What is the workup and management of posterior epistaxis (nosebleeds)?

From the Guidelines

Posterior nosebleeds require prompt medical attention due to their potential severity, and initial management involves stabilizing the patient and applying pressure to the nose, with potential progression to nasal packing, topical vasoconstrictors, and other interventions as necessary. The management of posterior epistaxis is crucial due to its potential impact on morbidity, mortality, and quality of life 1. Initial steps include ensuring airway patency, applying pressure to the nose by pinching the soft part for 10-15 minutes, and placing the patient in a forward-leaning position to prevent blood from draining down the throat. If bleeding persists, nasal packing is necessary, with options including a posterior nasal pack or an epistaxis balloon catheter (like a Rapid Rhino) 1.

Key Interventions

• Topical vasoconstrictors such as oxymetazoline or phenylephrine can be applied before packing to aid in bleeding control 1.
• Intravenous access should be established, and blood work including complete blood count, coagulation profile, and type and cross-match may be necessary, especially in cases of significant bleeding 1.
• Patients with significant bleeding may require fluid resuscitation or blood transfusion to maintain hemodynamic stability 1.
• Posterior packs typically remain in place for 48-72 hours, and prophylactic antibiotics (such as amoxicillin-clavulanate 875/125 mg twice daily) are often prescribed to prevent toxic shock syndrome and sinusitis 1.

Hospital Admission and Monitoring

Patients with posterior packing generally require hospital admission for monitoring of oxygen saturation, as the packs can cause respiratory compromise 1. Underlying causes such as hypertension should be addressed, and anticoagulant medications may need temporary adjustment to prevent further bleeding episodes 1. If conservative measures fail, surgical interventions including endoscopic sphenopalatine artery ligation or endovascular embolization may be necessary to control the bleeding 1.

Importance of Nasal Endoscopy

Nasal endoscopy is a valuable tool in the management of posterior epistaxis, allowing for the localization of the bleeding site in up to 93% of cases, which is crucial for targeted therapy 1. The decision to proceed with nasal endoscopy should be based on the severity of the bleeding and the presence of clinical symptoms or signs alerting the clinician to additional bleeding sites or intranasal pathology 1.

In summary, the management of posterior epistaxis involves a multifaceted approach that prioritizes patient stabilization, bleeding control, and prevention of complications, with a focus on improving outcomes related to morbidity, mortality, and quality of life.

From the Research

Workup of Posterior Epistaxis

• The workup of posterior epistaxis involves identifying the common bleeding sites in the nasal cavity 2
• A study found that bleeding points were identified in 36 out of 43 cases, with 20% of bleeding points located on the septum and 81% on the lateral nasal wall 2
• The lateral nasal wall, particularly the posterior aspect, is a common location for bleeding points, with the lateral surface of the middle and inferior turbinates being potential sites for concealed bleeding points 2

Management of Posterior Epistaxis

• Examination under general anesthesia is recommended when conservative measures fail to control bleeding, with a focus on the posterior aspect of the lateral nasal wall 2
• Electrothermocautery can achieve excellent results with minimal complications 2
• Selective Surgicel packing can be used to control hemorrhage without packing the entire nasal cavity, reducing patient morbidity and length of hospital stay 3
• Tranexamic acid, either oral or topical, can reduce the risk of re-bleeding in adult patients with epistaxis, compared to placebo 4
• Nasoendoscopic cautery is a more effective method than nasal packing for managing sphenopalatine artery bleeding, with shorter inpatient stay and reduced complications rate 5
• Endoscopic endonasal cauterization of the sphenopalatine branches is a safe and effective procedure for managing posterior epistaxis 5
• The use of fibreoptic nasolaryngoscope can help identify the exact location of the bleeding area and arrest haemorrhage by local treatment, reducing the duration of hospital stay and discomfort to the patient 6