ear, nose, and throat disorders
Epistaxis
Treatment of Epistaxis
Presumptive treatment for actively bleeding patients is that for anterior bleeding. The need for blood replacement is determined by the hemoglobin level, symptoms of anemia, and vital signs. Any identified bleeding disorders are treated. Bleeding can usually be controlled by pinching the nasal alae together for 10 minutes while the patient sits upright (if possible). If this maneuver is ineffective, a cotton pledget impregnated with a vasoconstrictor (eg,phenylephrine0.25%) and a topical anesthetic (eg,lidocaine2%) is inserted and the nose pinched for another 10 minutes. The bleeding point may then be cauterized with electrocautery orsilver nitrateon an applicator stick. Cauterizing four quadrants immediately adjacent to the bleeding vessel is most effective. Care must be taken to avoid burning the mucous membrane too deeply; therefore,silver nitrateis the preferred method. Alternatively, a nasal tampon of expandable foam may be inserted. Coating the tampon with a topical ointment, such asbacitracinormupirocin, may help as a lubricant and as prophylaxis against infection. If these methods are ineffective, various commercial nasal balloons can be used to compress bleeding sites. As another alternative, an anterior nasal pack consisting of 1 cm (1/2 inch) petrolatum gauze may be inserted; up to 175 cm (72 inch) of gauze may be required. This procedure is painful, and analgesics are usually needed; it should be done only when other methods are ineffective or unavailable. Posterior bleeding may be difficult to control. Commercial nasal balloons are quick and convenient; a gauze posterior pack is effective but more difficult to position. Both are very uncomfortable; IV sedation and analgesia may be needed, and hospitalization is required. Commercial balloons are inserted according to the instructions accompanying the product. The posterior gauze pack consists of 10 cm gauze squares folded, rolled, tied into a tight bundle with two strands of heavy silk suture, and coated with antibiotic ointment. The ends of one suture are tied to a catheter that has been introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx. The second suture, which is left long, hangs down the back of the throat and is trimmed below the level of the soft palate so that it can be used to remove the pack. The nasal cavity anterior to this pack is firmly packed with 1/2-inch petrolatum gauze, and the first suture is tied over a roll of gauze at the anterior nares to secure the postnasal pack. The packing remains in place for 4 to 5 days. An antibiotic (eg,amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) is given to prevent sinusitis and otitis media. Posterior nasal packing lowers the arterial PO2, and supplementary O2 is given while the packing is in place. This procedure is uncomfortable and should be avoided if possible. On occasion, the internal maxillary artery and its branches must be ligated to control the bleeding. The arteries may be ligated with clips using endoscopic or microscopic guidance and a surgical approach through the maxillary sinus (internal maxillary) or transnasal endoscopic approach (sphenopalatine). Alternatively, angiographic embolization may be done by a skilled radiologist. These procedures, if done in a timely manner, may shorten hospital stay. In Hereditary Hemorrhagic Telangiectasia (Rendu-Osler-Weber syndrome), a split-thickness skin graft (septal dermatoplasty) reduces the number of nosebleeds and allows the anemia to be corrected. Laser (Nd:YAG) photocoagulation can be done in the operating room. Selective embolization is also very effective, particularly if patients cannot tolerate general anesthesia or if surgical intervention has not been successful. New endoscopic sinus devices have made transnasal surgery more effective. Blood may be swallowed in large amounts and, in patients with severe liver disease, should be eliminated promptly with enemas and cathartics to prevent hepatic encephalopathy. The gastrointestinal tract should be sterilized with nonabsorbable antibiotics (eg,neomycin1 g orally 4 times a day) to prevent the breakdown of blood and the absorption of ammonia. 