• Outpatient (usually). Inpatient for severe hemorrhage.
• Elderly patient with posterior bleeds and balloon or packing usually requires admission.

• Resuscitation as indicated
• Sedation, analgesic, antihypertensive or anticoagulant reversal as needed
• Patient should be gowned and sitting, if stable. Gown, gloves, and eye protection for examiner.
• Attempt to locate bleeding site using headlamp, suction, nasal speculum and assistant. Clear nasal cavity of blood with suction, forceps withdrawal of clot or patient blowing nose. If bleeding has stopped, rub suspicious areas with wet cotton tipped applicator to identify site. Diffuse ooze or multiple sites suggests systemic cause. In cases of posterior bleed try to identify as either roof or low posterior site since each has different arterial supply (will be important if arterial ligation is necessary).
• Locating the bleeding site may be difficult if patient presents with bilateral bleed. Usually there is only one bleeding site and the blood appears on the other because of (1) Septal perforation, (2) Obstruction of the affected side by pinching or packing or (3) there is a posterior bleed and blood passes behind the nasal septum. Clues are the side on which bleeding started and a careful examination using suction, headlamp and speculum.
• Anterior bleed:
  • Place pledget soaked in vasoconstrictor and local anesthetic in cavity and pinch nostril for several minutes to stop bleeding by direct pressure
  • Remove pledget and visualize vessel. Cauterize with silver nitrate stick directly on vessel with firm pressure for 30 seconds.
  • Alternative chemical cautery includes bead of chromic acid or 25% trichloracetic acid. Larger vessels respond better to thermal cautery or bipolar electrocautery. Avoid indiscriminate cauterization of a large area.
  • If unsuccessful, apply second dose of anesthetic and place anterior pack using 1/2 x 72 inch ribbon gauze impregnated with petroleum jelly (Vaseline) or nasal tampons may be used. Use bayonet forceps and nasal speculum to insert in folding layers as far back as possible. Press each layer firmly down on the last in one continuous strip with the folded ends alternating front and back. The average nasal cavity will accommodate the full length if properly placed. Tape 2x2 gauze over nostril as drip catch and to prevent packing end from falling out of nostril.
• Posterior bleed:
  • Traditional posterior packing as described in ENT texts has been replaced by various balloon systems. However it is very effective if balloon systems fail to control bleeding.
  • Balloon systems include single large balloon with or without central tube for airway. They usually come in 3 or 4 sizes and right or left. Other systems provide a small (10 cc) posterior balloon and larger (30 cc) anterior balloon. After local anesthesia, the tube is placed in the affected nostril and is passed to the nasopharynx as one would a nasogastric tube. Inflate the posterior balloon with air or water (see manufacturer's directions) and pull forward to press upon the posterior area. Then inflate the anterior balloon (see note under Complications). A very effective method uses a 10 to 14 Fr Foley catheter. Place tip of Foley through the nostril to nasopharynx or upper oropharynx. Visualize through mouth avoiding placement in hypopharynx. Inflate balloon 7 to 15 cc. Pull forward until balloon wedges in posterior passage. Have assistant maintain gentle traction and place catheter along mid-section of lateral wall of nasal cavity. Insert anterior pack described above. Maintain catheter traction and stretch slightly. Place umbilical cord clamp on catheter across nostril against anterior pack so that elasticity of catheter compresses balloon against anterior pack. Protect facial skin from clamp by padding with 2x2 gauze. Drape rest of catheter over ear and tape in place.
• Intractable bleed:
  • Bilateral packing is sometimes required to achieve adequate compression (admission required)
  • Bleeding from roof may be controlled by placing double balloon system with small anterior pack placed above anterior balloon. Inflation then raises pack to place pressure on roof.
  • Intractable bleed will require surgical cauterization or arterial ligation (ideally after visual identification of bleeding site to define appropriate arterial supply). This can usually be achieved through transnasal endoscopic means. Alternative is angiographic selective arterial embolization.

• Arterial ligation for intractable bleeding

Bedrest with head at 45 to 90 degrees

No alcohol or hot liquids

Demonstrate proper pinching pressure techniques