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Primary care physicians often encounter epistaxis. Its treatment may involve nasal sponge tampons, double-balloon nasal catheters, and anterior gauze with posterior Foley catheters, depending on the location of the bleed. Topical anesthetic and decongestant agents are essential, and intravenous analgesia, which enhances comfort, should be considered in all cases. Here, Dr Randall investigates the practical aspects of epistaxis therapy and provides a simplified approach to treatment using three types of packs that work in virtually every situation.

Epistaxis is a common and often frustrating condition. Many excellent references1?4 discuss the causes of epistaxis and pertinent anatomy and describe both initial and interventional management. Unfortunately, these general reviews often focus less on the more practical ?pearls? that facilitate actual clinical management.

Many nosebleeds are treated with nasal packing. However, this treatment has been simplified by the development of several new devices. Placement of nasal packing is often painful and can be anxiety-provoking for both physician and patient. Topical anesthetic and decongestant agents are essential for the patient's comfort, and use of intravenous analgesia, if available, should be considered. Anterior sponge nasal tampons should control bleeding in 90% of epistaxis cases. Posterior bleeds are well addressed by double-balloon catheters or an anterior gauze pack with a posterior Foley catheter. Virtually all nosebleeds can be treated with these three types of packs.

Anesthesia and analgesia

Achieving adequate topical anesthesia need not be difficult. Most emergency departments stock both topical 4% (nonviscous) lidocaine hydrochloride and decongestant nasal spray. Oxymetazoline hydrochloride is suggested as a decongestant because it may be safer than phenylephrine hydrochloride in elderly and hypertensive patients.

Although a hospital pharmacy can provide a one-to-one mixture of these medications, it is usually more expeditious for the physician to mix them personally. The steps in this process are as follows: Remove spray tip of decongestant spray bottle.Add equivalent volume of lidocaine to the decongestant and replace the spray tip.Clear the nasal cavity of blood by gentle nose-blowing or suctioning.Create a generous spray (rather than a mist) by inclining the bottle downward while squirting. Warn the patient that this liquid will drain into the throat.Use the same mixture to saturate either ? ? 3-inch surgical pledgets or cotton strips (Codman, Raynham, Massachusetts) (figure 1). Normally, three of these are placed horizontally on the affected side of the nose. To start topical anesthesia, several applications are required. Initial spraying facilitates comfort during insertion.Keep pledgets in place for 10 minutes. This technique does not provide complete anesthesia but does greatly increase comfort. Decongestion facilitates placement of the pack and often diminishes bleeding. In addition, it reduces mucosal abrasion during packing, which is a common secondary source of epistaxis.

The patient may be made a great deal more comfortable by administration of intravenous analgesia. Promethazine hydro-chloride (Phenergan) or a similar antiemetic agent is given first, to avoid the nausea that often accompanies narcotic use, and it has some sedative benefit.

Morphine sulfate or meperidine hydrochloride (Demerol) is subsequently administered. Medications such as midazolam hydrochloride (Versed) may also be given, though these often necessitate more formal monitoring according to protocols of conscious sedation. The patient may remain in the emergency department longer after intravenous analgesia, but this is well justified because it makes the procedure more humane, more pleasant for the physician, and probably more effective.

Nasal packing options

Currently, many types of nasal packing are available. Anterior packs are primarily traditional gauze (saturated with petrolatum or antibiotic ointment), sponge-type tampons, and certain small, inflatable devices that have a topical thrombogenic sleeve. Lamb's wool, trimmed vaginal tampons, and Foley catheters and other inflatable devices have been used for posterior packing. However, almost all nosebleeds can be treated with sponge packs, the double-balloon (anteroposterior) nasal catheter, or a Foley catheter used with a standard anterior gauze pack.1?4

Antibiotic therapy

Two infectious conditions pertain to nasal packing: toxic shock syndrome and bacterial rhinosinusitis. Toxic shock syndrome occurs because of a toxin produced by certain strains of Staphylococcus aureus. Although primarily associated with vaginal tampon use, it has been reported with nasal packing and surgical infection as well. Bacterial rhinosinusitis can develop as a result of blockage of the sinus ostia and mucosal edema caused by packing.

No studies have shown that systemic or topical antibiotics prevent either toxic shock syndrome or bacterial rhinosinusitis.5?7 However, many physicians use an oral or a topical antibiotic, or both, in patients with nasal packing.1?4 Any disadvantages of antibiotic use are minimal and are outweighed by the potential benefit against sinusitis and toxic shock syndrome. I suggest consideration of topical mupirocin, given its Staphylococcus coverage. Also, oral antibiotic coverage of Staphylococcus and sinusitis flora is often prescribed with medications such as amoxicillin and clavulanate potassium (Augmentin) or a second-generation cephalosporin.

Highlights of epistaxis care

The following highlights summarize for physicians the primary practical points to cover in epistaxis care: ? Epistaxis is almost always unifocal and unilateral. However, after a while the patient usually has blood in both nasal cavities and anterior and posterior drainage. Inquire about the side of onset and whether it was first noted from the nostril or throat. Anterior epistaxis that occurs in the supine patient mimics posterior origin.? Of epistaxis cases, 90% are anterior bleeds. Failure of an anterior pack is usually due to suboptimal placement.? Inquire about the patient's use of nonsteroi-dal anti-inflammatory drugs, aspirin, and other anticoagulants. If medically acceptable to stop their use, discontinue these medications for 3 to 4 weeks during mucosal healing.? Packing placement without topical anesthesia can be quite painful. Efficacy is hampered when a patient is in pain and unable to cooperate.? Assess the intranasal anatomy with attention to septal deviation and spurs that will impede pack placement. Forcing a pack alongside an obstructing spur causes pain for the patient, is difficult, and results in additional bleeding from traumatized mucosa.? Have on hand the essential equipment: headlight, suction, nasal speculum, and bayonet forceps. Provide gowns for patient and physician and eye protection for medical staff.? Packs should remain in place for 3 to 5 days to allow healing of the original bleeding site and of any mucosa abraded by packing. This step also allows some platelet generation and recovery after the patient discontinues aspirin and similar anticoagulant medications.? Pad the external nose adequately when posterior packs are placed, to prevent alar or columellar notching.? Use an oral antibiotic that provides coverage of S aureus and sinusitis pathogens, and coat the nasal packing with an antibiotic such as mupirocin.? Provide appropriate pain medication, such as the combination drug acetaminophen and hydro-codone bitartrate.? When removing sponge packing, saturate the pack with topical oxymetazoline and lidocaine to soften and lubricate the pack, provide anesthesia, and decongest the mucosa.? For 3 to 4 weeks after packing removal, keep the nose and septum moist, using saline solution spray and with petrolatum four times a day. Instruct the patient on how to apply oxymetazoline to the septum by spray or cotton ball if bleeding occurs during the healing period.

Conclusion

Today, physicians have many choices in nasal packing for epistaxis. Progression from the anterior sponge pack to the double-balloon catheter and then to the Foley catheter and gauze pack offers a relatively straightforward, sequential approach to treatment. These techniques suffice in most cases of epistaxis that do not require advanced treatment with vessel ligation or embolization.

Dr Randall is a general otolaryngologist in private practice, Springfield ENT and Facial Plastic Surgery, Springfield, Missouri.
Correspondence: David A. Randall, MD, Springfield ENT and Facial Plastic Surgery, 3555 S Culpepper Cir, Springfield, MO 65804. E-mail: d.randall@springfieldent.com.

References

1. Emanuel J. Epistaxis. In: CummingsCW, FredricksonJ, HarkerL, et al, eds. Otolaryngology?head and neck surgery. 3rd ed. St Louis: Mosby, 1998: 852-65
2. Pond F, Sizeland A. Epistaxis. Strategies for management. Aust Fam Physician 2000; 29( 10): 933-8
3. Santos P, Lepore M. Epistaxis. In: BaileyBJ, CalhounK, HealyG, et al, eds. Head and neck surgery?otolaryngology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001: 415-28
4. Tan LK, Calhoun KH. Epistaxis. Med Clin North Am 1999; 83( 1): 43-56
5. Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery. Case reports and analysis of risk factors. Arch Otolaryngol Head Neck Surg 1986; 112( 3): 329-32
6. Hull HF, Mann JM, Sands CJ, et al. Toxic shock syndrome related to nasal packing. Arch Otolaryngol 1983; 109( 9): 624-6
7. Mansfield CJ, Peterson MB. Toxic shock syndrome: associated with nasal packing. Clin Pediatr (Phila) 1989; 28( 10): 443-5