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Clinical Procedures > Otolaryngologic and Dental Procedures
Nasal Pack - Posterior Epistaxis
Article Last Updated: Nov 20, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Scott Bailey, MD, Staff Physician, Department of Emergency Medicine, Diplomate Board of Internal Medicine, UCLA Medical Center, Center for the Health Sciences, Department of Emergency Medicine
Scott Bailey is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine
Editors: Prajoy P Kadkade, MD, Assistant Professor, Department of Surgery, Division of Otolaryngology Head and Neck Surgery, State University of New York at Stony Brook School of Medicine, Northport Veterans Affairs Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M. Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA, Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Emergency Medicine Center, UCLA Medical Center, David Geffen School of Medicine, Los Angeles, CA; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
nasal pack, posterior epistaxis, epistaxis, nosebleed, nasal trauma, nasal packing, rhino rocket, double balloon catheter, double-balloon catheter, double-balloon tamponade
Posterior epistaxis is usually treated by an otolaryngologist, but an emergency physician may be called upon to treat this condition in a medical environment with few support services (eg, a rural care facility).
Ten percent of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral. Posterior epistaxis may present in ways that suggest a more inferiorly located site of bleeding from the aerodigestive tract, such as hemoptysis, melena, anemia, or just nausea.
Identifying the source of bleeding is important. Ask the patient from which side the bleeding occurred initially. Patients frequently report bilateral bleeding after assuming a recumbent position that allows blood to make a U-turn around the posterior aspect of the septum. The bleeding site of a posterior epistaxis is either posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity. Branches of the sphenopalatine artery supply the blood for such an epistaxis.
Hypertension and atherosclerosis are the primary risk factors for posterior epistaxis. Anterior epistaxis is most common in children and young adults, while posterior epistaxis is more common in older patients with hypertension or atherosclerosis. Even in elderly patients, anterior epistaxis is the most common type of epistaxis overall.
Before attempting to control an epistaxis, assess patient stability, beginning with the ABCs. Determine whether the epistaxis was caused by trauma sufficient to create concern for oropharyngeal airway patency, intracranial injury, or stability of the c-spine. Assess underlying systemic comorbidities that might decrease the likelihood of success of hemostatic control procedures, such as anticoagulation or antiplatelet agent use. This assessment is particularly important in older patients. If the patient is stable, the intervention may be uncomplicated.
- Failure of anterior packing
- Reliable or high suspicion of posterior bleeding
- Patient spitting out blood
- Older patient with atherosclerosis
- No visible anterior bleeding site
- Patient with bleeding diathesis (Each of these states makes hemostatic control much more difficult, and each has its set of additional specific targeted therapies.)
- Hereditary hemorrhagic telangiectasia
- Von Willebrand disease
- Hemophilia
- Anticoagulation
- Antiplatelet therapy
- Temporizing measure until more definitive therapies are obtained
- Endoscopic ligation by otolaryngology
- Endovascular ligation by interventional radiology
- Do not perform a nasal pack in the presence of facial trauma that may include nasal bone and cribriform plate fractures.
- If the patient is in shock, has altered mental status, or is otherwise not protecting the airway, control the airway before attempting any nasal packing.
Topical anesthetics
Vasoconstrictors - Epinephrine (1:1000 or 1:10,000)
- Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
- Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)
Lidocaine, 2%.
Epinephrine 1:1000.
Epinephrine 1:10,000.
- Gloves
- Tape
- Tongue depressors
- Nasal speculum
- Posterior packing (balloon methods)
- Commercially produced double-balloon tampon
- Foley catheter, 10-14F
- Posterior packing (gauze method)
- Silk suture material, 0 gauge (ga)
- Gauze squares, 4 x 4
- Catheter (Foley or some other type; not to be inflated)
- Hemostats
- Commercially produced anterior nasal tampon
- Absorbable gelatin (Gelfoam)
- Oxidized cellulose (Surgicel)
Foley catheter, 10F.
Medtronic Xomed double-balloon catheter.
Epistaxis tray.
Bayonet forceps.
Frazier suction catheters.
Place patient in the upright position, unless hemodynamic instability prevents it.
Proper positioning of patient.
Positioning and examination - Position the patient in a strict upright position.
- Have patient blow his or her nose to expel any clot.
- Perform a thorough anterior nasal examination to rule out an anterior bleeding source.
- A brisk posterior bleed may have some anterior flow but predominantly manifests with posterior oropharyngeal blood flow.
Local anesthesia and vasoconstriction - Have the patient nasally insufflate a topical vasoconstrictor such as oxymetazoline (Afrin) or phenylephrine (Neo-Synephrine).
- To provide anesthesia, add 2% lidocaine solution to the vasoconstrictor first, and then have the patient inhale the combination.
Hemostasis - Technique 1 - Double-balloon device
- Apply mupirocin (Bactroban) nasal ointment 2% to the catheter.
- Insert the device completely into the nostril.
- Inflate the posterior balloon with up to 7-10 mL of sterile water.
- Withdraw catheter until posterior balloon seats. The balloon stops at the posterior nasal cavity.
- Inflate the anterior balloon with up to 15-30 mL of sterile water.
- Apply padding (eg, Xeroform wrap, iodoform strips) to prevent alar necrosis.
- Leave balloons in place for 3-5 days, until coagulopathy and hypertension have been controlled.
- Technique 2 - Foley catheter (10-14F 30-mL balloon)
- Apply mupirocin nasal ointment 2% to the catheter.
- Insert the catheter into the nostril.
- Visualize the catheter tip in the back of the throat.
- Inflate the balloon with up to 10 mL of sterile water. (Do not fully inflate the balloon to 30 mL.)
- Withdraw the balloon gently until it seats posteriorly.
- Pack the anterior nasal cavity with a balloon device, nasal tampon (eg, Rhino Rocket), or layered ribbon gauze.
- Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep the balloon from dislodging.
Posterior packing with 10F Foley catheter.
Aftercare - Antibiotics may be prescribed (see Pearls section).
- Posterior packing should be removed in 72-96 hours.
- Antibiotics that cover Staphylococcus species (eg, cephalexin, amoxicillin, ampicillin) can prevent sinusitis and toxic shock syndrome.
- Admit all patients with posterior packing to the hospital for observation.
- Reflex bradydysrhythmia can develop because of stimulation of the deep posterior oropharynx by the packing.
- Airway compromise may develop.
- Sinusitis
- Nasal septal pressure necrosis
- Abscesses
- Neurogenic syncope
- Toxic shock syndrome
- Persistent bleeding and restart of bleeding, in spite of above interventions
American College of Emergency Physicians
1125 Executive Cir
Irving TX 75038-2522
800-798-1822
American Academy of Otolaryngology – Head and Neck Surgery
1 Prince St
Alexandria VA 22314-3357
703-836-4444
eMedicine.com, Inc: Nasal Pack – Anterior Epistaxis
Columbia University Department of Otolaryngology/Head and Neck Surgery: Treatments for Nosebleeds
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Posterior packing with 10F Foley catheter. |
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- Frazee TA, Hauser MS. Non-surgical management of epistaxis. J Oral Maxillofac. 2000;58(4):419-424. [Medline].
- Saba HI, Morelli GA, Logrono LA. Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med. Jun 23 1994;330(25):1789-90. [Medline].
- Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope. Dec 1987;97(12):1392-6. [Medline].
- Tintinalli JE, Ruiz E, Krome RL, eds. Nasal Emergencies and Sinusitis. In: Emergency medicine: A comprehensive study guide. 4th. New York: McGraw-Hill, Health Professions Division; 1996:1083-93.
Nasal Pack - Posterior Epistaxis excerpt Article Last Updated: Nov 20, 2006
Topic originally published: Nov 20, 2006
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