6
Surgical Treatment of Epistaxis
William A. Numa and Robert G. McRae
- If a patient experiences brisk or prolonged blood loss, observe closely for postural hypotension, which may require careful rehydration with intravenous fluids.
- Control of hypertension is usually essential for epistaxis management. Some patients have hypertension-dependent cerebral blood flow, and hypertension control should be achieved with continuous input from the primary care physician (PCP) or emergency room physician.
- The patient receiving therapeutic anticoagulation/antiaggregation therapy (i.e., warfarin or aspirin) deserves special mention. Evaluation of the risk/benefit ratio of discontinuing therapy must be reached in close communication with the patient’s PCP/cardiologist as appropriate.
- Topical anesthesia and vasoconstrictors are pharmacological agents that can be very helpful in the initial treatment of epistaxis.
- Nonabsorbable packing materials include Merocel® (medtronic corp., minneapolis, MN), Rapid Rhino® (arthrocare corp., austin, TX), Epistat® balloon, and conventional anteroposterior (AP) petroleum jelly gauze strips.
- Lubricate these before application and moisten them before removal.
- Packing should be left in place for up to 3 to 5 days to allow for mucosal reepithelialization.
- Patients who undergo AP nasal packing should be admitted to the hospital to be monitored continuously for apnea and blood oxygen saturation variations mediated via the nasopulmonary (NP) reflex. The NP reflex has been well documented to cause hypoxemia and hypercarbia. This is especially important in the patient with chronic obstructive pulmonary disease (COPD).
- Anterior nasal packing is attempted first. If unsuccessful, AP packing is indicated.
- A 14-gauge Foley catheter is passed through the nasal passage with the heaviest bleeding until seen in the oropharynx. Ten milliliters of sterile water is injected into the Foley catheter balloon, and the catheter is gently withdrawn until resistance is met. Sterile water will not crystallize (unlike saline) and is noncompressible (unlike air).
- Special care is taken to ensure protection of the nasal ala/columella. A portion of the catheter is trimmed off and skewered onto itself prior to its insertion through the nose for this purpose.
- Petroleum jelly-gauze or Xeroform® packs are used to pack the anterior nasal cavity in a systematic (anterior to posterior and inferior to superior) layered fashion.
- A C-clamp is fitted over the Foley/guard complex, securing the packing in place, and ensuring decreased pressure on the ala/columella.
- For conventional packing, a dental roll will have a similar function with the strings tied over the dental roll.
- Patients who undergo any type of nasal packing should be placed on antibiotics covering gram-positive organisms to avoid toxic shock syndrome.
Approximately 10% of patients will fail the nonsurgical treatment outlined above. Indications for surgical management include the following:
Operative management for epistaxis is aimed at interrupting or significantly decreasing blood flow to the bleeding site. This requires being able to localize the exact bleeding site or assessing the general region from which bleeding may be originating.
