What methods do physicians use to control a nosebleed (epistaxis)?

Methods for Controlling Epistaxis (Nosebleeds)

All of the above (packing, ligation, and cauterization) are methods physicians use to control nosebleeds, with the approach determined by the severity, location, and persistence of the bleeding. 1, 2

First-Line Management Approaches

Cauterization

• Indication: When a specific bleeding site can be identified, especially for anterior bleeds 1
• Technique:
  • Requires direct visualization of the bleeding site using headlight, nasal speculum, and suction 1
  • Electrocautery (especially bipolar) is preferred over chemical cautery for efficacy, comfort, and cost-effectiveness 1, 2
  • Should only be performed when "an anterior bleeding site is clearly visible" 1
• Efficacy: More effective than nasal packing when a bleeding site can be identified 1
• Caution: Avoid bilateral septal cautery to prevent septal perforation 1, 2

Nasal Packing

• Indication: When cauterization fails or bleeding site cannot be identified 2
• Types:
  • Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino) 3
  • Absorbable materials: nasal tampon (Nasopore) 3
  • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) 3
• Complications:
  • Risk of infection, decreased blood flow to nasal areas, septal perforations, scar bands, pressure sores, worsening of obstructive sleep apnea 2
  • Consider prophylactic antibiotics if risk for infection is high 2

Advanced Management for Persistent Bleeding

Arterial Ligation

• Indication: Persistent or recurrent bleeding not controlled by packing or cauterization 1
• Technique:
  • Endoscopic ligation of arteries, primarily sphenopalatine artery (SPA) 3
  • Can be performed with concurrent endoscopic anterior ethmoidal artery ligation 1
• Efficacy: More effective than conventional nasal packing (97% vs. 62%) 3
• Considerations:
  • Typically requires general anesthesia 1
  • More cost-effective than endovascular embolization 1
  • Lower risk of stroke compared to embolization (0.1% vs. 0.9%) 1

Endovascular Embolization

• Indication: Alternative to surgical ligation for persistent bleeding 1
• Technique:
  • Requires detailed angiography of internal and external carotid arteries 1
  • Materials used include gelatin sponge, foam, PVA and coils 3
• Efficacy: Approximately 80% success rate 3
• Considerations:
  • Can be performed under sedation without direct trauma to nasal mucosa 1
  • Higher risk of serious complications including stroke (0.9-1.6%) compared to surgical ligation 1
  • Increased utilization from 2.8% of cases in 2003 to 10.7% in 2010 1

Stepwise Approach to Epistaxis Management

1. Initial assessment: Determine if bleeding is anterior (90-95% of cases) or posterior (5-10%) 2
2. First aid measures: External pressure to lower third of nose for 10-15 minutes 2
3. Visualization: Remove blood clots and perform anterior rhinoscopy; use nasal endoscopy for recurrent cases 2
4. Topical treatments: Apply vasoconstrictors (oxymetazoline) and topical anesthesia (lidocaine/tetracaine) 2
5. Cauterization: If bleeding site is visible, proceed with cautery (preferably electrocautery) 1, 2
6. Nasal packing: If cauterization fails or bleeding site cannot be identified 2
7. Advanced interventions: For persistent bleeding, consider arterial ligation or embolization 1

Important Considerations

• For patients on antiplatelet or anticoagulant therapy, temporary discontinuation may be necessary in persistent bleeding cases 2
• Evaluate for underlying conditions: hypertension, coagulation disorders, kidney/liver disease 2
• Tranexamic acid (oral or topical) may reduce risk of re-bleeding from 67% to 47% 4
• Endoscopic approaches have significantly improved the management of posterior epistaxis, reducing the need for blind packing 5

The management approach should progress from less to more invasive techniques based on the severity and persistence of bleeding, with consideration of the patient's medical history and available resources.