Overview of Posterior Epistaxis Nasal Pack
Epistaxis, or nosebleeds as they are commonly known, are one of the most frequent emergencies seen by ear, nose, and throat (otolaryngology) specialists. Over 60% of people in the US have experienced a nosebleed at some point in their lives. Nosebleeds can range from mild to severe, and in certain circumstances, they can even be life-threatening.
Nosebleeds are typically classified as either anterior (front) or posterior (back) based on where the bleeding is coming from. Only 5 to 11% of all nosebleeds are posterior. Posterior nosebleeds usually bleed heavily and are hard to pinpoint the exact source of the bleeding. This makes it more challenging to stop the bleeding.
Patients dealing with posterior nosebleeds are more likely to need hospital care and twice as likely to need their nose packed to stop the bleeding. This is why it’s important to identify whether a nosebleed is anterior or posterior – this can influence the type of treatment the patient will need. In the emergency department, one effective way to treat a posterior nosebleed non-surgically is by packing the back part of the nose.
Anatomy and Physiology of Posterior Epistaxis Nasal Pack
The nose is rich in blood supply, which is why nosebleeds can happen quite easily. Most nosebleeds happen in the front of the nose and come from a network of small arteries, known as Kiesselbach’s plexus. This area, also referred to as Little’s area, is located on the inner wall at the front of your nose.
Kiesselbach’s plexus is made up of several small arteries including the sphenopalatine artery, anterior ethmoidal artery, posterior ethmoidal artery, superior labial artery, and the greater palatine artery.
Backing up a bit, a nosebleed could also happen in the more back part of the nose or posterior, as doctors say. This bleeding usually comes from the sphenopalatine artery but can also come from other arteries such as the branches of the maxillary artery, the descending palatine artery, the posterior ethmoidal artery and the internal carotid artery.
Just for a bit more detail, the sphenopalatine artery (SPA) is a branch from an artery called the maxillary artery, which is then an off-shoot of the external carotid artery, one of the main arteries supplying the head and neck. The SPA divides into two smaller arteries just before it enters the nose. Once inside, these branches supply blood to the areas in the back of the nose.
Bleeding can also happen in the posterior part of the nose, in a region known as Woodruff’s plexus. This area, located behind the nose’s internal structure called the inferior turbinate, is a network of veins, rather than arteries.
Why do People Need Posterior Epistaxis Nasal Pack
The main reason to pack the back of the nose is suspected nosebleeds that are coming from the back of the nose. Specific findings during the physical exam might indicate this, like not being able to find a bleeding site in the front of the nose when the doctor looks into it, bleeding coming from both nostrils, bleeding in the throat, or coughing up blood or throwing it up. All of these could suggest the bleeding is coming from the back of the nose. Furthermore, if packing both front nostrils doesn’t stop the bleeding, it could be because the bleeding is coming from the back of the nose.
When a Person Should Avoid Posterior Epistaxis Nasal Pack
In some situations, a person cannot safely receive a treatment called posterior epistaxis nasal packing. This treatment involves putting packing material into the back part of your nose to stop a nosebleed. The following conditions might completely prevent a person from undergoing this treatment:
- Having fractured bones at the base of the skull
- Having significant trauma or injury to the nasal bone or the facial bone structure
- Having instability in the respiratory or circulation system (these must be stabilized before packing the nose)
Nevertheless, there are other conditions where a person can still receive the treatment, but it could be more challenging or risky:
- Having a significantly deviated septum, which is the thin wall dividing your nostrils. With this condition, it can make the nasal packing and the inflation of the balloon device used in the treatment more difficult.
- Having instability in the heart and lung system or a significant history of heart and lung disease. This condition could potentially increase the risks of illness and death with the nasal packing treatment.
Equipment used for Posterior Epistaxis Nasal Pack
Putting a bandage in the back of your nose, also known as posterior nasal packing, involves several steps and the use of different materials and equipment. Here’s what’s needed:
1. Personal protective gear: This includes items like glasses, a face mask, gloves, and a gown that the doctor will wear to keep both you and them safe during the procedure.
2. A light source: The doctor will use a headlamp or light source so they can see inside your nose more clearly.
3. Adjustable hospital bed: The bed can be adjusted so that you can sit with your back at a right angle (90-degrees).
4. Emesis basin: This is a dish used to collect any fluids or waste during the procedure.
5. Nose-viewing tool: A nasal speculum is used to spread the nostrils allowing the doctor to see inside.
6. Tongue depressors: These are used to make sure your tongue doesn’t block the view of your throat.
7. Suction equipment: The doctor will use a suction canister, Frazier suction tip, and Yankauer suction tip to remove any fluid or mucus from your nose.
8. Medical forceps: Bayonet forceps are used to handle delicate tissues inside your nose.
9. Inflatable balloon catheter: This tube, often a Foley catheter, is inflated inside your nose to stop the bleeding. Alternatively, a double balloon catheter that can be positioned in the front or back of your nose can be used.
10. Umbilical cord clamp: This is used to control the balloon catheter.
11. Nasal packing materials: These may include a nasal tampon or narrow bandage to help stop the nose bleed.
12. Topical anesthetic/vasoconstrictor: These medications such as cocaine 4% or lidocaine 4%, mixed with oxymetazoline 0.05%, numb your nose and reduce blood flow to the area. This helps to keep you comfortable and reduce bleeding.
13. Sterile water or saline and a 10mL syringe: These are used to rinse the nasal area.
14. A cardiac monitor and pulse oximeter: These are used to check your heart rate and oxygen levels during the procedure.
Other necessities include lubricant jelly, sterile gauze, and cotton wool balls or dental rolls to ensure your comfort and cleanliness during and after the procedure.
Who is needed to perform Posterior Epistaxis Nasal Pack?
Putting a pack in the back part of your nose, also known as posterior nasal packing, should only be done by experts who have lots of experience with it because it can potentially block your air pathway or affect your blood flow stability if not done properly. If you have a bleed in the back part of your nose, also known as posterior epistaxis, you will likely need to see a nose, ear, and throat specialist (otolaryngologist). Most likely, you’ll need to stay in the hospital where doctors can continuously watch your heart and lungs while the packs are in place for your safety.
Preparing for Posterior Epistaxis Nasal Pack
If someone is having a nosebleed that requires treatment using a method called “posterior nasal packing,” there are certain steps your doctor will take to make sure you’re safe. First up, they’ll make sure you’re comfortable, stable, and have easy access to your veins for any needed medication. They’ll also give you a checkup to see if you’re showing any signs of dehydration or shock. They’ll perform some tests for your blood to make sure everything is normal, and will ask you about any blood thinning medication you might be taking. If there’s a risk, the doctor may even lessen the effects of the blood thinner. If you have high blood pressure, doctors will help manage it but will make sure it doesn’t affect blood flow to the brain. They’ll also take a good look at your current health condition.
You will be asked to sit upright with your head positioned like you’re about to sniff a flower. To clear your nose, the doctor will use a suction tool and remove clots. You’ll then receive a treatment to help numb and constrict blood vessels in your nose, applied through a small roll or cotton ball placed inside your nose. After that, your doctor will check inside your nose and examine your mouth for bleeding.
If the front part of your nose doesn’t seem to be the source of the bleed, or if your treatments haven’t stopped bleeding, they might use posterior nasal packing. This method puts pressure on the source of the bleed to help stop it but can be uncomfortable. Therefore, your doctor will use pain medication and possibly relaxing drugs to make you more comfortable. As the procedure goes on, the team will keep a close watch on your heart and oxygen levels to make sure you’re safe.
How is Posterior Epistaxis Nasal Pack performed
There are several methods doctors can use to stop bleeding from the back of the nose, otherwise known as posterior nasal packing. In the past, doctors would use a type of gauze coated with a medicine or oil and carefully place it into the nose using a specific tool called bayonet forceps. This older method can be a bit tough for the doctor to do and can be uncomfortable for the patient. These days, Foley catheters, which are a kind of thin, flexible tube, are often used instead. They’re simple to use and are easy to find in most healthcare settings. Before inserting it, the doctor will inflate and then deflate the balloon on the catheter to check for leaks. The tip of the catheter is also coated with a lubricant to make it easier to put in. During this, you should sit up and tilt your head back. It might be difficult for some people, so someone might need to help hold your head still.
Once the doctor has given you some local anesthesia and vasoconstrictor spray to numb your nose, the catheter is gently placed into your nose. The doctor will make sure they can see the tip of it in the back of your mouth, which can sometimes be tricky since it can make you cough or spit out blood. The balloon on the catheter is filled with a small amount of sterile water or saline solution, and then slowly pulled back to sit against the area behind your nostril. If the bleeding continues, more sterile water or saline might be added to the balloon until the bleeding stops. However, the balloon should not be filled with more than 15 mL of fluid, otherwise it can cause a painful skin injury to the soft palate or back of your throat. If the balloon is inflated too far forward it can cause nasal discomfort; but if it’s too far back, it can cause problems with your breathing.
To keep the bleeding under control, packing materials, like a nasal tampon or old-style gauze, are placed in the nostril where the bleeding started. Sometimes the other nostril is packed too, which can help prevent your nasal septum, which separates the two nostrils, from deviating or moving to one side. A clamp or clip is placed on the catheter at your nostrils to keep it secure and to prevent it from accidentally being pulled out. The clamp shouldn’t touch the outer part of your nostril, as this can cause a painful skin injury. Thankfully, other options are available too, like padded clamps, strips of medicated gauze, or even parts of the catheter that have been cut off and used as cushions.
Other devices are also available to help manage bleeding in the back of your nose, like catheters with two balloons. These are put in the nostril where the bleeding is happening. The first balloon is filled with 5 to 10 mL of sterile fluid in the nasal cavity, and the second balloon is filled with 15 to 30 mL of fluid. A clamp is placed on the outside to secure it. This technique helps to block the area behind your nostril and apply pressure to the vessels that are bleeding. It also helps stabilize the placement of the packing material inside your nostrils. This procedure is a simple and straightforward way to manage nose bleeds and doesn’t usually require surgery. It successfully manages bleeding in about 70% of these kinds of nosebleed cases.
If packing at the back of the nose isn’t successful in stopping the bleeding, other more invasive procedures might be needed. One is a procedure performed by a specialist where the artery that supplies blood to the sphenopalatine artery is blocked, which has about an 88% success rate. Another is a procedure performed by a ear, nose, and throat doctor under anesthesia where the sphenopalatine artery is tied off. This procedure has a successful rate of over 85%. The nasal packing is usually left in place for two to three days, although it can be left in for up to days depending on the severity of the bleeding, the patient’s health, and the doctor’s preference. If the packing is removed too soon, the bleeding might start up again. There is some debate over whether antibiotics should be given when nasal packing is used since it could potentially cause an infection, including a rare life-threatening one known as toxic shock syndrome. That being said, antibiotics are often prescribed anyway and topical antibiotic ointments are also often used during the insertion of the packing.
Possible Complications of Posterior Epistaxis Nasal Pack
There can be a few complications that occur when a patient undergoes a medical procedure called posterior nasal packing. Here’s what could potentially happen:
- Pain when the nasal pack is put in
- Pain when the nasal pack is taken out
- Failure to stop the bleeding
- Bleeding starts again when the pack is removed
- Ear infection due to a block in the Eustachian tube, the tube that connects the middle ear to the back of your nose
- Sinus infection
- A severe and rare infection called toxic shock syndrome
- Death of tissue on the outer sides of the nostrils
- Damage to the nasal tissues from pressure
- Accidental breathing in of foreign material
- The nasal pack shifting and causing an airway blockage
Patients who undergo this procedure may also experience complications related to their heart and lungs, including a potentially fatal risk known as the “nasopulmonary reflex.” This condition can occur when nasal packs are placed in both sides of the nose, requiring continuous monitoring of the patient’s heart rate and oxygen levels. However, studies have reported inconsistent results on whether lowered heart rate or decreased oxygen levels actually occur in patients who receive this treatment.
Incorrect placement of nasal packs can block the airway, causing difficulty breathing. Patients with existing heart or lung conditions may have a higher risk of health complications and even death when they undergo posterior nasal packing for a nosebleed.
What Else Should I Know About Posterior Epistaxis Nasal Pack?
If you have to get a posterior nasal pack (a packing inserted in the back part of your nose), you will need to stay in the hospital. The doctors will monitor your heart rate and oxygen level closely, possibly in an intensive care unit. This is because the packing can block your nasal airflow and if it’s misplaced or comes out, it might block your airway.
Posterior nasal packs can also lead to the risks of aspirating (inhaling into the lungs) blood, using too many sedatives, or developing hypoxemia (low oxygen level in the blood), which can be worse if you already have respiratory problems. In some cases, serious heart and lung events have been reported right after the insertion of a posterior nasal pack.
These events may be related to the “nasopulmonary reflex” or the “trigeminocardiac reflex,” which is a response of the body that is not fully understood yet. It can cause serious complications and can be triggered by stimulating nerve receptors in your nasal passage. This may result in the sudden slowing of heart rate, cessation of breathing, a drop in oxygen level, and in extreme cases, cardiac arrest. If such changes occur, it’s crucial to remove the nasal packing right away.
