What is the order of treatment for anterior and posterior epistaxis?

Treatment Algorithm for Anterior and Posterior Epistaxis

For most patients with epistaxis, initial treatment should involve having the patient sit with their head slightly forward while pinching the soft portion of the nose for 10-15 minutes, which is often sufficient to control bleeding. 1

Initial Assessment and Management

Step 1: First Aid Measures

• Position patient sitting upright with head tilted slightly forward (to prevent blood from entering airway or stomach)
• Apply direct pressure by pinching the soft lower third of the nose continuously for 10-15 minutes
• Instruct patient to breathe through mouth and spit out any blood 1
• Avoid swallowing blood (can cause nausea/vomiting)

Step 2: Determine Bleeding Location

• Anterior epistaxis (90-95% of cases): Bleeding from Kiesselbach's plexus on the anterior nasal septum
• Posterior epistaxis (5-10% of cases): Bleeding from posterior sites on lateral nasal wall or septum, more common in older patients 1

Treatment Algorithm for Anterior Epistaxis

Step 1: Topical Vasoconstrictors

• Apply oxymetazoline or phenylephrine to bleeding site
• Success rate: 65-75% of cases resolve with vasoconstrictor application 1, 2

Step 2: Direct Visualization and Cautery

• Anesthetize the bleeding site with topical lidocaine or tetracaine
• Apply cautery only to the active bleeding site
• Electrocautery is more effective than chemical cautery with fewer recurrences (14.5% vs 35.1%) 1, 2
• Silver nitrate cauterization has shown 80% success rate with lowest recurrence 3

Step 3: Nasal Packing (if cautery fails)

• Options include:
  • Non-absorbable materials: petroleum gauze, Merocel® (PVA nasal tampons)
  • Absorbable materials: Nasopore
  • Hemostatic materials: Surgicel, Floseal, gelatin sponge, fibrin glue 2
• Monitor for complications: sinusitis, middle ear effusion, hypoxia 4

Step 4: Prevention of Recurrence

• After bleeding stops, apply moisturizing/lubricating agents to prevent recurrence 1
• Consider humidification and saline sprays 1

Treatment Algorithm for Posterior Epistaxis

Step 1: Endoscopic Evaluation

• Nasal endoscopy should be performed to localize the bleeding site (identifiable in 87-93% of cases) 1
• Posterior bleeding can originate from septum (70%) or lateral nasal wall (24%) 1

Step 2: Endoscopic Intervention

• Endoscopic cauterization of identified bleeding vessel
• More effective than conventional nasal packing (97% vs 62%) 2

Step 3: Posterior Packing (if endoscopic intervention fails)

• Options include:
  • Foley catheter
  • Balloon devices (e.g., Rapid-Rhino)
  • Formal posterior packing
• Requires hospitalization and antibiotic prophylaxis 5

Step 4: Advanced Interventions (for refractory cases)

• Endoscopic arterial ligation (primarily sphenopalatine artery)
• Angiographic embolization (80% success rate) using gelatin sponge, foam, PVA, or coils 2

Special Considerations

Anticoagulation Therapy

• Patients on anticoagulants or with bleeding disorders should seek professional care unless bleeding has stopped 1
• 61% of epistaxis patients may be on antiplatelet or anticoagulant therapy 3

Tranexamic Acid

• Topical tranexamic acid promotes hemostasis in 78% of patients (vs. 35% with oxymetazoline and 31% with nasal packing) 2
• Consider for patients on antiplatelet medications 1

When to Seek Immediate Medical Attention

• Epistaxis that doesn't stop after 15 minutes of continuous pressure
• Patient becomes lightheaded from blood loss
• Epistaxis due to trauma with signs of brain injury, nasal deformity, or facial fracture
• Patients with hypertension (present in 24-64% of epistaxis cases) 1

Pitfalls and Caveats

1. Bilateral cautery risk: Avoid bilateral septal cautery to minimize risk of septal perforation 1

2. Posterior epistaxis mortality: Posterior epistaxis has a 30-day all-cause mortality rate of 3.4%, requiring more aggressive management 1

3. Adolescent males with unilateral epistaxis: Consider juvenile nasopharyngeal angiofibroma, especially with nasal obstruction 1

4. Children with unilateral epistaxis: Consider foreign body, present in 7% of cases 1

5. Hypertension management: While hypertension is associated with epistaxis (OR 1.532), there is no proven causal relationship 1

By following this structured approach to epistaxis management based on bleeding location and severity, most cases can be effectively controlled with progressive interventions as needed.