-ANAGEMENTOF%PISTAXIS

#/229*+5#)+,4-#53.AND4)-/4(9#,%..%9#$2-#53.
.AVAL(OSPITAL*ACKSONVILLE*ACKSONVILLE&LORIDA

&AMILYPHYSICIANSFREQUENTLYENCOUNTERPATIENTSWITHEPISTAXISNASALBLEEDING )NRARECASES
THIS CONDITION MAY LEAD TO MASSIVE BLEEDING AND EVEN DEATH !LTHOUGH EPISTAXIS CAN HAVE AN
ANTERIOR OR POSTERIOR SOURCE IT MOST OFTEN ORIGINATES IN THE ANTERIOR NASAL CAVITY ! DIRECTED
HISTORYANDPHYSICALEXAMINATIONGENERALLYDETERMINETHECAUSEOFTHEBLEEDING"OTHLOCALAND
SYSTEMICPROCESSESCANPLAYAROLEINEPISTAXIS.ASALBLEEDINGUSUALLYRESPONDSTOFIRST AIDMEA
SURESSUCHASCOMPRESSION7HENEPISTAXISDOESNOTRESPONDTOSIMPLEMEASURESTHESOURCEOF
THEBLEEDINGSHOULDBELOCATEDANDTREATEDAPPROPRIATELY4REATMENTSTOBECONSIDEREDINCLUDE
TOPICALVASOCONSTRICTIONCHEMICALCAUTERYELECTROCAUTERYNASALPACKINGNASALTAMPONORGAUZE
IMPREGNATEDWITHPETROLEUMJELLY POSTERIORGAUZEPACKINGUSEOFABALLOONSYSTEMINCLUDING
AMODIFIED&OLEYCATHETER ANDARTERIALLIGATIONOREMBOLIZATION4OPICALORSYSTEMICANTIBIOTICS
SHOULDBEUSEDINSELECTEDPATIENTS(OSPITALADMISSIONSHOULDBECONSIDEREDFORPATIENTSWITH
SIGNIFICANTCOMORBIDCONDITIONSORCOMPLICATIONSOFBLOODLOSS2EFERRALTOANOTOLARYNGOLOGIST
ISAPPROPRIATEWHENBLEEDINGISREFRACTORYCOMPLICATIONSAREPRESENTORSPECIALIZEDTREATMENT
BALLOONPLACEMENTARTERIALLIGATIONANGIOGRAPHICARTERIALEMBOLIZATION ISREQUIRED!M&AM
0HYSICIAN #OPYRIGHT!MERICAN!CADEMYOF&AMILY0HYSICIANS
S

0ATIENTINFORMATION
!HANDOUTONNOSEBLEEDS
WRITTENBYTHEAUTHORSOF
THISARTICLEISPROVIDEDON
PAGE
3EEPAGEFOR
DEFINITIONSOFSTRENGTH OF
RECOMMENDATIONLABELS

%

PISTAXISORNASALBLEEDINGHASBEEN

REPORTEDTOOCCURINUPTOPER
CENT OF THE GENERAL POPULATION 
4HECONDITIONHASABIMODALDISTRI
BUTIONWITHINCIDENCEPEAKSATAGESYOUNGER
THANYEARSANDOLDERTHANYEARS%PI
STAXISAPPEARSTOOCCURMOREOFTENINMALES
THANINFEMALES
%PISTAXISISCOMMONANDAFFECTEDPERSONS

!NTERIORETHMOIDARTERY
0OSTERIORETHMOIDARTERY
3PHENOPALATINEARTERY

),,5342!4)/."9#(2)349+2!-%3

+IESSELBACHS
PLEXUS

3UPERIOR
LABIALARTERY

'REATERPALATINEARTERY

&IGURE6ASCULARANATOMYOFNASALSEPTALBLOODSUPPLY
*ANUARY U6OLUME.UMBER

WWWAAFPORGAFP

USUALLY DO NOT SEEK MEDICAL ATTENTION PAR

TICULARLYIFTHEBLEEDINGISMINORORSELF LIM
ITED )N RARE CASES HOWEVER MASSIVE NASAL
BLEEDINGCANLEADTODEATH 
!NATOMY
4HE RICH VASCULAR SUPPLY OF THE NOSE ORIGI
NATES FROM THE ETHMOID BRANCHES OF THE
INTERNAL CAROTID ARTERIES AND THE FACIAL AND
INTERNAL MAXILLARY DIVISIONS OF THE EXTERNAL
CAROTID ARTERIES !LTHOUGH NASAL CIRCULA
TIONISCOMPLEX&IGURE EPISTAXISUSUALLY
IS DESCRIBED AS EITHER ANTERIOR OR POSTERIOR
BLEEDING4HISSIMPLEDISTINCTIONPROVIDESA
USEFULBASISFORMANAGEMENT
-OSTCASESOFEPISTAXISOCCURINTHEANTE
RIOR PART OF THE NOSE WITH THE BLEEDING
USUALLY ARISING FROM THE RICH ARTERIAL ANAS
TOMOSES OF THE NASAL SEPTUM +IESSELBACHS
PLEXUS  0OSTERIOR EPISTAXIS GENERALLY ARISES
FROMTHEPOSTERIORNASALCAVITYVIABRANCHES
OFTHESPHENOPALATINEARTERIES3UCHBLEED
ING USUALLY OCCURS BEHIND THE POSTERIOR
PORTION OF THE MIDDLE TURBINATE OR AT THE
POSTERIORSUPERIORROOFOFTHENASALCAVITY
)NMOSTCASESANTERIORBLEEDINGISCLINI
CALLYOBVIOUS)NCONTRASTPOSTERIORBLEED
ING MAY BE ASYMPTOMATIC OR MAY PRESENT
INSIDIOUSLY AS NAUSEA HEMATEMESIS ANE
!MERICAN&AMILY0HYSICIAN 

$OWNLOADEDFROMTHE!MERICAN&AMILY0HYSICIAN7EBSITEATWWWAAFPORGAFP#OPYRIGHT2005!MERICAN!CADEMYOF&AMILY0HYSICIANS&ORTHEPRIVATENONCOMMERCIAL
USEOFONEINDIVIDUALUSEROFTHE7EBSITE!LLOTHERRIGHTSRESERVED#ONTACTCOPYRIGHTS AAFPORGFORCOPYRIGHTQUESTIONSANDORPERMISSIONREQUESTS

3TRENGTHOF2ECOMMENDATIONS
+EYCLINICALRECOMMENDATION

,ABEL

2EFERENCES

)FLOCALTREATMENTSFAILTOSTOPANTERIORBLEEDINGTHEANTERIORNASALCAVITY
SHOULDBEPACKEDFROMPOSTERIORTOANTERIORWITHRIBBONGAUZEIMPREGNATED
WITHPETROLEUMJELLYORANTIBIOTICOINTMENT
"ASEDONONESTUDYCHEMICALCAUTERYSILVERNITRATESTICKS CANBEUSEDFOR
SIMPLEANTERIOREPISTAXISBECAUSEITHASEFFICACYANDCOMPLICATIONRATES
SIMILARTOELECTROCAUTERY
"ECAUSEOFTHEPOSSIBILITYOFTOXICSHOCKSYNDROMEWITHPROLONGEDNASAL
PACKINGUSEOFATOPICALANTISTAPHYLOCOCCALANTIBIOTICOINTMENTONTHE
PACKINGMATERIALSHASBEENRECOMMENDED
%ITHERRIBBONGAUZEPACKINGORNASALTAMPONSCANBEUSEDFORPACKINGONE
STUDYFOUNDNOSIGNIFICANTDIFFERENCEINPATIENTCOMFORTOREFFICACY







"



!  CONSISTENT GOOD QUALITY PATIENT ORIENTED EVIDENCE "  INCONSISTENT OR LIMITED QUALITY PATIENT ORIENTED EVIDENCE
#CONSENSUSDISEASE ORIENTEDEVIDENCEUSUALPRACTICEOPINIONORCASESERIES3EEPAGEFORMOREINFORMATION

MIA HEMOPTYSIS OR MELENA )NFREQUENTLY

LARGERVESSELSAREINVOLVEDINPOSTERIOREPI
STAXIS AND CAN RESULT IN SUDDEN MASSIVE
BLEEDING
%TIOLOGY
-OSTCAUSESOFNASALBLEEDINGCANBEIDENTI
FIED READILY THROUGH A DIRECTED HISTORY AND
PHYSICALEXAMINATION4HEPATIENTSHOULDBE
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 !LTHOUGH THE DIFFERENTIAL DIAGNO
SIS SHOULD INCLUDE BOTH LOCAL AND SYSTEMIC
CAUSES 4ABLE   ENVIRONMENTAL FACTORS
SUCHASHUMIDITYANDALLERGENSALSOMUSTBE
CONSIDERED/FTENNOCAUSEFORTHEBLEED
INGISIDENTIFIED
-ANAGEMENT
'%.%2!,!002/!#(

)NITIAL MANAGEMENT INCLUDES COMPRESSION

OF THE NOSTRILS APPLICATION OF DIRECT PRES
SURETOTHESEPTALAREA ANDPLUGGINGOFTHE
AFFECTED NOSTRIL WITH GAUZE OR COTTON THAT
HAS BEEN SOAKED IN A TOPICAL
DECONGESTANT $IRECT PRESSURE
)NITIALMANAGEMENTOFEPI
SHOULDBEAPPLIEDCONTINUOUSLY
STAXISINCLUDESCOMPRESSION
FORATLEASTFIVEMINUTESANDFOR
OFTHENOSTRILSANDPLUG
UP TO  MINUTES 4ILTING THE
GINGOFTHEAFFECTEDNOSTRIL
HEAD FORWARD PREVENTS BLOOD
WITHGAUZEORCOTTONTHAT
FROM POOLING IN THE POSTERIOR
HASBEENSOAKEDINATOPI
PHARYNX THEREBY AVOIDING
CALDECONGESTANT
NAUSEAANDAIRWAYOBSTRUCTION
(EMODYNAMIC STABILITY AND
 !MERICAN&AMILY0HYSICIAN

WWWAAFPORGAFP

4!",%

#OMMON#AUSESOF%PISTAXIS
,OCALCAUSES
#HRONICSINUSITIS
%PISTAXISDIGITORUMNOSEPICKING
&OREIGNBODIES
)NTRANASALNEOPLASMORPOLYPS
)RRITANTSEGCIGARETTESMOKE
-EDICATIONSEGTOPICALCORTICOSTEROIDS
2HINITIS
3EPTALDEVIATION
3EPTALPERFORATION
4RAUMA
6ASCULARMALFORMATIONORTELANGIECTASIA
3YSTEMICCAUSES
(EMOPHILIA
(YPERTENSION
,EUKEMIA
,IVERDISEASEEGCIRRHOSIS
-EDICATIONSEGASPIRINANTICOAGULANTS
NONSTEROIDALANTI INFLAMMATORYDRUGS
0LATELETDYSFUNCTION
4HROMBOCYTOPENIA
)NFORMATIONFROMREFERENCESAND

AIRWAY PATENCY SHOULD BE CONFIRMED &LUID

RESUSCITATION SHOULD BE INITIATED IF VOLUME
DEPLETIONISSUSPECTED
%VERY ATTEMPT SHOULD BE MADE TO LOCATE
THESOURCEOFBLEEDINGTHATDOESNOTRESPOND
TO SIMPLE COMPRESSION AND NASAL PLUGGING
4HEEXAMINATIONSHOULDBEPERFORMEDINA
WELL LIGHTED ROOM WITH THE PATIENT SEATED
AND CLOTHING PROTECTED BY A SHEET OR GOWN
6OLUME.UMBER U*ANUARY

%PISTAXIS

&IGURE  4YPICAL CONTENTS OF AN EPISTAXIS TRAY 4OP ROW NASAL DECONGESTANT SPRAYS AND LOCAL
ANESTHETICSILVERNITRATECAUTERYSTICKSBAYONETFORCEPSNASALSPECULUM&RAZIERSUCTIONTIPPOS
TERIORDOUBLEBALLOONSYSTEMANDSYRINGEFORBALLOONINFLATION"OTTOMROW0ACKINGMATERIALS
INCLUDINGNONADHERENTGAUZEIMPREGNATEDWITHPETROLEUMJELLYANDPERCENTBISMUTHTRIBRO
MOPHENATE8EROFORM -EROCEL'ELFOAMANDSUCTIONCAUTERY

4HEPHYSICIANSHOULDWEARGLOVESANDOTHER
APPROPRIATEPROTECTIVEEQUIPMENTEGSUR
GICAL MASK SAFETY GLASSES  ! HEADLAMP OR
HEADMIRRORANDANASALSPECULUMSHOULDBE
USEDFOROPTIMALVISUALIZATION
!NEPISTAXISTRAYCANBECREATEDUSINGCOM
MON SUPPLIES AND A FEW SPECIALIZED INSTRU
MENTS &IGURE   #LOTS AND FOREIGN BODIES
IN THE ANTERIOR NASAL CAVITY CAN BE REMOVED
WITHASMALL&RAZIER SUCTIONTIPIRRIGATION
FORCEPSANDCOTTON TIPPEDAPPLICATORS
7HEN POSTERIOR BLEEDING IS SUSPECTED
THEGENERALLOCATIONOFTHESOURCESHOULDBE
DETERMINED4HISSTEPISIMPORTANTBECAUSE
DIFFERENT ARTERIES SUPPLY THE FLOOR AND ROOF
OFTHEPOSTERIORNASALCAVITYTHEREFORESELEC
TIVELIGATIONMAYBEREQUIRED
$IFFUSEOOZINGMULTIPLEBLEEDINGSITESOR
RECURRENT BLEEDING MAY INDICATE A SYSTEMIC
PROCESS SUCH AS HYPERTENSION ANTICOAGULA
TIONORCOAGULOPATHY)NSUCHCASESAHEMA
TOLOGIC EVALUATION SHOULD BE PERFORMED
*ANUARY U6OLUME.UMBER

!PPROPRIATE TESTS INCLUDE A COMPLETE BLOOD

COUNT ANTICOAGULANT LEVELS A PROTHROMBIN
TIMEAPARTIALTHROMBOPLASTINTIMEAPLATE
LETCOUNTANDIFINDICATEDBLOODTYPINGAND
CROSSMATCHING
!LTHOUGHMOSTPATIENTSWITHEPISTAXISCAN
BETREAT EDASOUTPATIENTSHOSPITALADMISSION
AND CLOSE OBSERVATION SHOULD BE CONSIDERED
FORELDERLYPATIENTSANDPATIENTS
WITHPOSTERIORBLEEDINGORCOAG
$IFFUSEOOZINGMULTIPLE
ULOPATHY !DMISSION ALSO MAY
BLEEDINGSITESORRECURRENT
BE PRUDENT FOR PATIENTS WITH
BLEEDINGMAYINDICATEA
COMPLICATING COMORBID CONDI
TIONS SUCH AS CORONARY ARTERY
SYSTEMICPROCESSSUCHAS
DISEASESEVEREHYPERTENSIONOR
HYPERTENSIONANTICOAGULA
SIGNIFICANTANEMIA
TIONORCOAGULOPATHY
!.4%2)/2%0)34!8)3

)FASINGLEANTERIORBLEEDINGSITEISFOUNDVASO
CONSTRICTIONSHOULDBEATTEMPTEDWITHTOPICAL
APPLICATIONOFAPERCENTCOCAINESOLUTIONOR
ANOXYMETAZOLINEORPHENYLEPHRINESOLUTION
WWWAAFPORGAFP

!MERICAN&AMILY0HYSICIAN 

&OR BLEEDING THAT IS LIKELY TO REQUIRE MORE

AGGRESSIVETREATMENTALOCALANESTHETICSUCH
ASAPERCENTCOCAINESOLUTIONORTETRACAINE
OR LIDOCAINE 8YLOCAINE SOLUTION SHOULD BE
USED!DEQUATEANESTHESIASHOULDBEOBTAINED
BEFORETREATMENTPROCEEDS
)NTRAVENOUSACCESSSHOULDBEOBTAINEDIN
DIFFICULT CASES ESPECIALLY WHEN ANXIOLYTIC
MEDICATIONSARETOBEUSED
#OTTON PLEDGETS SOAKED IN VASOCONSTRIC
TOR 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 4HEN
THE PLEDGETS CAN BE REMOVED
#OMPLICATIONSOFNASAL
FORREINSPECTIONOFTHEBLEEDING
PACKINGPROCEDURES
SITE )F THIS MEASURE IS UNSUC
INCLUDESEPTALHEMATOMAS
CESSFULCHEMICALCAUTERYCANBE
ANDABSCESSESSINUSITIS
ATTEMPTEDUSINGASILVERNITRATE
NEUROGENICSYNCOPEAND
STICK APPLIED DIRECTLY TO THE
PRESSURENECROSIS
BLEEDINGSITEFORAPPROXIMATELY
 SECONDS /THER TREATMENT
OPTIONS INCLUDE HEMOSTATIC PACKING WITH
ABSORBABLE GELATIN FOAM 'ELFOAM OR OXI
DIZEDCELLULOSE3URGICEL 5SEOFDESMOPRES
SIN SPRAY $$!60 MAY BE CONSIDERED IN A
PATIENTWITHAKNOWNBLEEDINGDISORDER
,ARGER VESSELS GENERALLY RESPOND MORE
READILY TO ELECTROCAUTERY (OWEVER ELECTRO
CAUTERY MUST BE PERFORMED CAUTIOUSLY TO
AVOID EXCESSIVE DESTRUCTION OF HEALTHY SUR
ROUNDING TISSUES .OTE THAT USE OF ELEC
TROCAUTERY ON BOTH SIDES OF THE SEPTUM
MAYINCREASETHERISKOFSEPTALPERFORATION
4HE!UTHORS
#/229*+5#)+,4-#53.ISANAVALFLIGHTSURGEONANDHYPERBARICMEDI
CALOFFICERWITH-ARINE&IGHTER!TTACK3QUADRON-ARINE#ORPS!IR3TATION
"EAUFORT 3# $R +UCIK RECEIVED HIS MEDICAL DEGREE FROM THE 5NIFORMED
3ERVICES5NIVERSITYOFTHE(EALTH3CIENCES&%DWARD(BERT3CHOOLOF-EDICINE
"ETHESDA -D AND COMPLETED A FAMILY MEDICINE INTERNSHIP AT .AVAL (OSPITAL
*ACKSONVILLE*ACKSONVILLE&LA
4)-/4(9#,%..%9#$2-#53.ISASTAFFFAMILYPHYSICIANAT.AVAL(OSPITAL
*ACKSONVILLE AS WELL AS A NAVAL UNDERSEA MEDICAL OFFICER !FTER GRADUATING
FROM THE 5NIVERSITY OF 3OUTH &LORIDA #OLLEGE OF -EDICINE 4AMPA $R #LENNEY
COMPLETED A FAMILY MEDICINE RESIDENCY AT .AVAL (OSPITAL *ACKSONVILLE (E ALSO
COMPLETED A FACULTY DEVELOPMENT FELLOWSHIP AND EARNED A MASTER OF PUBLIC
HEALTHDEGREEFROM%MORY5NIVERSITY!TLANTA
!DDRESSCORRESPONDENCETO4IMOTHY#LENNEY#$2-#53."ROAD7ATER
#T/RANGE0ARK&,E MAILTCLENNEY MSNCOM2EPRINTSARENOTAVAIL
ABLEFROMTHEAUTHORS

 !MERICAN&AMILY0HYSICIAN

WWWAAFPORGAFP

)NTERESTINGLY AT LEAST ONE STUDY FOUND NO

DIFFERENCE IN EFFICACY OR COMPLICATION RATE
BETWEEN CHEMICAL CAUTERY SILVER NITRATE
STICK ANDELECTROCAUTERY
)F LOCAL TREATMENTS FAIL TO STOP ANTERIOR
BLEEDINGTHEANTERIORNASALCAVITYSHOULDBE
PACKEDFROMPOSTERIORTOANTERIORWITHRIB
BONGAUZEIMPREGNATEDWITHPETROLEUMJELLY
OR POLYMYXIN " BACITRACIN ZINC NEOMYCIN
.EOSPORIN OINTMENT .ONADHERENT GAUZE
IMPREGNATEDWITHPETROLEUMJELLYANDPER
CENT BISMUTH TRIBROMOPHENATE 8EROFORM
ALSOWORKSWELLFORTHISPURPOSE"AYONET
FORCEPS AND A NASAL SPECULUM ARE USED TO
APPROXIMATE THE ACCORDION FOLDED LAYERS OF
THE GAUZE WHICH SHOULD EXTEND AS FAR BACK
INTOTHENOSEASPOSSIBLE%ACHLAYERSHOULD
BE PRESSED DOWN FIRMLY BEFORE THE NEXT
LAYER IS INSERTED &IGURE   /NCE THE CAVITY
HAS BEEN PACKED AS COMPLETELY AS POSSIBLE
A GAUZE hDRIP PADv MAY BE TAPED OVER THE
NOSTRILSANDCHANGEDPERIODICALLY
!LTERNATIVELY A PREFORMED NASAL TAMPON
-EROCEL OR $OYLE SPONGE MAY BE USED
4HE TAMPON IS INSERTED CAREFULLY ALONG THE
FLOOROFTHENASALCAVITYWHEREITEXPANDSON
CONTACTWITHBLOODOROTHERLIQUID!PPLICA
TIONOFLUBRICANTJELLYTOTHETIPOFTHETAM
PON FACILITATES PLACEMENT !FTER THE NASAL
TAMPONHASBEENINSERTEDWETTINGITWITHA
SMALLAMOUNTOFTOPICALVASOCONSTRICTORMAY
HASTEN EFFECTIVENESS )T MAY BE NECESSARY TO
DRIP SALINE INTO THE NOSTRIL TO ACHIEVE FULL
EXPANSIONOFTHETAMPONIFTHEBLEEDINGHAS
DECREASEDATTHETIMEOFINSERTION!LTHOUGH
ONE STUDY FOUND NO SIGNIFICANT DIFFERENCE
IN PATIENT COMFORT OR EFFICACY WITH NASAL
TAMPONSORRIBBONGAUZEPACKINGSIMPLICITY
OFPLACEMENTMAKESTHETAMPONSHIGHLYUSE
FULINPRIMARYCARESETTINGS7HENAPPLIEDIN
THEOUTPATIENTSETTINGNASALPACKINGMAYBE
LEFTINPLACEFORTHREETOFIVEDAYSTOENSURE
FORMATIONOFANADEQUATECLOT
#OMPLICATIONS OF NASAL PACKING PRO
CEDURES INCLUDE SEPTAL HEMATOMAS AND
ABSCESSESFROMTRAUMATICPACKINGSINUSITIS
NEUROGENIC SYNCOPE DURING PACKING AND
PRESSURE NECROSIS SECONDARY TO EXCESSIVELY
TIGHT PACKING "ECAUSE OF THE POSSIBILITY OF
TOXICSHOCKSYNDROMEWITHPROLONGEDNASAL
PACKINGUSEOFATOPICALANTISTAPHYLOCOCCAL
6OLUME.UMBER U*ANUARY

%PISTAXIS

ANTIBIOTICOINTMENTONTHEPACKINGMATERIALS
HASBEENRECOMMENDED
"AYONETFORCEPS

!

),,5342!4)/."9#(2)349+2!-%3

"

#

&IGURE  0ACKING OF THE ANTERIOR NASAL CAVITY

USING GAUZE STRIP IMPREGNATED WITH PETRO
LEUM JELLY ! 'AUZE IS GRIPPED WITH BAYONET
FORCEPS AND INSERTED INTO THE ANTERIOR NASAL
CAVITY " 7ITH A NASAL SPECULUM NOT SHOWN
USED FOR EXPOSURE THE FIRST PACKING LAYER IS
INSERTEDALONGTHEFLOOROFTHEANTERIORNASAL
CAVITY &ORCEPS AND SPECULUM THEN ARE WITH
DRAWN # !DDITIONAL LAYERS OF PACKING ARE
ADDED IN AN ACCORDION FOLD FASHION WITH THE
NASAL SPECULUM USED TO HOLD THE POSITIONED
LAYERS DOWN WHILE A NEW LAYER IS INSERTED
0ACKING IS CONTINUED UNTIL THE ANTERIOR NASAL
CAVITYISFILLED
*ANUARY U6OLUME.UMBER

0/34%2)/2%0)34!8)3

0OSTERIORBLEEDINGISMUCHLESSCOMMONTHAN
ANTERIORBLEEDINGANDUSUALLYISTREATEDBY
ANOTOLARYNGOLOGIST0OSTERIORPACKINGMAYBE
ACCOMPLISHEDBYPASSINGACATHETERTHROUGH
ONE NOSTRIL OR BOTH NOSTRILS  THROUGH THE
NASOPHARYNXANDOUTTHEMOUTH&IGURE 
! GAUZE PACK THEN IS SECURED TO THE END OF
THECATHETERANDPOSITIONEDINTHEPOSTERIOR
NASOPHARYNX BY PULLING BACK ON THE CATH
ETERUNTILTHEPACKISSEATEDINTHEPOSTERIOR
CHOANA SEALING THE POSTERIOR NASAL PASSAGE
ANDAPPLYINGPRESSURETOTHESITEOFTHEPOS
TERIOR BLEEDING !LTHOUGH THIS PROCEDURE IS
NOT OUTSIDE THE SCOPE OF FAMILY PRACTICE IT
REQUIRES SPECIAL TRAINING AND USUALLY IS PER
FORMEDBYANOTOLARYNGOLOGIST
6ARIOUS BALLOON SYSTEMS ARE EFFECTIVE FOR
MANAGING POSTERIOR BLEEDING AND ARE LESS
COMPLICATEDTHANTHEPACKINGPROCEDURE4HE
DOUBLE BALLOON DEVICE &IGURE  IS PASSED
INTOTHEAFFECTEDNOSTRILUNDERTOPICALANES
THESIAUNTILITREACHESTHENASOPHARYNX4HE
POSTERIOR BALLOON THEN IS INFLATED WITH  TO
M,OFSALINEANDTHECATHETEREXTENDING
OUTOFTHENOSTRILISWITHDRAWNCAREFULLYSO
THATTHEBALLOONSEATSINTHEPOSTERIORNASAL
CAVITY TO TAMPONADE THE BLEEDING SOURCE
.EXT THE ANTERIOR BALLOON IS INFLATED WITH
ROUGHLYTOM,OFSALINEINTHEANTERIOR
NASAL CAVITY TO PREVENT RETROGRADE TRAVEL OF
THEPOSTERIORBALLOONANDSUBSEQUENTAIRWAY
OBSTRUCTION !N UMBILICAL CLAMP OR OTHER
DEVICECANBEPLACEDACROSSTHESTALKOFTHE
BALLOON ADJACENT TO THE NOSTRIL TO FURTHER
PREVENT DISLODGEMENT THE CLAMP SHOULD BE
PADDED TO PREVENT PRESSURE NECROSIS OF THE
NASAL SKIN "ALLOON PACKS GENERALLY ARE LEFT
INPLACEFORTWOTOFIVEDAYS!SWITHANTERIOR
PACKINGTISSUENECROSISCANOCCURIFAPOSTE
RIORPACKISINSERTEDIMPROPERLYORBALLOONS
AREOVERINFLATED
)FASPECIALIZEDBALLOONDEVICEISNOTAVAIL
ABLEA&OLEYCATHETERTO&RENCH WITH
A M,BALLOONMAYBEUSED4HECATHETER
ISINSERTEDTHROUGHTHEBLEEDINGNOSTRILAND
VISUALIZEDINTHEOROPHARYNXBEFOREINFLATION
OFTHEBALLOON4HEBALLOONTHENISINFLATED
WWWAAFPORGAFP

!MERICAN&AMILY0HYSICIAN 

#ATHETER

!

"

),,5342!4)/."9#(2)349+2!-%3

'AUZEROLL

#

$

&IGURE0OSTERIORNASALPACKING!!FTERADEQUATEANESTHESIAHASBEENOBTAINEDACATHETER
ISPASSEDTHROUGHTHEAFFECTEDNOSTRILANDTHROUGHTHENASOPHARYNXANDDRAWNOUTTHEMOUTH
WITHTHEAIDOFRINGFORCEPS"!GAUZEPACKISSECUREDTOTHEENDOFTHECATHETERUSINGUMBILI
CALTAPEORSUTUREMATERIALWITHLONGTAILSLEFTTOPROTRUDEFROMTHEMOUTH#4HEGAUZEPACKIS
GUIDEDTHROUGHTHEMOUTHANDAROUNDTHESOFTPALATEUSINGACOMBINATIONOFCAREFULTRACTION
ON THE CATHETER AND PUSHING WITH A GLOVED FINGER 4HIS IS THE MOST UNCOMFORTABLE AND MOST
DANGEROUS PARTOFTHEPROCEDUREITSHOULDBECOMPLETEDSMOOTHLYANDWITHTHEAIDOFABITE
BLOCKNOTSHOWN TOPROTECTTHEPHYSICIANSFINGER$4HEGAUZEPACKSHOULDCOMETORESTIN
THEPOSTERIORNASALCAVITY)TISSECUREDINPOSITIONBYMAINTAININGTENSIONONTHECATHETERWITH
APADDEDCLAMPORFIRMGAUZEROLLPLACEDANTERIORTOTHENOSTRIL4HETIESPROTRUDINGFROMTHE
MOUTHWHICHWILLBEUSEDTOREMOVETHEPACKARETAPEDTOTHEPATIENTSCHEEK

WITHAPPROXIMATELYM,OFSALINEANDTHE
CATHETER IS WITHDRAWN GENTLY THROUGH THE
NOSTRILPULLINGTHEBALLOONUPANDFORWARD
4HEBALLOONSHOULDSEATINTHEPOSTERIORNASAL
CAVITY AND TAMPONADE A POSTERIOR BLEED
7ITH TRACTION MAINTAINED ON THE CATHETER
THE ANTERIOR NASAL CAVITY THEN IS PACKED AS
PREVIOUSLYDESCRIBED4RACTIONISMAINTAINED
BYPLACINGANUMBILICALCLAMPONTHECATHE
TERBEYONDTHENOSTRILSWHICHSHOULDBEPAD
DED TO PREVENT SOFT TISSUE DAMAGE !S WITH
ANTERIOREPISTAXISTOPICALANTISTAPHYLOCOCCAL
ANTIBIOTIC OINTMENT MAY BE USED TO PREVENT
TOXICSHOCKSYNDROME(OWEVERUSEOFORAL
 !MERICAN&AMILY0HYSICIAN

WWWAAFPORGAFP

ORINTRAVENOUSANTIBIOTICSFORPOSTERIORNASAL
PACKINGMOSTLIKELYISUNNECESSARY
0%23)34%.4",%%$).'

0ATIENTS WITH ANTERIOR OR POSTERIOR BLEEDING

THAT CONTINUES DESPITE PACKING OR BALLOON
PROCEDURES MAY REQUIRE TREATMENT BY AN
OTOLARYNGOLOGIST %NDOSCOPY MAY BE USED
TOLOCATETHEEXACTSITEOFBLEEDINGFORDIRECT
CAUTERIZATION
(OTWATERIRRIGATIONATECHNIQUEDESCRIBED
MORETHANYEARSAGOHASBEENREEXAM
INED RECENTLY 4HIS TECHNIQUE HAS SHOWN
PROMISE IN REDUCING DISCOMFORT AND LENGTH
6OLUME.UMBER U*ANUARY

%PISTAXIS

OF HOSPITALIZATION IN PATIENTS WITH POSTE

RIOREPISTAXIS-OREINVASIVEALTERNATIVES
INCLUDE ARTERIAL LIGATION AND ANGIOGRAPHIC
ARTERIALEMBOLIZATION
4HEAUTHORSINDICATETHEYDONOTHAVEANYCONFLICTSOF
INTEREST3OURCESOFFUNDINGNONEREPORTED
4HEOPINIONSANDASSERTIONSCONTAINEDHEREINARETHE
PRIVATEVIEWSOFTHEAUTHORSANDARENOTTOBECONSTRUED
ASOFFICIALORASREFLECTINGTHEVIEWSOFTHE53.AVY
-EDICAL$EPARTMENTORTHE53.AVAL3ERVICEATLARGE
4HEAUTHORSTHANK*AMES20HELAN#$2-#53.HEAD
OFOTORHINOLARYNGOLOGYATTHE.AVAL!EROSPACE-EDICAL
)NSTITUTE0ENSACOLA&LAFORGUIDANCEANDREVIEWOFTHE
MANUSCRIPT
-EMBERSOFVARIOUSFAMILYPRACTICEDEPARTMENTSDEVELOP
ARTICLESFORh0RACTICAL4HERAPEUTICSv4HISARTICLEISONE
INASERIESCOORDINATEDBYTHE$EPARTMENTOF&AMILY
-EDICINEAT.AVAL(OSPITAL*ACKSONVILLE&LA'UESTEDI
TOROFTHESERIESIS!NTHONY*6IERA,#$2-#53.2
2%&%2%.#%3

 ,UCENTE&%4HANATOLOGYASTUDYOFDEATHS4RANS
!M!CAD/PHTHALMOL/TOLARYNGOL 
 +OH % &RAZZINI 6) +AGETSU .* %PISTAXIS VASCULAR
ANATOMYORIGINSANDENDOVASCULARTREATMENT!*2!M
*2OENTGENOL 
 0OND & 3IZELAND ! %PISTAXIS 3TRATEGIES FOR MANAGE
MENT!UST&AM0HYSICIAN 
3MITH*!.ASALEMERGENCIESANDSINUSITIS)N4INTINALLI
*%2UIZ%+ROME2,EDS%MERGENCYMEDICINEACOM
PREHENSIVE STUDY GUIDE TH ED .EW 9ORK -C'RAW
(ILL(EALTH0ROFESSIONS$IVISION 
 !DORNATO3'%PISTAXISNEWAPPROACH;,ETTER=/TOLAR
YNGOL(EAD.ECK3URG
 &RAZEE 4! (AUSER -3 .ONSURGICAL MANAGEMENT OF
EPISTAXIS*/RAL-AXILLOFAC3URG 
,ETHAGEN32AGNARSON4ENNVALL'3ELF TREATMENTWITH
DESMOPRESSININTRANASALSPRAYINPATIENTSWITHBLEEDING
DISORDERSEFFECTONBLEEDINGSYMPTOMSANDSOCIOECO
NOMICFACTORS!NN(EMATOL 
4ONER*'7ALBY!0#OMPARISONOFELECTROANDCHEMI
CAL CAUTERY IN THE TREATMENT OF ANTERIOR EPISTAXIS *
,ARYNGOL/TOL 
#ORBRIDGE 2* $JAZAERI " (ELLIER 70 (ADLEY * ! PRO
SPECTIVERANDOMIZEDCONTROLLEDTRIALCOMPARINGTHEUSE
OF -EROCEL NASAL TAMPONS AND ")00 IN THE CONTROL OF
ACUTEEPISTAXIS#LIN/TOLARYNGOL 

 0OLLICE0!9ODER-'%PISTAXISARETROSPECTIVEREVIEW

OF HOSPITALIZED PATIENTS /TOLARYNGOL (EAD .ECK 3URG
 

6IDUCICH 2! "LANDA -0 'ERSON ,7 0OSTERIOR EPI

STAXIS CLINICAL FEATURES AND ACUTE COMPLICATIONS !NN
%MERG-ED 

 0ETRUSON"%PISTAXIS!CLINICALSTUDYWITHSPECIALREFERENCE
TOFIBRINOLYSIS!CTA/TOLARYNGOL3UPPL 

 -C&ERRAN $* %DMONDS 3% 4HE USE OF BALLOON CATH

ETERS IN THE TREATMENT OF EPISTAXIS * ,ARYNGOL /TOL
 

 3CHAITKIN " 3TRAUSS - (OUCK *2 %PISTAXIS MEDICAL

VERSUSSURGICALTHERAPYACOMPARISONOFEFFICACYCOM
PLICATIONSANDECONOMICCONSIDERATIONS,ARYNGOSCOPE
 
 2UBIN'RANDIS*ETAL4HEMANAGEMENTOFEPISTAXISD
ED!LEXANDRIA6A!MERICAN!CADEMYOF/TOLARYNGOL
OGYn(EADAND.ECK3URGERY&OUNDATION

7ILLIAMS - /NSLOW * !IRWAY DIFFICULTIES ASSOCIATED

WITHSEVEREEPISTAXIS!NAESTHESIA 
 $ERKAY #3 (IRSCH "% *OHNSON *4 7AGNER 2, 0OSTERIOR
NASALPACKING!REINTRAVENOUSANTIBIOTICSREALLYNECESSARY
!RCH/TOLARYNGOL(EAD.ECK3URG 

 4AN ,+ #ALHOUN +( %PISTAXIS -ED #LIN .ORTH !M

 

3TANGERUP 3% $OMMERBY ( ,AU 4 (OT WATER IRRIGA

TION AS A TREATMENT OF POSTERIOR EPISTAXIS 2HINOLOGY
 

 #ASSISI .* "ILLER (& /GURA *( #HANGES IN ARTERIAL

OXYGENTENSIONANDPULMONARYMECHANICSWITHTHEUSE
OF POSTERIOR PACKING IN EPISTAXIS A PRELIMINARY REPORT
,ARYNGOSCOPE 

 3TANGERUP 3% $OMMERBY * 3IIM # +EMP , 3TAGE *

.EW MODIFICATION OF HOT WATER IRRIGATION IN THE TREAT
MENT OF POSTERIOR EPISTAXIS !RCH /TOLARYNGOL (EAD
.ECK3URG 

*ANUARY U6OLUME.UMBER

WWWAAFPORGAFP

!MERICAN&AMILY0HYSICIAN