Management of Nasopharyngeal Bleeding
For active nasopharyngeal bleeding, immediately apply firm sustained compression to the lower third of the nose for at least 5 minutes while simultaneously assessing for airway compromise and hemodynamic instability, which would require emergent hospital evaluation. 1
Initial Assessment and Triage
The first critical decision is determining the urgency of care based on bleeding severity and patient stability 1:
Emergent Hospital/ED Evaluation Required:
- Active bleeding with signs of airway compromise (bleeding into oropharynx/airway) 1
- Hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1
- Bleeding from both nostrils or from the mouth 1
- Bleeding duration >30 minutes over 24 hours 1
- History of hospitalization or transfusion for nosebleeds 1
3 recent bleeding episodes 1
Ambulatory Setting Acceptable:
- Minor active bleeding without airway or hemodynamic concerns 1
- No active bleeding with history of only minor prior bleeding 1
Immediate Management Algorithm
Step 1: Nasal Compression (First-Line)
Apply firm sustained compression to the lower third of the nose for 5 minutes or longer, with or without patient/caregiver assistance 1. This is the least invasive and most readily available intervention 1.
Step 2: Identify Bleeding Source
After any blood clot removal, perform anterior rhinoscopy to identify the bleeding site 1. If the source cannot be identified or bleeding is difficult to control, perform or refer for nasal endoscopy to examine the nasal cavity and nasopharynx 1.
Step 3: Site-Specific Treatment
Once the bleeding site is identified, treat with one or more of the following 1:
- Topical vasoconstrictors
- Nasal cautery (anesthetize first and restrict application only to the active/suspected bleeding site) 1
- Moisturizing or lubricating agents
Step 4: Nasal Packing (If Bleeding Persists)
If bleeding precludes identification of the site despite compression, proceed with nasal packing 1:
Critical distinction for packing type:
- Use resorbable packing for patients with suspected bleeding disorders OR those on anticoagulant/antiplatelet medications 1
- Standard packing may be used in other patients 1
Important caveat: In patients with ipsilateral septal deviation, nasal packing (particularly Merocel®) can traumatize the sphenopalatine area and paradoxically worsen bleeding 2. Consider endoscopic cauterization in these anatomic situations.
Risk Factor Documentation
Document factors that increase bleeding frequency or severity 1:
- Personal or family history of bleeding disorders 1
- Anticoagulant or antiplatelet medication use 1
- Intranasal drug use 1
- Prior nasal/sinus surgery 1
- Nasal trauma 1
- Nasal cannula oxygen or CPAP use 1
- Chronic kidney or liver disease 1
- Hypertension, cardiopulmonary disease, anemia 1
Management of Patients on Anticoagulation
In the absence of life-threatening bleeding, initiate first-line treatments (compression, cautery, packing) BEFORE transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1. This prioritizes hemostasis without unnecessarily exposing patients to thromboembolic risks.
Refractory Bleeding
For persistent or recurrent bleeding not controlled by packing or cauterization, evaluate candidacy for 1:
- Surgical arterial ligation
- Endovascular embolization
These interventions require specialist referral and are reserved for cases failing conservative measures 1.
Patient Education and Follow-up
For Patients with Nasal Packing:
Educate about 1:
- Type of packing placed
- Timing and plan for removal (if non-resorbable)
- Post-procedure care (nasal saline sprays, head elevation, avoid straining/lifting >10 pounds) 1
- Warning signs requiring prompt reassessment: fever >101°F, return of bleeding, increasing pain, vision changes, shortness of breath, facial swelling, diffuse rash 1
General Prevention:
Educate all patients about preventive measures, home treatment techniques, and indications to seek additional care 1.
Special Considerations
Assess for hereditary hemorrhagic telangiectasia (HHT) in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds by examining for nasal and oral mucosal telangiectasias 1.
Document outcomes within 30 days or document transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1.