Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much more common, but posterior bleeding is more dangerous and is managed differently; thus, identifying the site of bleeding is critical. Epistaxis that persists without an evident anterior nasal source is most often caused by a posterior bleeding site.
Posterior bleeding is sometimes controlled using topical vasoconstrictors. If not, it usually requires treatment with tamponade. Historically, gauze packing was used but balloon tamponade is easier to do and more comfortable to the patient and thus is usually preferred. Some balloons can occlude both the anterior and posterior nasal cavity simultaneously.
Posterior nasal packing is very uncomfortable. Intravenous sedation and analgesia are often needed and hospitalization is often required. Applying a cardiac monitor and pulse oximetry Pulse Oximetry Gas exchange is measured through several means, including Diffusing capacity for carbon monoxide Pulse oximetry Arterial blood gas sampling The diffusing capacity for carbon monoxide (DLCO)... read more is strongly recommended.
(See also Epistaxis Epistaxis Epistaxis is nose bleeding. Bleeding can range from a trickle to a strong flow, and the consequences can range from a minor annoyance to life-threatening hemorrhage. Most nasal bleeding is anterior... read more , How To Treat Epistaxis With Cautery How To Treat Epistaxis With Cautery Epistaxis (nasal hemorrhage) can often be stopped with cautery (sealing off a blood vessel using current or chemicals). Epistaxis may be due to bleeding from the anterior or posterior nasal... read more and How To Treat Anterior Epistaxis With Tamponade How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may... read more .)
Epistaxis from a suspected posterior source
Possible or identified skull base fracture
Significant maxillofacial or nasal bone trauma
Uncontrolled airway or hemodynamic instability
Procedures described here are intended for spontaneous posterior epistaxis. Epistaxis in patients with significant facial trauma should be managed by a specialist.
Severe nasal septal deviation toward the bleeding side (makes it difficult to insert balloon device)
Injury (eg, pressure necrosis)
Migration of the nasal packing and aspiration into the airway or airway compromise
Infections such as sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more , otitis media Introduction to Middle Ear and Tympanic Membrane Disorders Middle ear disorders may be secondary to infection, eustachian tube obstruction, or trauma. Information about objects placed in the ear and symptoms such as rhinorrhea, nasal obstruction, sore... read more , or rarely toxic shock syndrome Toxic Shock Syndrome (TSS) Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which... read more
Penetration of the catheter through the skull base and into the brain parenchyma, though this is unlikely in the absence of preexisting skull base trauma
Otitis media secondary to eustachian tube obstruction
Necrosis of the nasal ala
Sometimes hypoxemia, particularly if patients are also sedated
Activation of the trigemino-cardiac reflex leading to cardiac arrhythmia and even cardiac arrest*
* Such cardiac complications have been reported in the literature, although this remains controversial.
Gloves, mask, and gown
Gown or drapes for patient
Cardiac monitor, pulse oximeter
IV setup: 18-gauge (or larger) angiocatheter and 1 L isotonic crystalloid solution (eg, 0.9% saline)
Drugs for sedation/analgesia if needed (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect)
Sterile gauze sponges
Suction source and Frazier-tip suction catheter
Chair with headrest or ear, nose, and throat (ENT) specialist's chair
Light source and head mirror or headlamp with adjustable narrow beam
12 to 16 French inflatable balloon (eg, Foley) catheter or commercial epistaxis balloon (single or dual-balloon)
Topical anesthetic/vasoconstrictor mixture (eg, 4% cocaine, 1% tetracaine, or 4% lidocaine plus 0.5% oxymetazoline) or topical vasoconstrictor alone (eg, 0.5% oxymetazoline spray)
Water-soluble lubricant or anesthetic jelly (eg, viscous lidocaine)
Cotton pledgets or swabs
Sometimes supplies and equipment for anterior nasal packing How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may... read more using a gauze strip
Initiate treatment for any hypovolemia or shock before treating epistaxis.
Ask about use of anticoagulant or antiplatelet drugs.
Check complete blood count (CBC), prothrombin time (PT), and partial thromboplastin time (PTT) if there are symptoms or signs of a bleeding disorder or patient has severe or recurrent epistaxis.
If posterior packing fails to control nasal hemorrhage, invasive methods done by specialists may be needed:
Sphenopalatine artery (SPA) ligation, typically done using a transnasal endoscopic approach; success rates exceed 85% ( 1 References Posterior epistaxis (nasal hemorrhage) can often be controlled with balloon tamponade. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much... read more )
Endovascular SPA embolization; reported success rate 88% ( 2 References Posterior epistaxis (nasal hemorrhage) can often be controlled with balloon tamponade. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior bleeding is much... read more ).
Endoscopic SPA ligation is done by an otolaryngologist and has a lower risk of major complications (eg, stroke, blindness) than endovascular SPA embolization and may be more appropriate for patients who can safely tolerate general anesthesia or if the embolization procedure is not readily available.
Endovascular SPA embolization is done by an interventional radiologist under local anesthesia and may be better for patients with multiple comorbidities that preclude safe general anesthesia, for those on anticoagulant therapy, and for patients who present with bleeding after previously having had endoscopic SPA ligation.
Severe or intractable posterior epistaxis often stems from the sphenopalatine artery or its proximal branches.
The patient should sit upright in the sniffing position with head extended, preferably in an ENT specialist's chair. The patient's occiput should be supported to prevent sudden backward movement. The patient's nose should be level with the physician's eyes.
The patient should hold an emesis basin to collect any continued bleeding or emesis of swallowed blood.
Step-by-Step Description of Procedure
Start IV and send any laboratory studies needed.
Place patient on cardiac monitor and pulse oximeter.
Have the patient blow the nose to remove clots, or suction the nasal passageway gently.
To help identify the bleeding site (and possibly stop the bleeding), apply a vasoconstrictor/anesthetic mixture: Place about 3 mL of 4% cocaine solution or 4% lidocaine with oxymetazoline in a small medicine cup and soak 2 or 3 cotton pledgets with the solution and insert them into the nose, stacked vertically (or spray in a topical vasoconstrictor such as oxymetazoline and place pledgets containing only topical anesthetic).
Leave the topical drugs in place for 10 to 15 minutes to stop or reduce the bleeding, provide anesthesia, and reduce mucosal swelling.
Insert a nasal speculum with your index finger resting against the patient's nose or cheek and the handle parallel to the floor (so the blades open vertically).
Slowly open the speculum and examine the nose using a bright headlamp or head mirror, which leaves one hand free to manipulate suction or an instrument.
If no bleeding site is visible in the anterior nose, use a tongue depressor and look into the oropharynx. Continued bleeding suggests a posterior source.
Place balloon catheter to tamponade active posterior bleeding:
Give IV analgesia (eg, 0.5 to 1.0 mcg/kg fentanyl to a maximum dose of 100 mcg; consider lower doses in those older than age 65 and titrate to effect).
Insert the balloon catheter into the nose, and gently advance it parallel to the floor of the nasal cavity. Advance the catheter until the tip can be seen in the oropharynx when looking through the mouth.
Follow inflation instructions for any commercial epistaxis balloon. If using a Foley catheter, partially inflate the balloon with 5 to 7 mL of water. Gently pull the catheter anteriorly until it is firmly seated in the posterior nasal cavity. Then slowly add another 5 to 7 mL of water.
If pain or inferior displacement of the soft palate occurs, deflate the balloon until the pain resolves or the soft palate is no longer displaced.
While maintaining traction on the catheter, place anterior nasal packing How To Treat Anterior Epistaxis With Tamponade Epistaxis (nasal hemorrhage) can often be controlled by tamponade of the involved area. Epistaxis may be due to bleeding from the anterior or posterior nasal passage. Anterior epistaxis may... read more of layered petrolatum gauze.
Consider packing the contralateral anterior nasal cavity to avoid septal deviation.
Wrap a piece of gauze around the catheter at the naris to protect the nasal ala and place a clamp on the catheter to prevent the balloon from sliding back out of the posterior nasal cavity.
If using a dual-balloon catheter, first inflate the posterior balloon, using the same general technique as for the single balloon catheter. Then inflate the anterior balloon (typically with 30 mL). Anterior nasal packing with layered gauze is unnecessary when using a dual-balloon catheter.
Admit all patients with posterior balloon packing. Manage hypoxemia as required.
Avoid use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 days post-treatment.
Give an antibiotic (eg, amoxicillin/clavulanate 875 mg orally twice a day for 7 to 10 days) to prevent sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more and otitis media Introduction to Middle Ear and Tympanic Membrane Disorders Middle ear disorders may be secondary to infection, eustachian tube obstruction, or trauma. Information about objects placed in the ear and symptoms such as rhinorrhea, nasal obstruction, sore... read more .
Deflate the balloon and remove the catheter after 48 to 72 hours.
Warnings and Common Errors
Do not open the nasal speculum laterally or use in an unsupported manner. (Brace a finger of the hand holding the speculum on the patient's cheek or nose.)
Overfilling the catheter balloon can cause significant pain.
Tips and Tricks
Elevating the patient's chair to eye height is easier on the practitioner's back than bending down.
Always consult an otolaryngologist after placement of a posterior nasal pack to ensure follow-up.
After placement of the posterior pack, look through the mouth to make sure that there is no further bleeding down the throat. If there is bleeding, put more fluid into the catheter balloon. If this fails to control bleeding, consult an otolaryngologist immediately.
1. Rudmik L, Smith TL: Management of intractable spontaneous epistaxis. Am J Rhinol Allergy 26(1):55-60, 2012.
2. Christensen NP, Smith DS, Barnwell SL, et al: Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg 133:748-753, 2005. doi: 10.1016/j.otohns.2005.07.041