Posterior Epistaxis Nasal Pack

Anatomy and Physiology

The nose has a rich arterial supply. Most nosebleeds are anterior and come from Kiesselbach's plexus, situated on the anteroinferior nasal septum in a region known as Little's area. Kiesselbach's plexus is an anastomosis of several small arteries, including the sphenopalatine artery, the anterior ethmoidal artery, the posterior ethmoidal artery, the superior labial artery, and the greater palatine artery. Posterior epistaxis occurs at more posterior sites on the nasal septum or the lateral wall. Bleeding usually comes from the sphenopalatine artery but can also involve terminal branches of the maxillary artery, the descending palatine artery, the posterior ethmoidal artery, and the internal carotid artery.[5] The sphenopalatine artery (SPA) is a branch of the maxillary artery, a branch of the external carotid artery. The SPA typically branches into the posterior septal artery and the posterior lateral nasal artery just before entering the nasal cavity through the sphenopalatine foramen on the posterior lateral nasal wall, after which the branches supply blood to the posterior septum and the lateral nasal wall. The posterior septal artery courses across the inferior aspect of the face of the sphenoid sinus, below the ostium, and can bleed from this location. The posterior lateral nasal artery sends branches into the posterior aspects of the inferior and middle turbinates and can be injured due to trauma or surgery involving these structures.[6] Not all epistaxis is arterial. A notable portion of posterior epistaxis arises in Woodruff's plexus on the postero-lateral wall of the nasal cavity, just posterior to the inferior turbinate. This vascular network is not well characterized but is thought to be a submucosal venous plexus.[7]

Indications

The primary indication for posterior nasal packing is suspected epistaxis from a posterior source. Physical examination findings such as the absence of an anterior bleeding site on rhinoscopy, bleeding from bilateral nares, bleeding in the posterior pharynx, or hemoptysis or hematemesis may suggest a posterior source.[2] Furthermore, the failure of bilateral anterior nasal packing to achieve hemostasis may indicate a posterior source.[8]

Contraindications

Absolute contraindications for posterior epistaxis nasal packing include:

• Skull base fractures 
• Significant nasal bone or maxillofacial trauma 
• Airway compromise or hemodynamic instability (airway must be protected before nasal packing)

Relative contraindications include:

• Significant septal deviation (nasal packing and inflation of the balloon device be more difficult)
• Cardiopulmonary instability or significant cardiopulmonary history (which may increase morbidity and mortality with posterior nasal packing)

Equipment

Posterior nasal packing requires the following:

• Personal protective equipment: goggles, face mask, gloves, gown
• Headlamp or light source and head mirror 
• Hospital bed with a back that can be positioned to 90 degrees
• Emesis basin 
• Nasal speculum
• Tongue depressors 
• Suction canister and source 
• Frazier suction tip 
• Yankauer suction tip
• Bayonet forceps 
• 10 to 14 French inflatable balloon catheter (Foley) 
  • Alternatively, a double (anterior/posterior) balloon catheter
• Umbilical cord clamp
• Anterior nasal packing devices such as a nasal tampon or ribbon gauze
• Topical anesthetic/vasoconstrictor (eg, cocaine 4%, lidocaine 4% and oxymetazoline 0.05%, or oxymetazoline 0.05%).
• Sterile water or saline 
• 10 mL syringe 
• Lubricant jelly 
• Sterile gauze
• Cotton wool ball or dental roll
• Cardiac monitor 
• Pulse oximeter

Personnel

Posterior nasal packing should only be performed by those familiar and experienced with the procedure, given the risk of causing airway obstruction or hemodynamic instability. Patients with posterior epistaxis will likely require referral to an otolaryngologist and need hospital admission with cardiorespiratory monitoring while the packs are in place.

Preparation

Before posterior nasal packing, a patient with epistaxis should be appropriately resuscitated and managed according to the Advanced Trauma Life Support protocol. The patient should have a patent airway and be hemodynamically stable with good intravenous access, and fluid resuscitation should be commenced if any signs of shock or hypovolemia are present. A complete blood count, type and crossmatch, and coagulation panel should be drawn, and the patient must be asked about antiplatelet or anticoagulant use. Anticoagulation should be reversed if clinically appropriate. Likewise, hypertension should be corrected if it is possible to do so without compromising cerebral perfusion. A thorough medical history should be taken, and a physical examination should help determine the severity and likely site of bleeding.[9] 

The patient should sit upright with the head extended in a "sniffing position." Using a Yankauer suction tip, the nose should be gently suctioned to remove clots. A topical anesthetic/vasoconstrictor spray should be applied, or a dental roll or cotton wool ball soaked in the solution and placed in the nostril. The nose should then be examined again for any obvious anterior bleeding points. The oropharynx should also be examined for fresh bleeding, and the patient should have an emesis basin ready. 

If no anterior bleeding is seen at this point and a posterior source of bleeding is suspected, or if cautery and/or anterior nasal packing has failed to achieve hemostasis, posterior nasal packing should be performed. Posterior packing is extremely uncomfortable for patients; it requires thorough analgesia and potentially also intravenous sedation. Cardiac monitoring and continuous pulse oximetry should be performed during the procedure while the posterior pack is in place.

Technique or Treatment

Posterior nasal packing can be performed using several techniques. Historically, nasal packing was performed using ribbon gauze impregnated with bismuth iodoform paraffin paste or petrolatum and inserted in a layered fashion using bayonet forceps. This technique can be challenging for the clinician and extremely uncomfortable for the patient. Foley catheters are commonly used in posterior nasal packing as a simple and readily available method to tamponade the bleeding. The catheter's balloon should be inflated and then deflated before insertion to check for leaks, and the tip of the catheter should be lubricated to ease passage through the nose. The patient should remain upright with the head extended, and an assistant may need to support the head to prevent sudden movement. After the patient has had appropriate intravenous analgesia and topical anesthetic/vasoconstrictor spray, the catheter should be gently passed directly along the nose floor on the side thought to be bleeding.[10] 

The Foley catheter tip should be visualized in the oropharynx through the patient's open mouth. This can be difficult in practice because the patient may cough and spit blood. The balloon should be inflated, initially with 5-7 mL of sterile water or saline, and traction applied to seat the balloon against the posterior aspect of the choana. A further 5-7 mL may be added if bleeding continues and the patient can tolerate it. The maximum recommended volume is 15 mL; if more volume is used, the risk of causing pressure necrosis of the soft palate increases, which can be very painful for the patient. If the balloon is inflated anteriorly in the nasal cavity, it can also be very painful for the patient; however, inflating too low in the hypopharynx can cause airway obstruction.[9] 

With continued traction on the catheter, anterior nasal packing should subsequently be performed on the same side as the posterior packing. This can be done by inserting a nasal tampon or layered gauze impregnated with bismuth iodoform paraffin paste or petrolatum. Many physicians also anteriorly pack the contralateral side to prevent septal deviation. While maintaining traction, an umbilical clip should be placed on the catheter at the nostril to secure it and prevent it from slipping backward. This clip must not be placed directly against the alar rim, as prolonged contact can lead to pressure necrosis. Various alternatives to the umbilical clamp are available as well, including padded clamps, gauze or other padding, iodoform strips, or even cutting the drainage port directly from the proximal end of the catheter and using this as a cushion against the nasal ala.[11][12] Overinflation of the balloon can also result in nasal mucosal damage and pressure necrosis.

Alternative options for posterior nasal packing also exist, such as newer dual balloon catheters. These devices should be inserted on the side if bleeding is present. The posterior balloon is first inflated with 5 to 10 mL in the posterior nasal cavity, after which anterior traction is applied. The anterior balloon is then inflated with 15 to 30 mL, and an umbilical clamp is applied externally, as above. Posterior nasal packing occludes the choana, causing direct pressure on the posterior vessels, further stabilizing the anterior pack's placement.[13] If correctly performed, posterior nasal packing with Foley catheters or double-balloon catheters is a straightforward way of arresting hemorrhage and managing patients non-operatively; double-balloon catheters effectively manage bleeding in 70% of posterior epistaxis cases.[14] 

For cases where posterior packing is unsuccessful, more invasive measures to achieve hemostasis must be considered. One option is endovascular SPA embolization by an interventional radiologist, which has a success rate of 88%, according to a 2005 study.[15] Alternatively, an otolaryngologist performing SPA ligation under a general anesthetic via a transnasal endoscopic approach may be necessary. Transnasal endoscopic sphenopalatine artery ligation has a high success rate, greater than 85%.[16] Nasal packing is typically left in place for 48-72 hours, although some authors advocate longer (up to 5 days) depending on physician preference, patient co-morbidities, and bleeding severity. At <48 hours, premature pack removal is associated with higher rates of recurrent bleeding. Systemic antibiotic prophylaxis with nasal packing remains controversial, although antibiotics are commonly prescribed. Nasal packs act as potential sources of infection, and rare cases of toxic shock syndrome associated with nasal packing have been reported; therefore, an anti-staphylococcal antibiotic may be helpful.[17] For this reason, topical antibiotic ointments are also often used as lubricants during pack insertion.

Complications

There are several complications associated with posterior nasal packing, including:

• Pain on insertion
• Pain on removal [11]
• Failure to achieve hemostasis 
• Rebleeding on removal 
• Otitis media due to Eustachian tube obstruction [18]
• Sinusitis  
• Toxic shock syndrome [17] 
• Nasal ala necrosis 
• Pressure necrosis of nasal mucosa 
• Aspiration 
• Dislodgement and airway obstruction [19]
• Cardiopulmonary complications, including the risk of death - the "nasopulmonary reflex" has historically been cited as a deadly complication that arises from bilateral posterior nasal packs and necessitates continuous telemetry of patients with posterior nasal packs in place; however, studies have failed to reproduce bradycardia or desaturation reliably in patients with posterior nasal packs.[20][21] Malposition of the nasal packs can, nevertheless, cause airway obstruction and patients with cardiopulmonary conditions are at a higher risk for morbidity and mortality when they receive posterior nasal packing for epistaxis.

Clinical Significance

All patients with posterior nasal packs require hospital admission and should be monitored with telemetry and continuous pulse oximetry, ideally in intensive care. Posterior nasal packs obstruct nasal airflow and, if malpositioned or dislodged, risk airway obstruction.[18] Packing can also result in aspiration of blood, overuse of sedatives, or hypoxemia, which is worsened in patients with pre-existing respiratory problems. Furthermore, serious cardiopulmonary events have been reported immediately after posterior nasal packing.[19] These events may be sequelae of the so-called "nasopulmonary reflex." This reflex, also called the "trigeminocardiac reflex," is poorly understood but has been historically reported to result in fatal complications.[22] Sensing sensory trigeminal nerve receptors that innervate the nasal passage may result in sudden onset bradycardia, apnea, hypoxemia, and even asystole.[23] In patients with sudden hemodynamic changes, such as bradycardia, immediate cessation of the stimulus by removing the nasal packing is critical.

Enhancing Healthcare Team Outcomes

Posterior nasal packing is frightening and unpleasant for patients. Placing the packs requires reassurance from healthcare professionals as well as appropriate analgesia, all while carefully avoiding over-sedation. Emergency medicine clinicians should be able to distinguish between anterior and posterior bleeding to help determine appropriate management strategies and also recognize severe or refractory cases. A good relationship between the emergency and otolaryngology departments is necessary when managing posterior epistaxis. The otolaryngologist can provide valuable technical expertise concerning pack placement and will most likely be the one to remove the pack after an appropriate interval.