eMedicine Specialties > Clinical Procedures > Otolaryngologic and Dental Procedures

Nasal Pack, Anterior Epistaxis

Eric Goralnick, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Updated: May 17, 2009

Introduction

Epistaxis is a common problem in the emergency department. It is relatively benign in nature but can produce serious, life-threatening situations. Up to 60% of the population is estimated to have had at least one episode of epistaxis at some point in their lives. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization.¹

Most cases of epistaxis occur in children younger than 10 years. Epistaxis is more common in colder seasons and in northern climates because of decreased humidity and the consequent drying of the nasal mucosa.² Other major etiologies include inhaled medications, mucosal breakdown caused by infiltration by malignancy or granulomatous disease, and nasal trauma.

Ninety percent of epistaxes are anterior, originating from the Kiesselbach plexus (see diagram below). Anterior epistaxes exhibit unilateral, steady, nonmassive bleeding. Just 10% of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral.

Nasal vascular anatomy.

• Which side is bleeding?
• Which side was bleeding initially?
• What is the estimated amount of blood loss?
• Is it recurrent?
• Is it in the pharynx?
• Has any trauma recently occurred?
• Are symptoms of hypovolemia present?
• What are the patient’s past medical history and current medications (eg, aspirin, warfarin)?³

As with any unstable patient, initial management begins by assessing airway, breathing, and circulation (the ABCs). Next, the source of the bleeding should be identified. The source of most anterior bleeds can be identified using a headlight and adequate suction.

Once the bleeding point is identified, cautery usually provides definitive treatment. Cautery can be chemical (silver nitrate) or electrical (hotwire or bipolar cautery).⁴ If cautery is unsuccessful, anterior nasal packing is the next step. Nasal packing is the placement of an intranasal device that applies constant local pressure to the nasal septum. Nasal packing works by 1) direct pressure; 2) consequent mucosal irritation, which decreases bleeding; and 3) clot formation surrounding the foreign body, which enhances pressure.

Indications

• Overt or suspected epistaxis after attempt at direct pressure, topical agents, or silver nitrate cautery
• May be indicated in hematemesis or melena (Posterior epistaxis can present as hematemesis or melena.)

Contraindications

• Patients with respiratory compromise may first require airway control and mechanical ventilation.
• Patients with hemodynamic compromise may first require volume and blood product resuscitation.

Anesthesia

• Topical anesthetics: Lidocaine (2% or 4% solution)
  
  

  

  Lidocaine 2%.

  
  
• Topical nasal vasoconstrictors
  • Phenylephrine (Neo-Synephrine Fast-Acting Nasal)
  • Oxymetazoline (Afrin, Neo-Synephrine 12-hour Maximum Strength Nasal)
  • Epinephrine
• Mixture of anesthetic and vasoconstrictor
  • Phenylephrine plus lidocaine
  • Epinephrine (0.25 mL of 1:1000 solution [ie, 0.25 mg]) plus lidocaine (20 mL 2% [ie, 400 mg])
    
    

    

    Epinephrine 1:1000.

    
    

Equipment

• Gloves
• Eye shield
• Procedure lighting (best to use a headlamp)
• Tape
• Cotton
• Tongue depressors
• Commercially produced nasal tampon
  • Gelfoam (absorbable gelatin)
  • Surgicel (oxidized cellulose)
  • Merocel nasal tampon
    
    

    

    Merocel nasal packing with airway, 8 cm.

    
    
    

    

    Smaller Merocel epistaxis pack.

    
    
  • Rapid Rhino anterior balloon tampon
    
    

    

    Rapid Rhino anterior balloon tampon.

    
    
• Topical vasoconstrictors and anesthetics
• Nasal speculum
  
  

  

  Nasal speculum.

  
  
• Suction apparatus (Frazier suction tip)
  
  

  

  Frazier suction tip.

  
  
• Silver nitrate cautery sticks
  
  

  

  Silver nitrate sticks.

  
  
• Epistaxis tray (comprises much of above at some institutions)
  
  

  

  Epistaxis tray.

  
  

Positioning

Place the patient in the upright, not recumbent, position, unless hemodynamic instability prevents it.

Patient sitting in an inappropriate, reclined position.

Patient sitting in an appropriate, upright position.

Technique

Preparation

• Apply anterior nasal pressure to the cartilaginous part of the nose for 20 minutes. If this maneuver does not control the bleeding, a more invasive approach is required.
• Assemble equipment and put on gown, goggles, and gloves. If available, a headlamp facilitates the visual field.
• Keep patient in upright or minimally reclined position.

• Soak cotton ball in a mix of 2% lidocaine and 1:1000 epinephrine.
• Put 1-2 cotton balls into the bleeding nostril. (If bleeding is not clearly unilateral, put cotton balls into both nostrils.)
• Place a dry cotton ball at the external nares to prevent leakage and dripping.
• Leave cotton balls in place for 10 minutes.
• If these anesthetic supplies are unavailable, a commercially-produced topical nasal decongestant may be quickly inhaled; then, place cotton balls and apply anterior nasal pressure.

• Remove cotton balls.
• To evacuate clots, use suction or have patient blow gently.
• Previously accumulated blood comes out in a gush and then stops.
• Ongoing bleeding appears as steadily dripping, bright red blood.

• The practitioner should stabilize his or her hand on the patient’s face and visualize the septum using the nasal speculum.
• Examine the Kiesselbach plexus for bleeders.
• If the offending vessel has stopped bleeding, it appears as a red dot on the mucosa that may have a small amount of clot on it. If the vessel is still bleeding, active oozing is visible.

• A clear view of the bleeding source is mandatory for the use of cautery methods.
• Cauterize to cease unilateral septal bleeding only. Bilateral cautery, both chemical and electrical, leads to increased risk of septal perforation.
• Chemical cautery
  • Apply silver nitrate stick to red dot or oozing vessel for 5-10 seconds and then roll over the surrounding area (1 cm) for 5-10 seconds to cauterize feeding vessels.
  • Apply antibiotic ointment over cauterized area. This provides prophylaxis against infection as well as a topical barrier to prevent desiccation and restart of bleeding.
• Electrical cautery
  • This method is typically used by an otolaryngologist in the context of endoscopic visualization.

• If external pressure and cautery fail to control anterior bleeding, anterior nasal packing is required. Some clinicians use this as the first-line approach. The goal is to place an intranasal device that applies constant local pressure to the nasal septum. Traditional gauze packing is sufficient if prefabricated nasal tampons like Rapid Rhino or Merocel are not available (see Equipment).
• A prospective study of 42 patients was performed to compare the efficacy and patient tolerance of Merocel and Rapid Rhino nasal tampons. No significant difference in efficacy or patient comfort was revealed between the 2 types of packs. Rapid Rhino produced significantly lower scores for subjective patient discomfort during insertion and removal of pack.⁵
• Commercial products packing technique
  • Apply anesthetic to nasal mucosa with cotton or via inhalation.
  • Apply surgical lubricant to the tampon.
  • Gently insert the tampon to maximum achievable depth.
  • Insert the tampon almost horizontally, along the floor of the nasal cavity.
  • The Merocel nasal tampon is made of polyvinyl alcohol, which is a compressed foam polymer that is inserted into the nose and expanded by application of water.
    • The nasal tampon swells and fills the nasal cavity and applies pressure over the bleeding point.
    • The Merocel tampon is believed to aggregate clotting factors to reach a critical level, thereby promoting coagulation.
    • The Merocel success rate is 85% (equal to that of traditional ribbon gauze).
  • The Rapid Rhino anterior balloon tampon is made of carboxymethylcellulose, a hydrocolloid material.
    • It acts as a platelet aggregator and also forms a lubricant upon contact with water.
    • Unlike Merocel, the Rapid Rhino balloon has a cuff that is inflated by air.
    • The hydrocolloid or Gel-Knit reportedly preserves the newly-formed clot during tampon removal.
• Traditional gauze packing
  • Apply anesthetic to nasal mucosa with cotton or via inhalation.
  • Prepare ribbon gauze impregnated with petrolatum jelly and pack it anterior to posterior.
  • Use bayonet forceps and a nasal speculum to place the gauze in a layered, accordion fashion.
    
    

    

    Nasal vascular anatomy.

    
    
  • The gauze should be placed as far posteriorly as is possible.

Failed anterior nasal packing

• If anterior packing failed to stop a confirmed and visualized anterior bleeding source, consider bilateral packing to increase the pressure on the nasal septum.
• If the anterior bleeding source was unconfirmed and bleeding continues, suspect posterior bleeding. For a detailed description of posterior nasal packing, see eMedicine article Nasal Pack, Posterior Epistaxis.

Pearls

• Airway, breathing, and circulation (ABCs) take priority in the acute management of epistaxis.
• All patients treated with nasal packing need to be prescribed an antistaphylococcal antibiotic as prophylaxis against sinusitis and staphylococcal toxic shock syndrome.
• Patients should be given a follow-up appointment for removal of the packing in 48 hours.
• Patients who were cauterized only (and did not receive nasal packing) should gently apply antibiotic ointment to the cauterized area daily for 1 week and use a humidifier while sleeping.
• Instruct the patient to maintain upright posture for 48 hours (including sleep hours) and avoid laughter or heavy lifting for 24 hours. The goal is the reduction of intracranial venous blood pressure to minimize the likelihood of rebleeding.

Complications

• Hemorrhagic shock
• Septic shock
• Pneumocephalus
• Sinusitis
• Septal pressure necrosis
• Neurogenic syncope during packing
• Epiphora (from blockage of the lacrimal duct)
• Hypoxia (from impaired nasal air movement)
• Staphylococcal toxic shock syndrome
• Failure to control bleeding
  • If bleeding cannot be controlled, ENT consultation is necessary.
  • Advanced hemostatic measures may also be necessary.
    • Arterial embolization
    • Arterial ligation (internal maxillary, sphenopalatine)
    • Nasal septal dermoplasty
    • Laser ablation
    • Aminocaproic acid for bleeding diatheses such as hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

Multimedia

Media file 1: Nasal speculum.

Media file 2: Nasal vascular anatomy.

Media file 3: Lidocaine 2%.

Media file 4: Epinephrine 1:1000.

Media file 5: Epistaxis tray.

Media file 6: Frazier suction tip.

Media file 7: Bayonet forceps.

Media file 8: Silver nitrate sticks.

Media file 9: Merocel nasal packing with airway, 8 cm.

Media file 10: Rapid Rhino anterior balloon tampon.

Media file 11: Smaller Merocel epistaxis pack.

Media file 12: Anterior nasal pressure with joined tongue depressors.

Media file 13: Packing in place.

Media file 14: Nasal packing with bayonet forceps and ribbon gauze.

Media file 15: Patient sitting in an inappropriate, reclined position.

Media file 16: Patient sitting in an appropriate, upright position.

References

1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. Mar 2006;64(3):511-8. [Medline].

2. Marx, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6^th ed. 2006.

3. Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. Jul 2005;22(7):470-2. [Medline].

4. Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. Jun 2007;15(3):180-3. [Medline].

5. Moumoulidis I, Draper MR, Patel H, et al. A prospective randomised controlled trial comparing Merocel and Rapid Rhino nasal tampons in the treatment of epistaxis. Eur Arch Otorhinolaryngol. Aug 2006;263(8):719-22. [Medline].

6. Frazee TA, Hauser MS. Nonsurgical management of epistaxis. J Oral Maxillofac Surg. Apr 2000;58(4):419-24. [Medline].

7. 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].

8. 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].

9. Nasal emergencies and sinusitis. In: Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A comprehensive study guide. 4^th ed. New York: McGraw-Hill, Health Professions Division; 1996:1083-93.

Keywords

epistaxis, anterior epistaxis, posterior epistaxis, nosebleed, nasal pack, nasal fracture, cautery, cauterize, nasal packing, Merocel, Rapid Rhino anterior balloon tampon, nasal tampon, gauze packing, ribbon gauze, Kiesselbach’s plexus, nasal trauma, desiccation, epiphora, hypoxia, unilateral nosebleed, nose bleed

Contributor Information and Disclosures

Author

Eric Goralnick, MD, Staff Physician, Department of Emergency Medicine, Yale New Haven Hospital
Eric Goralnick, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Prajoy P Kadkade, MD, Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital-Long Island Jewish Hospital System, Albert Einstein College of Medicine
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Scott Bailey, MD, to the development and writing of this article.

Columbia University Department of Otolaryngology/Head and Neck Surgery: Treatment for Nosebleeds

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)