How To Treat Anterior Epistaxis With Cautery

ByWaleed M Abuzeid, BSc, MBBS, University of Washington
Lawrence R. Lustig, MD, Columbia University Medical Center and New York Presbyterian Hospital
Reviewed/Revised Modified Jun 2025
v14453469
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Epistaxis (nasal hemorrhage) can often be stopped with cautery (sealing off a blood vessel using current or chemicals).

Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Epistaxis is a common diagnosis; however, only approximately 6% of people experiencing epistaxis seek medical attention. Epistaxis accounts for 0.5% of all emergency department visits. The mean age of patients presenting with epistaxis is 53 years.

Anterior epistaxis should initially be treated with digital compression by applying firm sustained compression of the lower one third of the nose for a minimum of 10 full minutes. Pressure can be applied by the treating clinician or by patients and caregivers under the direction of the clinician. An alternative to digital compression is the use of a commercial nose clip, if available. Applying local vasoconstrictors to the nasal cavity can be a useful adjunct to digital nasal compression.

Rhinoscopy, or nasal endoscopy, is usually performed next to identify the source of the bleeding. If pinching fails and the bleeding site is accessible and identifiable through anterior rhinoscopy, the next step is to control anterior epistaxis using cautery, which avoids some of the disadvantages of nasal packing (eg, discomfort, risk of infection, and/or migration of packing material).

If bleeding continues from an unidentified anterior site despite use of nasal compression and cautery, nasal packing is required.

If bleeding is seen in the posterior pharynx but not in the anterior nasal passage, posterior epistaxis should be considered. Posterior epistaxis, occurring in approximately 5 to 10% of epistaxis cases, is managed differently from anterior epistaxis, so identifying the site of bleeding is important whenever possible (1).

Indications for Treating Anterior Epistaxis With Cautery

  • Anterior nasal bleeding from a clearly visible site

  • Failure of nasal compression to stop nasal bleeding

Anterior bleeding sites are usually apparent on direct examination. If no site is apparent and there have been only 1 or 2 minor nosebleeds, no further examination is needed. If bleeding is continuing or recurrent and no site is visualized, it may be necessary to use an anterior nasal packing method.

Contraindications to Treating Anterior Epistaxis With Cautery

Absolute contraindications

  • Inability to see the source of bleeding

Procedures described here are intended for epistaxis that is spontaneous or resulting from minor trauma. Epistaxis in patients with significant facial trauma should be managed by a specialist.

Relative contraindications

  • Patients with a pacemaker and/or defibrillator may require cardiology consultation before doing monopolar electrocauterization.

  • Patients with a cochlear implant may not be able to undergo monopolar electrocauterization.

Complications of Treating Anterior Epistaxis With Cautery

  • Injury or perforation of the nasal septum, particularly from multiple, overly aggressive or bilateral attempts at cauterization

  • Intranasal adhesions

Equipment for Treating Anterior Epistaxis With Cautery

  • Gloves, mask, and gown

  • Gown or drapes for patient

  • Suction source and Frazier-tip suction of varying sizes with integrated finger control to regulate the strength of the suction

  • Sterile gauze sponges

  • Emesis basin

  • Chair with headrest or an ear, nose, and throat (ENT) specialist's chair

  • Light source and headlamp with adjustable narrow beam

  • Nasal speculum

  • Tongue depressors

  • Frazier-tip suction

  • Silver nitrate sticks or electrocauterySilver nitrate sticks or electrocautery

  • Antibiotic ointment (eg, bacitracin)Antibiotic ointment (eg, bacitracin)

  • Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)

  • Cotton swabs or pledgets

Additional Considerations for Treating Anterior Epistaxis With Cautery

  • Ask about use of anticoagulant or antiplatelet medications.

  • Perform a complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or the patient has severe or recurrent epistaxis.

Relevant Anatomy for Treating Anterior Epistaxis With Cautery

  • The submucosal vascular plexus supplying the anterior nasal septum is the most common site of anterior epistaxis. This plexus consists of branches from the anterior ethmoid artery, sphenopalatine artery, greater palatine artery, and septal branch of the superior labial artery.

Positioning for Treating Anterior Epistaxis With Cautery

  • The patient should sit upright in the sniffing position with the head extended, preferably in an ENT specialist's chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should ideally be level with the physician's eyes.

  • The patient should hold the emesis basin to collect any continued bleeding or emesis (eg, of swallowed blood).

Step-by-Step Description of Treating Anterior Epistaxis With Cautery

  • Have the patient gently blow the nose to remove clots. Alternatively, suction the nasal passageway carefully.

  • Insert a nasal speculum with your index finger resting against the patient's nose and the handle parallel to the floor (so the blades open vertically).

  • Gently open the speculum and examine the nose using a bright headlamp or directed light source which permits the clinician to keep one hand free for manipulating suction or other instruments during the examination.

  • Use a Frazier-tip suction to remove any blood and clots obscuring the view.

  • Inspect the anterior septum for blood flow originating from the area of the vascular plexus, and also assess for blood flowing from the back of the nose.

  • Apply a topical vasoconstrictor/anesthetic mixture: Place approximately 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in 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 as oxymetazoline and place pledgets containing only topical anesthetic).Apply a topical vasoconstrictor/anesthetic mixture: Place approximately 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in 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 as oxymetazoline and place pledgets containing only topical anesthetic).

  • Leave the topical medications in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.

  • Use silver nitrate sticks to cauterize the site only if vasoconstriction has stopped the bleeding and the bleeding site is clearly visible. Place the tip of the silver nitrate stick against the site and roll the tip over the bleeding site for 4 to 5 seconds until an eschar forms. This will turn the mucosa a grayish color.Use silver nitrate sticks to cauterize the site only if vasoconstriction has stopped the bleeding and the bleeding site is clearly visible. Place the tip of the silver nitrate stick against the site and roll the tip over the bleeding site for 4 to 5 seconds until an eschar forms. This will turn the mucosa a grayish color.

  • Wipe or suction away any excess silver nitrate to avoid any further cautery at this site or other sites in the nose.Wipe or suction away any excess silver nitrate to avoid any further cautery at this site or other sites in the nose.

  • Patients often sneeze after silver nitrate cautery, which may restart bleeding, necessitating repeat cautery.Patients often sneeze after silver nitrate cautery, which may restart bleeding, necessitating repeat cautery.

  • If using electrocautery, place the tip of the instrument on the area of bleeding mucosa and apply coagulation current for a few seconds until charred mucosa is visible. If using thermal cautery, place the heated tip of the device on the area of bleeding for several seconds until the mucosa is charred. Protracted duration of cautery, application of cautery over a wide area, or bilateral use of cautery on the nasal septum can result in irreversible tissue injury including septal necrosis with resultant perforation. Other risks include infection and scarring.

  • If cautery has not stopped the bleeding after 2 attempts, another technique, such as nasal packing, should be used.

  • After hemostasis is successful, apply antibiotic ointment (such as bacitracin) to the cauterized area.After hemostasis is successful, apply antibiotic ointment (such as bacitracin) to the cauterized area.

Aftercare for Treating Anterior Epistaxis With Cautery

  • Advise the patient not to use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days after treatment of epistaxis.Advise the patient not to use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days after treatment of epistaxis.

  • The cauterized area should be coated with petroleum jelly 2 to 3 times a day for 3 to 5 days.

  • Advise the patient that if bleeding recurs, the nostrils should be pinched closed for 20 minutes without interruption. Applying oxymetazoline nasal spray before pinching the nostrils may help control bleeding. If this does not stop the bleeding or if the bleeding is profuse, the patient should return to the emergency department.Advise the patient that if bleeding recurs, the nostrils should be pinched closed for 20 minutes without interruption. Applying oxymetazoline nasal spray before pinching the nostrils may help control bleeding. If this does not stop the bleeding or if the bleeding is profuse, the patient should return to the emergency department.

Warnings and Common Errors When Treating Anterior Epistaxis With Cautery

  • Do not open the nasal speculum laterally or use the nasal speculum in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)

  • Avoid burning the mucous membrane too deeply. Cautery with silver nitrate is less likely to burn too deeply and is preferred to electrocautery.Avoid burning the mucous membrane too deeply. Cautery with silver nitrate is less likely to burn too deeply and is preferred to electrocautery.

  • Do not cauterize the nasal septum bilaterally because doing so increases the risk of septal injury and perforation.

Tips and Tricks for Treating Anterior Epistaxis With Cautery

  • Elevating the patient's chair to eye level puts less strain on the clinician's back compared to bending down.

  • When using silver nitrate sticks, apply gentle rather than firm pressure to avoid cauterizing too deeply.When using silver nitrate sticks, apply gentle rather than firm pressure to avoid cauterizing too deeply.

  • When using silver nitrate, start peripherally around the site of bleeding and work toward the center. Avoid cauterizing large areas of mucosa.When using silver nitrate, start peripherally around the site of bleeding and work toward the center. Avoid cauterizing large areas of mucosa.

  • Reinspect the nasal cavity 10 to 15 minutes after completion of cauterization to ascertain that bleeding has not restarted.

Reference

  1. 1. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

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