What are the management options for posterior epistaxis?

Management of Posterior Epistaxis

For patients with posterior epistaxis, a stepwise approach should be followed, beginning with first-line measures and progressing to more invasive interventions including nasal packing, endoscopic arterial ligation, or embolization if bleeding persists. 1

Initial Assessment and First-Line Management

• Diagnostic Evaluation:

  • Perform anterior rhinoscopy after removing blood clots
  • If bleeding site cannot be identified or is suspected to be posterior, perform nasal endoscopy 1
  • Document risk factors: bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use, hypertension, chronic alcohol use 1

• First-Line Interventions:

  • Position patient sitting with head slightly forward 1
  • Apply firm sustained compression to the lower third of the nose for 10-15 minutes 1
  • Apply topical vasoconstrictors (e.g., oxymetazoline) which can stop 65-75% of nosebleeds 2
  • Consider topical tranexamic acid (TXA) which promotes hemostasis in 78% of patients (versus 35% with oxymetazoline) 2

Management of Persistent Posterior Bleeding

Nasal Packing Options

If first-line measures fail, proceed to nasal packing:

• Non-absorbable materials:

  • Petroleum jelly gauze
  • BIPP gauze
  • PVA nasal tampons (Merocel)
  • Foley catheter
  • Balloon devices (Rapid-Rhino) 2

• Absorbable materials:

  • Nasal tampon (Nasopore)
  • Hemostatic gauzes (Surgicel)
  • Thrombin matrix (Floseal)
  • Gelatin sponge (Spongostan)
  • Fibrin glue 2

Important: Posterior nasal packing is often associated with pain and risk of aspiration if dislodged. Consider prophylactic antibiotics for patients with nasal packing. 3

Surgical Interventions

For persistent/recurrent bleeding not controlled by packing:

• Endoscopic arterial ligation:

  • Success rate of 97% (compared to 62% with conventional nasal packing) 2
  • Target vessels include sphenopalatine artery and posterior nasal artery
  • Consider anterior ethmoidal artery control if needed 4

• Endovascular embolization:

  • Success rate of approximately 80%
  • Uses materials such as gelatin sponge, foam, PVA, and coils
  • Higher risk of serious complications including stroke (0.9-1.6%) 1, 2

Management of Specific Bleeding Sites

• Posterior bleeding sites are commonly located on:

  • Lateral nasal wall (52%)
  • Nasal septum (27%)
  • Anterior face of sphenoid sinus (3.5%) 5

• Prophylactic electrocoagulation of common bleeding points can significantly reduce rebleeding rates (8.8% vs 38.5%) when no definite bleeding site is identified 5

Special Considerations

Anticoagulant/Antiplatelet Management

• In the absence of life-threatening bleeding, initiate first-line treatments before considering withdrawal of anticoagulation/antiplatelet medications 1
• For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with the prescribing physician 1

Indications for Hospital Admission

• Posterior epistaxis
• Bleeding not controlled with anterior packing
• Significant hemodynamic instability
• Need for blood transfusion 1

Follow-up Care

• Schedule follow-up within 3-5 days to assess for recurrence 1
• Provide patient education on nasal moisturization techniques and when to seek emergency care (bleeding lasting >30 minutes or signs of hypovolemia) 1
• Document outcome of intervention within 30 days 1

Caution: Posterior epistaxis is more likely to require hospitalization and twice as likely to need nasal packing compared to anterior epistaxis. After stabilization, patients with posterior packing often require referral to otolaryngology for definitive treatment. 3