis control with separate anterior and posterior balloons
3. Rapid Rhino: Features a hydrocolloid-covered balloon for improved comfort and hemostasis
4. Double-balloon catheters: Provide simultaneous anterior and posterior tamponade

How do healthcare providers choose the appropriate balloon catheter? The selection depends on factors such as availability, practitioner preference, and the specific anatomical considerations of the patient.

Step-by-Step Guide to Balloon Tamponade Insertion

Proper insertion of a balloon tamponade device is crucial for effective control of posterior epistaxis. Here’s a general outline of the procedure:

1. Prepare the patient and equipment
2. Apply topical anesthesia and decongestants to the nasal cavity
3. Lubricate the balloon catheter
4. Carefully insert the catheter along the floor of the nasal cavity
5. Advance the catheter until resistance is felt or the desired depth is reached
6. Inflate the posterior balloon with the recommended volume of saline
7. Gently pull the catheter forward to seat the balloon against the posterior choana
8. Inflate the anterior balloon if using a double-balloon system
9. Secure the catheter externally to prevent displacement

What precautions should be taken during insertion? Gentle technique is essential to avoid trauma to nasal structures. Practitioners should be aware of anatomical landmarks and potential complications, such as inadvertent intracranial insertion in patients with skull base fractures.

Patient Care and Monitoring During Balloon Tamponade

Once the balloon tamponade is in place, careful monitoring and supportive care are essential:

• Continuous cardiac monitoring and pulse oximetry
• Regular assessment of balloon pressure and position
• Pain management and sedation as needed
• Monitoring for signs of infection or complications
• Prophylactic antibiotics in some cases

How long should the balloon tamponade remain in place? Typically, the device is left in situ for 48 to 72 hours, allowing time for natural hemostasis to occur. However, the duration may vary based on individual patient factors and the severity of the bleeding.

Potential Complications and Their Management

While balloon tamponade is generally safe and effective, healthcare providers must be aware of potential complications:

• Pressure necrosis of nasal tissues
• Sinusitis or otitis media
• Toxic shock syndrome (rare)
• Aspiration of the balloon if dislodged
• Trigemino-cardiac reflex leading to arrhythmias

How are these complications prevented and managed? Regular assessment, proper balloon pressure management, and prompt recognition of warning signs are key. In some cases, early removal of the tamponade or additional interventions may be necessary.

Alternative and Adjunctive Treatments for Posterior Epistaxis

While balloon tamponade is often effective, other treatment options may be considered in certain cases:

1. Endoscopic cauterization
2. Arterial embolization
3. Surgical ligation of feeding vessels
4. Topical hemostatic agents

When might these alternative treatments be preferred? Factors such as the specific location of the bleed, patient comorbidities, and the availability of specialized interventions can influence the choice of treatment.

The Role of Endoscopic Approaches

Endoscopic techniques have revolutionized the management of posterior epistaxis in many cases. These approaches offer several advantages:

• Direct visualization of the bleeding site
• Precise application of treatment
• Reduced need for prolonged packing
• Faster recovery for many patients

How do endoscopic techniques compare to balloon tamponade in effectiveness? While endoscopic approaches can be highly effective, they often require specialized equipment and expertise. Balloon tamponade remains a valuable option, particularly in settings where endoscopic intervention is not immediately available.

Post-Treatment Care and Follow-Up for Posterior Epistaxis

Proper post-treatment care is crucial for ensuring long-term success and preventing recurrence of posterior epistaxis:

1. Gradual deflation and removal of the balloon tamponade
2. Nasal irrigation to remove clots and debris
3. Humidification to promote mucosal healing
4. Avoidance of nasal trauma and irritants
5. Management of underlying conditions (e.g., hypertension, coagulopathies)
6. Follow-up examinations to assess healing and identify potential rebleeding

What long-term precautions should patients take after treatment for posterior epistaxis? Patients are often advised to avoid strenuous activities, maintain nasal hygiene, and address any contributing factors such as medications or medical conditions that may increase the risk of recurrent bleeding.

Preventing Recurrence of Posterior Epistaxis

While not all cases of posterior epistaxis are preventable, several strategies can help reduce the risk of recurrence:

• Proper nasal hygiene and moisturization
• Management of underlying medical conditions
• Avoidance of nasal irritants and trauma
• Modification of medications that may contribute to bleeding risk
• Regular follow-up with healthcare providers

Can lifestyle modifications impact the risk of posterior epistaxis? Certain lifestyle changes, such as smoking cessation and avoiding excessive alcohol consumption, may help reduce the risk of recurrent nosebleeds in some individuals.

In conclusion, the management of posterior epistaxis requires a comprehensive approach, with balloon tamponade serving as a cornerstone of treatment in many cases. By understanding the nuances of this condition and the various treatment options available, healthcare providers can effectively manage this potentially serious medical issue, improving patient outcomes and quality of life.

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

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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

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Balloon Sinuplasty Information | Wake Ear, Nose & Throat Center

How Is Balloon Sinuplasty Performed?

A flexible balloon catheter (a long catheter with an inflatable balloon on the tip) is inserted through the nose and to the opening of the sinus. The balloon is slowly inflated, which allows the nasal passages to drain normally, relieving sinus pain and pressure. The balloon catheter is then removed, leaving the sinuses cleared of mucus and facilitating normal drainage. There is little to no disruption to the mucosal lining of the sinuses. Watch the video below to learn more about the balloon sinuplasty procedure.

What Are The Benefits Of Balloon Sinuplasty Compared to Traditional Sinus Procedures?

The number one advantage to Balloon Sinuplasty™ is that it’s less invasive than traditional sinus surgery. Sinus tissue is not cut and removed, but rather, simply widened. This results in less trauma to the general sinus area, reducing post-operative pain, scarring, bleeding and overall recovery time.

Compared to traditional functional endoscopic sinus surgery (FESS), Balloon Sinuplasty™ is truly a breakthrough procedure. FESS was the standard surgical option since the 1980s. Using cutting instruments, FESS removes bone and tissue to enlarge sinus openings, clearing blocked nasal passages and restoring normal sinus drainage. The procedure is performed in the operating room with general anesthesia, and normally takes 2 to 4 hours. Of course, not everyone wants the stress and hassle of a hospital operating room procedure, nor does a long recovery period appeal to most people. With FESS, recovery following the operation is usually 1 to 2 weeks, with very limited activity during that period.

Click Image to View Full-Size

FESS is performed using general anesthesia in a hospital operating room. During the operation, a surgeon cuts and removes both tissue and bone. This can result in complications such as scarring, severe pain, blood loss and the chance of infection, along with a 1 to 2 week recovery time. In 2005, a new revolutionary, new treatment option became available: Balloon Sinuplasty™. This is a minimally invasive, outpatient procedure which utilizes small, flexible balloons to open blocked sinuses. Balloon Sinuplasty™ is performed in our medical office, usually under local anesthesia.

Clinical research has indicated that the Balloon Sinuplasty™ system is safe and effective, delivering immediate relief to sinusitis sufferers. Many report instantly being able to breathe ‘normally’ for the first time in years! For those with progressive disease, this procedure does not limit future treatment options.

What Are The Risks Associated With Balloon Sinuplasty?

While the use of any surgical instrument involves some risk, the Balloon Sinuplasty™ technology is minimally invasive and has been clinically demonstrated to be safe by leading ear, nose and throat doctors around the world. Furthermore, balloon catheter technology has been used successfully in other medical procedures such as balloon angioplasty for the heart. Side effects are rare, and the complication rate is low. View the images below to see how the balloon sinuplasty procedure is performed.

However, as is true with any type of medical intervention, there are some potential risks and complications with balloon sinus dilation, including damage to tissue and mucus around the infected area, injury to the eyes and brain, post-operative bleeding, and allergic reaction to anesthesia or other medications administered during the procedure. In general, though, the risks involved with Balloon Sinuplasty™ are much lower than with functional endoscopic sinus surgery (FESS), and the majority of Balloon Sinuplasty™ patients report significant improvement in their symptoms with no adverse effects. Watch the video below to learn more.

What Is Recovery Like After Balloon Sinuplasty?

While the recovery period varies for each person, most people are able to return to normal activities within 24 hours following Balloon Sinuplasty™. This makes it a good option for those with relatively minor sinus issues, who have busy schedules and wish to get back to their normal, daily lives as soon as possible. This procedure is also recommended for people who are adverse to surgery in general, or those with a history of complications with general anesthesia.

Do Patients Have To Stay In The Hospital Overnight After The Balloon Sinuplasty™ Procedure?

No, Balloon Sinuplasty™ is an outpatient procedure, which is usually done using local anesthesia, so you are not required to stay in the hospital overnight. Most patients are capable of driving themselves home within 15 to 30 minutes after undergoing the procedure, or shortly after the effects of the anesthesia wears off.

How Long Does It Take To Recover From Balloon Sinuplasty™?

Because the Balloon Sinuplasty™ system is minimally invasive and no bone or tissue is removed, most patients are able to return to their normal activities fairly quickly. While recovery time varies from person to person, many people can return to normal activities (including work) within 24 to 48 hours following surgery. We do advise our patients to avoid strenuous activities or exercise that makes them feel strained (aerobics, jogging, exercising, swimming, contact sports, etc.) during the two weeks after the procedure. However, moderate exercise (such as brisk walking) is fine during the recovery period.

Will There Be Much Bleeding Or Pain Afterward?

Most patients will have some bloody nasal drainage the first night following surgery. This discharge will decrease in amount and turn lighter in color over the next several days after surgery. In order to prevent bleeding, you should not blow your nose for the first week after surgery, but rather sniff back any secretions. If you need to sneeze, you should do so with your mouth open. Do not hold back a sneeze.

Patients may also experience a slight sinus headache or nasal congestion for a day or two after the procedure. This can be easily managed with over-the-counter analgesics (such as an ibuprofen-based painkiller like Excedrin or Motrin), or a prescribed pain killer, if needed. (Do not take aspirin or non-steroidal anti-inflammatory pain relievers such as Advil, Tylenol and Aleve, as they may increase chances of bleeding.

Will Nasal Packing Be Necessary After The Procedure?

While light bleeding after any nasal procedure can be expected, with Balloon Sinuplasty™ patients rarely need to have their noses packed with gauze following the procedure. That is good news for patients, since nasal packing can be extremely uncomfortable.

How Long Does Symptom Relief Last After Balloon Sinuplasty™?

Numerous studies have shown that the benefits of Balloon Sinuplasty™ last for at least two years in the vast majority of patients, which is as good or better than what’s achieved with conventional sinus surgeries. Exactly how long your sinuses stay open depends on the extent of your sinus disease and other factors regarding your personal health status. In general, though, we have every reason to expect that the improvement is permanent.

Will Surgery With Balloon Sinuplasty™ Devices Limit My Treatment Options?

No. Balloon Sinuplasty™ devices are endoscopic tools used within FESS and may be used with other medical therapies as well. They do not limit future treatment options for patients with progressive disease.

Does Alcohol Consumption Or Smoking Affect Recovery?

Alcohol is a potent vessel dilator and can promote edema or swelling and even bleeding. We advise patients to abstain from heavy drinking for one week prior to surgery and avoid any alcohol intake the week after surgery. We also discourage patients from smoking during the month before and after the procedure, as smoking can severely affect the outcome. Smoking causes increased scar tissue, poor healing and greater risk of complications.

Read What Our Balloon Sinuplasty Patients Had To Say

“After my first exam with Dr. Gupta he explained the balloon method. No cutting or breaking bones needed. That made me feel much better. After the procedure, I had no pain and was able to breath better immediately. ” — Don H. ( Google Review)

“After balloon sinoplasty, an in-office procedure with Dr. Gupta, I have had my first fall/winter season without sever and debilitating sinus infections in over 8 years! This procedure was life-changing for me and I’m grateful to the care and professionalism shown by Wake ENT and Dr. Gupta.” — Mark D.( Google Review)

Contact Us Today! Skills & Expertise You Can Count On.

You don’t have to just live with chronic sinusitis for the rest of your life. Schedule a consultation with Dr. Gupta today to find out if Balloon Sinuplasty™ is the right option for you. You can book your appointment by calling us at 919.851.5636, or by filling out our online contact form. We look forward to providing you relief from your sinus symptoms! If you have been diagnosed with chronic sinusitis and are not responding well to medications, you may be a candidate for Balloon Sinuplasty™. As is true when using any surgical instrument, there are some potential risks, and results may vary. To find out if this procedure is right for you, contact us today to make an appointment with Dr. Gupta for an evaluation. Take our sinus quiz to see if you qualify.

Anterior and posterior nasal tamponade – what is this procedure, how is nasal tamponade performed for bleeding

Nasal tamponade is a medical procedure performed to stop massive nosebleeds. As a rule, anterior epistaxis, the source of which is the vessels of the Kisselbach bundle in the region of the anterior part of the nasal septum, is mild, it can be easily stopped by pressing or using hemostatic drugs. Posterior bleeding from the nose is associated with a violation of the integrity of larger vessels located closer to the pharynx, it is abundant, sometimes profuse, and leads to the loss of a large volume of blood. Incessant anterior and all cases of posterior nosebleeds require nasal tamponade – anterior or posterior.

Species

Depending on the type of bleeding and the technique of the doctor’s manipulations, there are anterior and posterior nasal tamponade.

Anterior nasal packing

Technically simple procedure, used frequently.

The mucous membrane of the nasal cavity is treated with an anesthetic solution (usually lidocaine or dicaine). When the drug works (after 3-5 minutes), tamponade begins. As a rule, the loop method according to Mikulich is used. For this, a gauze turunda is prepared, the width of which is 1.5-2 cm, the length is 55-70 cm. It is impregnated with a solution of 3% hydrogen peroxide, a hemostatic agent or an indifferent ointment, for example, petroleum jelly. With cranked tweezers, the turunda is captured at a distance of 6-7 cm from the end and inserted into the nasal cavity on the side of bleeding as deep as possible, to the very choanae. The next section of the turunda is intercepted with tweezers, and also injected into the nose. Thus, the entire turunda, which fills half of the nose, is tightly laid – from the choana to the vestibule. If the bleeding is bilateral, conduct anterior nasal tamponade of the other half of the nose. Apply a sling bandage.

The tampons can stay in the nose for 3-6 days depending on whether the bleeding has stopped. From the third to the sixth day, turundas are treated daily with a solution of an antibacterial drug.

Before removal, swabs are soaked in a solution of 3% hydrogen peroxide – this will facilitate their removal.

An alternative to anterior nasal tamponade for nosebleeds according to Mikulicz are sterilized cotton-gauze swabs. They densely fill the nasal cavity to ensure clamping of the damaged blood vessel. This is also an effective method, and it is more comfortable for the patient.

Posterior packing

With abundant, long-lasting nosebleeds, posterior nasal tamponade is used. It is carried out by an otolaryngologist who is well acquainted with the technique.

A Nelaton soft catheter, previously lubricated with petroleum jelly, is inserted into the patient’s nasal cavity. When the end of this catheter is shown in the pharynx, it is grasped with tweezers and removed through the mouth. A previously prepared sterile tampon is tied to this end – a ball the size of a walnut, made of cotton covered with gauze, tied crosswise with silk thread. One of the four ends of the thread is cut off, with two – the ball is tied to the catheter removed from the patient’s mouth, then the catheter is pulled up by the nasal end and the tampon threads are passed into the nasal cavity and out through the nostril. At the same time, the tampon enters the oral cavity, the doctor’s finger and tweezers are installed in the nasopharynx, pulled up by the threads so that half of the nose is tightly plugged. Outside, a tight ball of gauze is applied to the nostril, to which threads are tied. The remaining, third free thread of a cotton-gauze swab, hanging from the patient’s mouth, is fixed with a plaster on the outside of his cheek. Subsequently, by pulling on it, it will be possible to remove the tampon from the nasopharynx.

A tampon with a posterior nasal tamponade is left for 1-3 days, considering, however, that the longer it is in the nasal cavity, the higher the risk of complications, in particular infection.

Sources

• Soldatov I.B. Guide to otorhinolaryngology / I.B. Soldatov, V.F. Antoniv; ed. I.B. Soldatov. — M.: Medicine, 1994. — 616 p.
• Arkhipova Yu.V. Profuse nosebleeds. – Abstract. dis. cand. honey. Sciences // Moscow, 2000. – 17 p.
• Volkov A.G., Boyko N.V., Kiselev V.V. Nosebleeds // M .: APP “Dzhangar”, 2002. – 276 p.

Clinical case. Stopping dangerous nosebleeds

Narrated by Olga Romanova,

otorhinolaryngologist. PhD

Stopping dangerous nosebleeds from the anterior ethmoid artery

In the evening, a 45-year-old man was admitted to the emergency and emergency department of the EMC with severe nosebleeds, which required line hospitalization. The nose bled not constantly, but sporadically: gushing streams of blood occurred with a frequency of about once every half an hour, and during one episode the patient lost about 100 ml of blood.

Cases of nosebleeds (epistaxis) occur in the practice of ENT doctors quite often and account for about 10% of the total number of patients. Usually these are capillary bleedings from the outer parts of the nasal septum, the so-called “light” nosebleeds. In the anterior section of the nasal septum, on both sides, there is the Kisselbach zone (the bleeding zone of the nose), which serves as a source of bleeding in 90-95% of cases. The frequency of damage to this area is due to the large number of anastomosing with each other capillaries emanating from the arteries located in this area. The mucous membrane of this area is thin, practically devoid of a submucosal layer, which makes the vessels located here vulnerable both to external mechanical stress and to an increase in blood pressure. Such bleeding is not life-threatening, but causes a lot of trouble for patients. These bleedings are treated quite simply: mainly with the use of ointment or oily preparations, less often with the help of electrocoagulation of the vessels of the nasal septum.

In case of arterial nosebleeds (damage to rather large vascular trunks, which are mainly localized in the walls of the deep sections of the nasal cavity), the volume of blood loss increases rapidly, which can be life-threatening. It is extremely rare to stop such bleeding on your own. In such cases, tightly obturating nasal tampons are used, which are in the nasal cavity from 3 to 7 days. During this time, the patient is under the supervision of a doctor on an outpatient basis.

Bleeding of this nature occurred in a patient admitted to our clinic for the first time, and at first the doctors did not have an understanding of the causes that caused it. During the examination, it turned out that the patient suffers from arterial hypertension, which he did not know about. Probable weakness of the vascular wall, combined with a slight increase in blood pressure (up to 150 mm Hg) against the background of stress, provoked bleeding from one of the arteries that feed the brain and nasal cavity.

Anatomically, the mucous membrane of the anterior and posterior parts of the nose is fed by branches of the pterygopalatine, anterior and posterior ethmoidal and superior labial arteries, which are branches of the internal and external carotid arteries. High blood pressure in these vessels causes extremely intense bleeding and makes it difficult to determine which artery is the source of epistaxis.

Upon admission to the emergency and emergency department, the patient underwent anterior nasal packing in parallel with massive intravenous hemostatic therapy and administration of drugs to lower blood pressure. Because the anterior tamponade did not allow to stop the bleeding, after a while the otorhinolaryngologist on duty installed tampons in the posterior sections of the nasal cavity.

None of the above methods of treatment was effective, and against the background of the loss of a large amount of blood, the patient’s hemoglobin decreased, weakness and dizziness appeared, so it was decided to perform an urgent surgical intervention to stop the bleeding. At the first stage, it was necessary to find out which of the branches of the carotid arteries was bleeding. The anesthesiologists reduced the pressure with medication to a level at which the bleeding was stopped. An endoscopic examination of the nasal cavity revealed that the anterior ethmoidal artery, which passes through the orbit of the eye, is the source of the problem. When the source of epistaxis is the ethmoid arteries (branches of the internal carotid artery), an endonasal opening of the ethmoid labyrinth on the side of bleeding can be performed, however, surgeons Jean-Rene Milieu and Romanova Olga Nikolaevna decided to clip the ethmoid artery through the orbit above the rupture site. An incision was made between the inner edge of the orbit and the bridge of the nose. The artery was clipped with two metal staples. The operation lasted about 20 minutes, and the manipulations performed helped stop the bleeding. In the postoperative period, the volume of blood flow was redistributed along the extensive network of anastomoses of the facial vessels, and the blockade of the anterior ethmoid artery did not cause negative consequences in the blood supply to the organs. The operation did not affect the appearance and function of the eye. The patient was fully conscious 2 hours after the end of the operation. He was in the hospital under the supervision of a doctor for another 3 days. The sutures were removed after 7 days. Due to the fact that a cosmetic suture was applied to the surgical wound, there was practically no trace of the incision on the face. After completion of treatment, the patient was recommended to consult a cardiologist in order to prescribe a course of treatment to stabilize blood pressure and avoid recurrence of difficult bleeding in the future.