Why Silver Nitrate is Applied in Epistaxis
Silver nitrate is applied in epistaxis because it chemically cauterizes bleeding vessels in the nasal mucosa, achieving hemostasis in approximately 80% of cases when a visible anterior bleeding site can be identified, making it a simple, effective, and widely available treatment option that requires no specialized equipment. 1, 2
Mechanism of Action and Clinical Effectiveness
Silver nitrate (typically used in 25-75% concentrations) works as a chemical cautery agent that coagulates proteins in the vessel wall and surrounding tissue, creating a chemical burn that seals the bleeding point 1
When applied to visible anterior septal vessels (particularly in Kiesselbach's plexus), silver nitrate demonstrates an 80% initial treatment success rate in emergency department settings, which is the highest success rate among all treatment modalities studied 2
The chemical cauterization provides immediate hemostasis without requiring electrical equipment, making it particularly practical in office and emergency settings where electrocautery may not be readily available 1
Proper Application Technique
The bleeding site must be anesthetized first with topical lidocaine or tetracaine (applied via spray or pledgets soaked with the agent) before silver nitrate application to improve patient tolerance 1
Silver nitrate should be applied only to the active or suspected bleeding site after performing anterior rhinoscopy and removing any blood clots, restricting application to minimize unnecessary tissue damage 1
The application should be brief and controlled—studies show that even 5 seconds of contact time produces significant tissue penetration, with 95% concentration penetrating twice as deep as 75% concentration 3
Advantages Over Alternative Methods
Silver nitrate cautery is simpler to perform than electrocautery and requires no specialized equipment, making it more accessible in various clinical settings 1, 4
Patients treated with silver nitrate cautery have no need for follow-up removal procedures (unlike nasal packing), reducing healthcare utilization and patient burden 2
A prospective randomized study found no statistically significant difference in effectiveness between electrocautery and silver nitrate for simple anterior epistaxis, but silver nitrate's simplicity makes it the treatment of choice 4
Bilateral silver nitrate cauterization demonstrates 93% significant improvement rates in recurrent epistaxis with low complication rates when performed properly 5
Critical Safety Considerations and Complications
Bilateral simultaneous septal cautery should be performed judiciously because clinical experience suggests it increases the risk of septal perforation, though quality evidence is limited 1
The 95% silver nitrate concentration produces twofold greater tissue penetration depth compared to 75% concentration, potentially increasing perforation risk with repeated or bilateral cautery 3
Complications from silver nitrate cautery include infection, tissue injury, and possible septal necrosis leading to perforation, though prospective studies report no complications in 97 patients treated with chemical cautery 1
Excessively vigorous or extensive cautery may damage the nasal lining and septum, and bleeding may recur requiring repeat cautery or alternative treatments 1
When Silver Nitrate is Preferred
Silver nitrate is the treatment of choice when an anterior bleeding site is clearly visible on examination, as recommended by French guidelines for first-line epistaxis treatment 1
It is particularly appropriate after initial compression (5-10 minutes) and vasoconstrictor application have failed to control bleeding, but a discrete bleeding point can be identified 1
For pediatric patients, silver nitrate is preferred over electrocautery as it avoids the need for electrical equipment and can be performed more easily in uncooperative children 6
Comparison with Electrocautery
While systematic review evidence suggests electrocautery is more effective than chemical cautery overall, bipolar electrocautery may be preferable in terms of efficacy, comfort, and cost when equipment and expertise are available 1
However, equipment availability and technical expertise limit electrocautery use, particularly in office settings, making silver nitrate the more practical option in many clinical scenarios 1
One randomized trial showed bipolar cautery to be less painful with faster healing than monopolar cautery, but both electrical methods require specialized equipment not always available 1
Post-Cautery Management
After silver nitrate application, patients should receive petroleum jelly or other emollient creams applied to the anterior nasal septum to prevent recurrence 1, 6
Regular saline nasal sprays should be prescribed to maintain nasal mucosal moisture and prevent re-bleeding 1, 6
Patients should avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after cauterization 7
Common Pitfalls to Avoid
Do not apply silver nitrate without first anesthetizing the area, as the procedure may be painful and patient movement can lead to excessive tissue damage 1
Avoid bilateral cautery at the same session when possible—if bilateral treatment is necessary, consider staging the procedures or using extreme caution to prevent septal perforation 1
Do not apply silver nitrate blindly or to large areas of mucosa; direct visualization with headlight, nasal speculum, and suction is essential to target only the bleeding site 1
Recognize that silver nitrate alone offers no added advantage over antiseptic nasal cream (Naseptin) for preventing recurrent epistaxis in patients without active bleeding, so it should be reserved for acute bleeding control 8