Topic Resources
Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much more common, but posterior bleeding is more dangerous and is managed differently; thus, identifying the site of bleeding is critical. Epistaxis that persists without an evident anterior nasal source is most often caused by a posterior bleeding site.
Posterior bleeding is sometimes controlled using topical vasoconstrictors. If not, it usually requires treatment with nasal packing. Historically, gauze packing was used but balloon tamponade is easier to do and more comfortable to the patient and thus is usually preferred. Some balloons can occlude both the anterior and posterior nasal cavity simultaneously (1).
Posterior nasal packing with gauze can be quite uncomfortable, and should be avoided if possible. However, it is less expensive than commercially available balloons, and may be the only available option in lower-resource settings. Intravenous sedation and analgesia are often needed and hospitalization is required. Applying a cardiac monitor and pulse oximetry is strongly recommended.
The posterior gauze pack consists of 10 cm gauze squares folded, rolled, and 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 As the catheter is withdrawn from the nose, the postnasal pack is pulled into place above the soft palate in the nasopharynx.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.The posterior gauze pack consists of 10 cm gauze squares folded, rolled, and 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.
(See Epistaxis, How To Treat Epistaxis With Cautery and How To Treat Anterior Epistaxis With Nasal Packing.)
Indications for Treating Posterior Epistaxis With a Balloon
Epistaxis from a suspected posterior source
Contraindications to Treating Posterior Epistaxis With a Balloon
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 spontaneous posterior epistaxis. Epistaxis in patients with significant facial trauma should be managed by a specialist.
Relative contraindications
Severe nasal septal deviation toward the bleeding side (makes it difficult to insert balloon device)
Complications of Treating Posterior Epistaxis With a Balloon
Injury (eg, pressure necrosis)
Migration of the nasal packing and aspiration into the airway or airway compromise
Infections such as sinusitis, otitis media, or rarely toxic shock syndrome
Penetration of the catheter through the skull base and into the brain parenchyma, though this is unlikely in the absence of preexisting skull base trauma
Dysphagia
Otitis media secondary to eustachian tube obstruction
Necrosis of the nasal ala
Sometimes hypoxemia, particularly if patients are also sedated
Activation of the trigemino-cardiac reflex leading to cardiac arrhythmia and even cardiac arrest*
* Such cardiac complications have been reported in the literature, although this remains controversial.
Equipment for Treating Posterior Epistaxis With a Balloon
Gloves, mask, and gown
Gown or drapes for patient
Cardiac monitor, pulse oximeter
IV setup: 18-gauge (or larger) angiocatheter and 1 L isotonic crystalloid solution (eg, 0.9% saline)
Medications for sedation/analgesia if needed (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect)Medications for sedation/analgesia if needed (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect)
Sterile gauze sponges
Emesis basin
Suction source and Frazier-tip suctions of varying sizes and with integrated finger control to regulate the strength of the suction
Chair with headrest or ear, nose, and throat (ENT) specialist's chair
Light source and headlamp with adjustable narrow beam
Nasal speculum
Tongue depressors
Bayonet forceps
12 to 16 French inflatable balloon (eg, Foley) catheter or commercial epistaxis balloon (single or dual-balloon)
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)
Water-soluble lubricant or anesthetic jelly (eg, viscous lidocaine)Water-soluble lubricant or anesthetic jelly (eg, viscous lidocaine)
Cotton pledgets or swabs
Sometimes supplies and equipment for anterior nasal packing using a gauze strip
Additional Considerations for Treating Posterior Epistaxis With a Balloon
Initiate treatment for any hypovolemia or shock before treating epistaxis.
Ask about use of anticoagulant or antiplatelet medications.
Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or patient has severe or recurrent epistaxis.
If posterior packing fails to control nasal hemorrhage, invasive methods performed by specialists may be needed:
Sphenopalatine artery (SPA) ligation, typically using a transnasal endoscopic approach; success rates exceed 85% (2)
Endovascular SPA embolization; reported success rate 88% (3).
Endoscopic SPA ligation is performed by an otolaryngologist and has a lower risk of major complications (eg, stroke, blindness) than endovascular SPA embolization and may be more appropriate for patients who can safely tolerate general anesthesia or if the embolization procedure is not readily available.
Endovascular SPA embolization is performed by an interventional radiologist under local anesthesia and may be better for patients with multiple comorbidities that preclude safe general anesthesia, for those on anticoagulant therapy, and for patients who present with bleeding after previously having had endoscopic SPA ligation.
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. Alternatively, angiographic embolization may be performed by a skilled radiologist.
Relevant Anatomy for Treating Posterior Epistaxis With a Balloon
Severe or intractable posterior epistaxis often stems from the internal maxillary or sphenopalatine arteries or their proximal branches.
Positioning for Treating Posterior Epistaxis With a Balloon
The patient should sit upright in the sniffing position with 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 be level with the physician's eyes.
The patient should hold an emesis basin to collect any continued bleeding or emesis of swallowed blood.
Step-by-Step Description for Treating Posterior Epistaxis With a Balloon
Initial steps:
Start an IV and send any laboratory studies needed.
Place the patient on a cardiac monitor and pulse oximeter.
Have the patient blow the nose to remove clots. Alternatively, suction the nasal passageway carefully.
To help identify the bleeding site (and possibly stop the bleeding), apply a 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). To help identify the bleeding site (and possibly stop the bleeding), apply a 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.
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).
Gently open the speculum and examine the nose using a directed light source, which allows the clinician to keep one hand free for manipulating suction or other instruments during the examination.
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 catheter to tamponade active posterior bleeding:
Give IV analgesia (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect).Give IV analgesia (eg, 0.5 to 1.0 mcg/kg fentanyl to 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 anterior 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.
Aftercare for Treating Posterior Epistaxis With a Balloon
Admit all patients with posterior balloon packing to a monitored unit (to facilitate cardiac dysrhythmia and airway monitoring for accidentally dislodged balloon/packing). Manage hypoxemia as required.
Avoid the use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days post-treatment. Avoid the use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days post-treatment.
Prescribe an antibiotic (eg, amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) to prevent Prescribe an antibiotic (eg, amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) to preventsinusitis and otitis media.
Deflate the balloon and remove the catheter after 48 to 72 hours.
Warnings and Common Errors When Treating Posterior Epistaxis With a Balloon
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.)
Overfilling the catheter balloon can cause significant pain.
Tips and Tricks for Treating Posterior Epistaxis With a Balloon
Elevating the patient's chair to eye level puts less strain on the clinician's back compared to bending down.
Always consult an otolaryngologist after placement of a posterior nasal pack to ensure follow-up.
After placement of the posterior pack, look through the mouth to make sure that there is no further bleeding down the throat. If there is bleeding, put more fluid into the catheter balloon. If this fails to control bleeding, consult an otolaryngologist immediately.
References
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
2. Rudmik L, Smith TL. Management of intractable spontaneous epistaxis. Am J Rhinol Allergy. 26(1):55-60, 2012. doi:10.2500/ajra.2012.26.3696
3. Christensen NP, Smith DS, Barnwell SL, et al. Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg.133:748-753, 2005. doi: 10.1016/j.otohns.2005.07.041