Posterior Epistaxis

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October 23  |  Blog, York ENT Blog  |   James Rejowski

Epistaxis, or nosebleed, is a common problem that we see and treat in our practice.  60% of the population will suffer a nosebleed at some time in their life.  Most the bleeding is anterior, or from the front of the nose.  This is usually treated in the office with simple cautery or packing.

Posterior epistaxis, or bleeding from the back of the nose, presents more of a problem.  It is frequently seen in older people with underlying health problems such as diabetes or vascular disease.  This type of bleeding can require admission to the hospital for treatment, but fortunately this occurs only in a small percentage of patients.

A recent study compared different modalities of treatment for posterior epistaxis.  Using a national data base of over 50,000 admissions, outcome results for nasal packing, surgical ligation of bleeding vessels, and endovascular embolization were obtained.  Nasal packing involves the placement of a Vaseline gauze, tampon, or balloon in the nasal cavity, leaving it in place for 48-72 hours.  Arterial surgical ligation is usually done with an operation done through a person’s mouth, in the area above the canine teeth.  Dissection proceeds through the maxillary sinus until the arterial feeding vessels are identified and clips are placed on them.  Arterial embolization is done by interventional radiologists, who will place a catheter through the arterial system from the groin and perform very selective occlusions of the vessels behind the nose in order to stop the bleeding.

The length of stay in the hospital for each of these treatments was quite comparable to each other.  The cost of treatment for the embolization group was highest.  There was an increased risk of stroke with the embolization procedures compared to packing, which is not surprising given the fact that particulate matter was injected into the arterial circulation in the former group.

The data in this study was extracted from the discharge diagnosis that was coded following these hospitalizations.  It was not actually done by a review of the individual charts, so it needs to be taken with a grain of salt.  None of the treatments is intrinsically better than the others.  Practically speaking, when we see patients presenting with bleeding it is more efficacious to place a pack and wait a bit to determine its success or failure, rather than go right to the operating room or the angiography suite with a bleeding patient.  The latter treatments are a fall back when the packing, a less invasive procedure, isn’t successful in controlling the bleeding, or if the epistaxis recurs following this initial treatment.

Reference: Recent Trends in Epistaxis Management in the United States 2008-2010, Drs. Vilwock and Jones, JAMA Otolaryngology/Head and Neck Surgery, 2013

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