Anterior Epistaxis Treatment

para>Infections

such as rhinitis, nasopharyngitis, and

sinusitis

Trauma,
inflicted (e.g., facial bone fractures) and
self-induced (e.g., nose picking)

Nasal
foreign body

Mucosal
atrophy from chronic steroid nasal sprays

Nasal
surgery

Local
irritants such as nasal sprays and cocaine
abuse

Dry nasal
mucosa

Allergic
and atrophic rhinitis

Hypertension and atherosclerotic cardiovascular
disease

Tumors and
polyps, benign or malignant

Nasal
defects, congenital or acquired

Bleeding
disorders, including hemophilia A, hemophilia B,
von Willebrand disease, thrombocytopenia, and
hypoprothrombinemia

Liver
disease

Renal
failure or uremia

Disseminated intravascular coagulation

Drug
induced, including nonsteroidal anti-inflammatory
drugs (especially salicylates), heparin, warfarin, thrombolytics, and
heavy metals

Anterior epistaxis usually can be

stopped by direct pressure, use of vasoconstrictors, simple cautery, and

packing. The first therapy is usually direct pressure, accomplished by

grasping the alae distally using the closed hand technique. This

provides firm compression and makes it easier for the patient to

maintain his or her grip. Time the nasal compression (5 to 10 minutes),

because patients usually underestimate the elapsed time. If direct

pressure is unsuccessful, apply a combined vasoconstrictive agent and

anesthetic (Table 95-2) using a spray bottle, atomizer, or pledget. A

moistened pledget provides better contact with the nasal mucosa while

also providing a local tamponade effect. ‚

Chemical cautery with silver nitrate sticks is effective treatment for

minor anterior nasal bleeding. First, control bleeding using

vasoconstrictors, direct pressure, or both, as it is difficult to

cauterize an actively bleeding area by chemical means alone. Electrical

and thermal cautery also may be used, but these are no better at

hemorrhage control than chemical cautery. Battery-powered, disposable,

heat cautery devices are difficult to control for the depth of cautery,

and significant injury can occur. ‚

Anterior nasal packing should be

considered when the previous methods fail after three attempts. Prepare

the nasal cavity with a combined vasoconstrictor and anesthetic agent

(Table 95-2). The nasal cavity is packed using strips of petrolatum-

or iodoform-impregnated gauze or an appropriate commercial device. If

nasal packing does not control isolated anterior bleeding, the anterior

pack should be reinserted to ensure proper placement. Leave anterior

packs in place for 48 hours. Ask the patient to report any fever or

recurrent bleeding and to return immediately if bleeding recurs or if

there is a sensation of blood trickling down the back of the throat. ‚

‚

TABLE 95-2. Vasoconstrictive and Anesthetic Agents for

Epistaxis View Large TABLE 95-2. Vasoconstrictive and Anesthetic Agents for

Epistaxis

• 0.5% " “1.0% " ‚phenylephrine (Neo-Synephrine) mixed 2:1 with 4% " ‚lidocaine up to a total dosage of 4 mg/kg of lidocaine
• 0.05% oxymetozaline (Afrin) mixed with 4% " ‚lidocaine up to a total dosage of 4 mg/kg of lidocaine
• 0.25 mL of 1% (1:1,000 concentration) epinephrine mixed with 20 mL of 4% " ‚lidocaine up to a total dosage of 4 mg/kg of lidocaine

Commercial products have been

developed specifically to make the insertion of an anterior nasal pack

easier and more comfortable for the patient. Polyvinyl alcohol (PVA)

compressed foam sponges are made of dehydrated, spongelike material that

expands on contact with moisture. They may be more comfortable than a

balloon or gauze packing. It has been reported that the efficacy of this

device is comparable to other methods. Gelfoam packs also can be

used. ‚

Posterior packing may be required

for uncontrolled posterior bleeding. Posterior padding requires skill

and practice in the face of vigorous bleeding and is best performed in

emergency departments or hospital settings by physicians experienced in

such insertion. ‚

Equipment

• Handsfree light source (can be an overhead surgical lamp, battery-operated headlamp, or light held by an assistant)
• Nasal speculum
• Cotton-tipped applicators
• Frazier tip suction tip connected to continuous wall suction
• Bayonnet forceps
• Material to tamponade the site of bleeding, potentially including cotton pledgets, gelfoam packs, and Merocel nasal sponges
• Chemical cautery agent
• Topical antibiotic ointment (e.g., Bacitracin or Neosporin) if using Merocel
• Local medication for vasoconstriction: either 0.5% to 1.0% " ‚phenylephrine (Neo-Synephrine) or 0.05% oxymetozaline (Afrin) nasal spray
• Local medication for anesthesia: 4% " ‚lidocaine (up to 4 mg/kg total dose)
• Personal protective equipment including eyewear, mask, gown, and gloves

Indications

• Epistaxis that persists despite adequate external pressure

Contraindications

• No current epistaxis
• Clotting abnormalities, as aggressive packing may cause further bleeding (normalize clotting mechanisms before removing nasal packs if possible)
• Chronic obstructive pulmonary disease (monitor for a drop in oxygen partial pressure)
• Trauma, especially facial trauma (consider referral)
• Known or suspected cerebrospinal fluid leak
• Drug abuse (e.g., cocaine)
• Allergy to anesthetics or vasoconstrictors

The Procedure

Step 1

Arterial anatomy of the nasal

septum. The Kiesselbach plexus is a complex anastomosis of

arterioles in the superficial region of the nasal mucosa on the

nasal septum. It is fed by the septal branches of the anterior

ethmoid (AE), posterior ethmoid (PE), sphenopalatine (S), superior

labial (SL), and greater palatine (GP) arteries. ‚

Step 1 View Original Step 1 View Original

Step 2

For acute, short-term

bleeding, apply pressure using the closed-hand method.

Vasoconstrictors may be used in conjunction with or independent of

directed pressure. Visualize the source of bleeding. Have the

patient blow his or her nose to remove all clots from the nasal

cavity and apply a vasoconstrictive agent (Table 2) in both nasal

cavities. Place the nasal speculum in the affected nare with your

left hand. With your right hand, apply a cotton-tipped applicator to

the medial wall of the affected nasal cavity to remove clots and

look for active sources of bleeding. If bleeding is brisk, use the

Frazier tip suction to identify the site of bleeding. ‚

• PITFALL: Using two fingers to pinch the nose (rather than the closed-hand method) makes it more difficult to maintain a grip and keep adequate pressure on the nose.
• PITFALL: Bleeding will sometimes stop after application of a vasoconstictive agent and subsequent direct pressure. Wait at least 1 hour to make certain that bleeding is controlled before putting away your equipment and releasing the patient.
• PITFALL: If you cannot visualize the site of active bleeding by utilizing a nasal speculum and Frazier tip suction, the bleeding is likely to be from a posterior source and will require referral for posterior packing. In this instance, the anterior nares will need to be packed by utilizing Merocel as described below to slow down the bleeding.

Step 2 View Original Step 2 View Original

Step 3

Chemical cautery or gelfoam

can be used if anterior epistaxis cannot be controlled with

vasoconstrictors, direct pressure, or both. Prepare the nasal cavity

with combined vasoconstrictor and anesthetic agent. After the

bleeding has stopped, dry the mucosa. Visualize the nasal cavity

using a nasal speculum to ensure proper gauze placement. Cauterize

the mucosa by touching the bleeding source with the tip of a silver nitrate stick for 10 to 15 seconds. Wipe

away any residual silver nitrate, and apply

antibiotic ointment if desired. Alternatively, gently place a piece

of gelfoam against the site of bleeding. The blood at the site will

adhere it to the surface of the nasal cavity. Carefully remove the

nasal speculum, and observe for any further bleeding. ‚

• PITFALL: Tissue necrosis may occur if both sides of the septum are cauterized in the same session.

Step 3 View Original Step 3 View Original

Step 4

Next, apply gauze packing for

resistant anterior epistaxis. Using bayonet forceps, grasp one end

of a long strip of ‚ ¼-inch petrolatum, iodoform, or plain

gauze saturated with antibiotic ointment approximately 2 to 3 cm

from its end. Allow the end to double over so that the first pass

applies two layers of gauze. ‚

• PITFALL: Blind packing often results in loose placement of the gauze and inadequate compression. Inadequate packing is probably the most common cause of treatment failure.

Step 4 View Original Step 4 View Original

Step 5

Insert the gauze through the

nasal speculum to the posterior limit of the floor of the nose. ‚

Step 5 View Original Step 5 View Original

Step 6

Withdraw the bayonet forceps

and nasal speculum. Reintroduce the nasal speculum on top of the

first layer of packing. Grasp another loop of gauze with the bayonet

forceps. Insert the gauze on top of the previous course using an

"accordion " ¯ technique so that part of each layer lies

anterior to the previous layer, preventing the gauze from falling

posteriorly into the nasopharynx. With each layer, use the forceps

to gently push the underlying strip downward. ‚

Step 6 View Original Step 6 View Original

Step 7

Repeat until the entire nasal

cavity is filled with layers of packing material. Observe the

patient for 30 minutes to make sure that adequate hemostasis has

been achieved. ‚

• PEARL: If the patient complains of choking or a foreign body sensation in the back of the throat, look for layers of an anterior nasal pack that have fallen backward into the nasopharynx.

Step 7 View Original Step 7 View Original

Step 8

Alternatively, the PVA

compressed foam sponge may be used for anterior packing. PVA sponges

absorb blood and secretions from the nasal cavity, quickly expanding

to fill the cavity and tamponade the bleeding. Before insertion into

the bleeding nasal cavity, cover the sponge with antibiotic

ointment. Insert the sponge directly into the nare, placing it

posteriorly until resistance is felt. The proximal end of the sponge

should be flush with the nasal opening. Repeat this procedure for

the nonbleeding nasal cavity. Packing both sides prevents deviation

of the nasal septum, allowing the site of bleeding to be effectively

tamponaded by the packing. ‚

• PEARL: Drops of the vasoconstrictive agent can be added to the PVA sponge if further expansion is needed.
• PEARL: Some sponges have a suture attached to one end to facilitate future removal. The suture needs to be left outside the nasal cavity and can be taped to the cheek to keep it out of the way.

Step 8 View Original Step 8 View Original

Complications

• Continued bleeding
• Rebleeding with removal of pledget/gelfoam or packing
• Sinusitis
• Pain
• Toxic shock syndrome (very rare)
• Septal perforations (very rare)

Pediatric Considerations

Anterior nosebleed management may be

managed as in the adult population. However, referral to a specialist

may be necessary for an uncooperative patient. ‚

Postprocedure Instructions

All patients with anterior epistaxis

should refrain from blowing the nose, avoid digital trauma, and use a

room humidifier. Saline nasal spray can be used to maintain the moisture

of nasal mucosal membranes. Patients with any type of nasal packing

should be prescribed both analgesic medication and prophylactic oral

antibiotics (amoxicillin-clavulanate,

fluoroquinolones) to prevent development of sinusitis and toxic shock

syndrome. Patients should be instructed to pinch their nares for 15 to

20 minutes prior to seeking medical care if bleeding recurs. If this

stops the bleeding, there is no immediate need for them to seek medical

attention for the epistaxis. The nasal packing should remain in place

for 24 to 48 hours, and the patient should come in for follow-up at that

time. ‚

If the bleeding is controlled,

instruct the patient not to manipulate the external nares or insert

foreign objects or fingers into the nasal cavity. Petrolatum or triple

antibiotic ointment may be applied to dry nasal mucosa with a

cotton-tipped applicator once or twice each day for several days. Have

patients avoid aspirin or nonsteroidal

anti-inflammatory drugs for 3 or 4 days. If bleeding recurs, the patient

should use home measures such as over-the-counter nasal sprays or direct

pressure for 5 to 10 minutes before returning for medical care. If

bleeding continues after repeating compression twice more, have the

patient seek immediate medical help. ‚

Coding Information and Supply Sources

‚

View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 30901 Control nasal hemorrhage, anterior, simple (limited cautery

and nasal packing), any method $221.00 0 30903 Control nasal hemorrhage, anterior, complex (extensive

cautery and nasal packing), any method $327.00 0 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

Coding Guide.

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