ear, nose, and throat disorders
How To Treat Posterior Epistaxis With a Balloon
Step by Step Description for Treating Posterior Epistaxis With a Balloon
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%cocainesolution or 4%lidocainewithoxymetazolinein 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 asoxymetazolineand 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 catheterto tamponade active posterior bleeding: Give IV analgesia (eg, 0.5 to 1.0 mcg/kgfentanylto 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 How To Treat Anterior Epistaxis With Nasal Packing 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. 