Nasal Pack, Posterior Epistaxis
Posterior epistaxis is usually treated by an otolaryngologist, but an emergency physician may be called upon to treat this condition in a medical environment with few support services.
Epistaxis is a common problem in the emergency department. It is relatively benign in nature but can produce serious, life-threatening situations. Up to 60% of the population is estimated to have had at least one episode of epistaxis at some point in their lives. Of this group, 6% seek medical care to treat epistaxis, with 1.6 in 10,000 requiring hospitalization.1
Ten percent of epistaxes are posterior, exhibiting massive bleeding that is initially bilateral. Posterior epistaxis may present in ways that suggest a more inferiorly located site of bleeding from the aerodigestive tract, such as hemoptysis, melena, anemia, or just nausea. A posterior source of the bleeding must be sought when epistaxis is bilateral, brisk, and not controlled with anterior nasal packing.
A focused history aids the clinician in managing the acutely bleeding patient. This history should include some or all of the following questions:
Which side is bleeding?
Which side was bleeding initially?
What is the estimated amount of blood loss?
Is it recurrent?
Is it in the pharynx?
Has any trauma recently occurred?
Are symptoms of hypovolemia present?
What are the patient’s past medical history and current medications (eg, aspirin, warfarin)?2
The bleeding site of a posterior epistaxis is either posterior to the middle turbinate or at the posterior superior aspect of the nasal cavity. Branches of the sphenopalatine artery supply the blood for such an epistaxis. The vast majority of posterior bleeding sites originate from the septum.3
As with any unstable patient, initial management begins by assessing the ABCs: airway, breathing, and circulation. Next, the physician should identify the source of the bleed with a thorough examination of the nasopharynx.
A posterior pack is placed to occlude the choanal arch and, in conjunction with an anterior nasal pack, provides hemostasis. A posterior pack can be completed with a gauze pack, a Foley catheter, a nasal sponge/tampon, or an inflatable nasal balloon catheter. Posterior packing is very uncomfortable and may require procedural sedation. (Click here to complete a Medscape CME activity on pediatric procedural sedation.) An anterior nasal pack is always required on the side of a posterior back, and a contralateral nasal pack is strongly encouraged to maintain the septum midline.4
Failure of anterior packing
Reliable or high suspicion of posterior bleeding
Patient spitting out blood
Older patient with atherosclerosis
No visible anterior bleeding site
Patient with bleeding diathesis (Each of these states makes hemostatic control much more difficult, and each has its set of additional specific targeted therapies.)
Hereditary hemorrhagic telangiectasia
Von Willebrand disease
Temporizing measure until more definitive therapies are obtained
Endoscopic ligation by otolaryngology
Endovascular ligation by interventional radiology
Do not perform a nasal pack in the presence of facial trauma that may include nasal bone and cribriform plate fractures. For more information on treating facial trauma, see eMedicine’s Plastic Surgery Facial Fractures section.
If the patient is in shock, has altered mental status, or is otherwise not protecting the airway, control the airway before attempting any nasal packing.