How To Treat Anterior Epistaxis With Nasal Packing

• Anterior nasal bleeding from a site that is not clearly visible

• Failure of nasal compression and cautery to stop nasal bleeding

Absolute contraindications

• Possible or identified skull base fracture

• Significant maxillofacial or nasal bone trauma

• Uncontrolled airway or hemodynamic instability

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

• Severe nasal septal deviation toward bleeding side (makes it difficult to insert nasal packing material)

• Injury to the nasal mucosa including pressure necrosis with possible septal perforation, particularly with bilateral nasal packing

• Migration of anterior nasal packing to the posterior nasopharyngeal area or aspiration into the airway

• Infections such as sinusitis or rarely toxic shock syndrome

• Rebleeding when pack is removed

• Gloves, mask, and gown

• Gown or drapes for patient

• Suction source and Frazier-tip and/or other suction-tip catheters

• Nasal packing device or material*

• Emesis basin

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

• Light source and head mirror or headlamp with adjustable narrow beam

• Nasal speculum

• Tongue depressors

• Bayonet forceps

• Scissors for cutting nasal gauze or sponges

• 5-mL sterile saline solution

• Cotton swabs or pledgets

* There are several types of nasal packing materials/devices divided into the following resorbable and nonresorbable options:

Resorbable packing

• Carboxymethylcellulose compounds

• Oxidized regenerated cellulose

• Synthetic polyurethane sponge

• Chitosan-containing polymers

Nonresorbable packing

• Polyvinyl acetate sponge (sometimes with an internal airway tube), ideally with removal strings that can be secured to the patient's cheek to prevent aspiration and aid removal

• High-volume, low-pressure inflatable ballon with carboxymethylcellulose fabric cover

• One or two balloon catheters

• 1.25 cm (½-inch) petrolatum gauze strip

Resorbable packing is associated with less discomfort than nonresorbable packing. Placement instructions vary for the different types of resorbable packing; follow the manufacturer's instructions. Use of resorbable packing is recommended in patients with bleeding disorders, those on antithrombotic medications, and in those with vascular malformations (eg, hereditary hemorrhagic telangiectasia) to avoid potential mucosal trauma and re-bleeding associated with the removal of nonresorbable packing.

Nonresorbable nasal sponges are highly compressed for ease of insertion and expand and become soft when hydrated. Nasal sponges and inflatable balloon packing are easier to insert and cause less discomfort than petrolatum gauze strips and are, therefore, preferred when available. Some types of inflatable balloon packing have a carboxymethylcellulose outer fabric that facilitates insertion and removal, which reduces patient discomfort.

Insertion of a petrolatum gauze strip is uncomfortable and often requires some analgesia and/or mild sedation (however, not enough to risk airway compromise). Thus, this procedure should be done only when other methods fail or are not available.

• Ask about use of anticoagulant or antiplatelet drugs.

• Check 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.

• Kiesselbach's plexus is a vascular watershed area on the anterior nasal septum that is the most common site of anterior epistaxis.

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

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

Initial steps

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

• 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.

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

• Look for blood flowing from the anterior septum in the area of Kiesselbach's plexus, and look for blood flowing from the back of the nose.

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

To insert resorbable packing 

• Oxidized regenerated cellulose is supplied as a powder or as a fabric. The powder formulation is ideal for epistaxis control because it covers broad surfaces and does not require precise placement. The powder is provided in a syringe-like delivery device with an attached catheter. Place the catheter into the nasal cavity. Pump the delivery device as needed to coat the nasal cavity with the hemostatic powder.

• Synthetic polyurethane and chitosan-containing polymers are provided as resorbable sponges. Insertion is similar to the placement of nonresorbable sponges. Place the sponge perpendicular to the face and advance it parallel to the nasal floor in a single, smooth movement. The sponge should not be coated in any medication or substance prior to insertion. The sponge expands automatically with the absorption of blood.

• Always observe the patient for at least 10 minutes after placement of resorbable packing to ensure that bleeding has been controlled.

To insert a nonresorbable compressed (expandable) nasal sponge

• Trim the length and width of the sponge to fit the nose. A typical 8-cm commercial nasal sponge can fit into an adult nasal cavity without modification.

• Insert the sponge perpendicular to the face and advance it parallel to the floor of the nasal cavity in a single, smooth movement to limit discomfort.

• After the sponge has been properly inserted, expand the sponge by injecting 5 to 10 mL of saline or local anesthetic onto the sponge using an 18- to 22-gauge angiocatheter.

• Tie the drawstring (if present) around a piece of gauze to prevent displacement posteriorly, or tape the string to the cheek.

• If necessary, insert a second sponge to fill the nasal cavity. Be sure that the tips of both sponges are at the level of the nares or protrude slightly.

• Observe the patient for 10 minutes after sponge insertion to ascertain control of bleeding.

To insert an inflatable balloon device

• If the balloon has a carboxymethylcellulose outer fabric, soak the device in sterile water for up to 30 seconds (do not soak in saline). Follow the manufacturer's instructions.

• Insert the device perpendicular to the face and advance it parallel to the floor of the nasal cavity until the plastic ring is within the nasal cavity.

• Inflate the device with air using a 20-mL syringe until the pilot cuff becomes rounded and firm. Do not inflate with water or saline and do not apply lubricants or antibiotic ointments to the device.

• Secure the inflation port to the patient's face using tape or a transparent dressing.

To insert petrolatum gauze packing

• Grasp the petrolatum gauze with bayonet forceps about 10 cm from the end (this determines how deeply the gauze will be placed). Advance the strip of petrolatum gauze posteriorly into the nasal cavity parallel to the nasal floor until the end of the gauze strip is just outside the opening of the naris.

• Grasp another 8 to 10 cm of strip gauze and place this on top of the prior layer in an accordion fashion, being sure that it is inserted parallel to the nasal floor and extends the full length of the nasal cavity.

• Be sure to grasp a long enough piece each time to allow insertion to the back of the nose in a single motion.

• Place each layer slightly anterior to the previous layer to prevent the packing from slipping posteriorly.

• Press down on the packing with the bayonet forceps to pack it tighter after placement of every several layers.

• Continue to add layers of strip gauze until the nasal cavity is packed. The full length of strip gauze—typically, 180 cm (72 inches)—may be required.

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• Nonresorbable anterior packs are usually left in place for 3 to 5 days.

• Nonresorbable nasal sponges should be moistened 3 times a day with water or saline.

• Resorbable nasal packing will dissolve on exposure to moisture. To encourage dissolution of the packing and to reduce nasal crusting, patients should apply nasal saline sprays to the nasal cavity 3 times a day.

• Consider treating with a course of antibiotics because of the small risk of sinusitis and rare toxic shock syndrome.

• Follow up within 5 days after placement of either nonresorbable or resorbable packing to allow for pack removal (in the case of nonresorbable products) and to monitor for proper healing of nasal mucosa.

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

• Insert the sponge or balloon straight back, parallel to the floor of the nasal cavity, not angled upward parallel to the contour of the nose.

• Avoid bunching gauze in the anterior nasal passage; if nearly the full 180 cm (72 inches) of prepackaged gauze could not be inserted, it was probably not inserted deeply enough.

• When using inflatable balloon devices, avoid excessive inflation (particularly of bilateral devices) because this can cause pressure necrosis of the septum.

• When removing an inflatable balloon device, be sure to deflate it completely before removal.

• Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.

• If necessary, packing the contralateral nasal cavity can improve nasal packing and prevent septal deviation.

• Compressed nasal sponges can be wrapped in a layer of resorbable oxidized regenerated cellulose fabric prior to insertion to facilitate hemostasis.