**5. Management**

It is important to evaluate epistaxis patients thoroughly because the method of controlling epistaxis depends largely on the specifics of an individual case, with an entire menu of options available. (Table 2)

Anterior flexion of head can prevent nausea or airway obstruction, as blood does not flow back to pharynx. It is important to keep the blood pressure low and keep the airway clean. Also, fluid replacement can be considered according to the amount of blood loss. Systemic diseases can cause multiple bleeding sites or frequent recurrent epistaxis so blood testing should be performed in patients with those findings. Patients with posterior epistaxis, coagulopathy, coronary artery disease, uncontrolled hypertension, severe anemia or old age should be considered to treat as in-patient basis.

#### **5.1 Medical treatment**

On the first visit of a patient with minimal or moderate history of nasal bleeding, an empiric trial of medical therapy is advised. This includes several measures designed to increase humidification of the mucosa to allow the bleeding site to heal. This approach is based on the assumption that dryness is one of the most important factors causing epistaxis. The

ligation.

perforation.

**5.2 General treatment** 

**5.2.1 General treatment for anterior epistaxis** 

length at a time to build up the pack. (Cho, 2009 )

against which the blood can clot.

decongestant and anesthetic agent.

Epistaxis 33

Second-line therapy is then indicated, including nasal packing, cauterization, and vessel

If the bleeding site is identified, it is recommended to use pledgets impregnated with decongestant containing bosmin or phenylephrine solution. Compress both nasal dorsum directly for at least 5 minutes after packing the nasal cavity with gauzes impregnated with

In cases with coagulopathy, packing with pledget can damage the mucosa so hemostatic agents such as Avitene, Surgicel or gelfoam can be used. Electric cautery should be performed carefully because it can damage surrounding normal tissue. Also, physician should keep in mind that electric cautery on bilateral septum can lead to septal

In case epistaxis continues with former treatments, nasal packing using gauze with Vaseline and antibiotics, from posterior to anterior and from inferior to superior, should be done. Using bayonet forceps, grasp the packing about 10 cm from one end and place into the back of the nose. Loops of the packing are then placed one on top of another, gently but firmly pressing the loop onto the floor of the nose as each is placed. In this way, the pack is built up

Fig. 3. Placement of traditional or standard anterior nasal packing. A. The gauze is grasped 10cm from one end and placed into the posterior choanae. B. The gauze is layered one

Instead of gauze, compressed sponge (Merocel) can be used. The pack is introduced in a dehydrated state and is expanded by either instilling saline or by absorbing blood from the patient. As the material expands, it fills the nasal or sinus cavity, helping to stop the bleeding in two ways: by applying pressure against the mucosa and by providing a surface

sequentially. The final pack should tightly fill the nasal cavity. (Figure 3)


Table 2. Management options of epistaxis.

recommendations include applying an ointment to the anterior nose each morning and night. In between ointment applications, nasal saline is sprayed into the nose every 2 to 3 hours. In addition, every effort should be made to humidify the air of the home environment. This usually requires using a room air humidifier in the bedroom every night. Maximum effect is achieved by running the humidifier on full with the doors and windows to the room closed.

Also, medical conditions that contribute to epistaxis should be controlled. For example, in patients with hypertension, medication should be administered to lower the blood pressure to within normal range. For patients with coagulopathy, every attempt should be made to normalize clotting function. This may require discontinuing Coumadin or aspirin therapy. For patients with acute and life-threatening bleeding, platelet or plasma transfusions may be administered to reverse the bleeding disorder.

Patients with epistaxis should also minimize their activity while the nose is healing. Exercise should be deferred until the bleeding has stopped for at least 1 week. Bed rest is generally not necessary, nor is staying home from work or school. However, patients should be aware of their level of activity and take steps to avoid any activities that would elevate the blood pressure. Nose blowing should be minimized, and patients should be instructed to blow gently. Patients should also be instructed to avoid rubbing and picking at the nose. Finally, adjunctive therapy, including stool softeners and antitussives, should be considered in selected patients.

If initial attempts to control epistaxis with these conservative medical therapies fail, a more comprehensive approach to the problem should be initiated. This may include specific investigations to evaluate the haemoglobin, platelet levels and coagulation function. An endoscopic examination, if not already performed, should also be considered. This subset of patients might also benefit from a CT scan to rule out the possibility of an occult tumor.

Transantral ligation of the internal maxillary artery

recommendations include applying an ointment to the anterior nose each morning and night. In between ointment applications, nasal saline is sprayed into the nose every 2 to 3 hours. In addition, every effort should be made to humidify the air of the home environment. This usually requires using a room air humidifier in the bedroom every night. Maximum effect is achieved by running the humidifier on full with the doors and windows to the room closed. Also, medical conditions that contribute to epistaxis should be controlled. For example, in patients with hypertension, medication should be administered to lower the blood pressure to within normal range. For patients with coagulopathy, every attempt should be made to normalize clotting function. This may require discontinuing Coumadin or aspirin therapy. For patients with acute and life-threatening bleeding, platelet or plasma transfusions may be

Patients with epistaxis should also minimize their activity while the nose is healing. Exercise should be deferred until the bleeding has stopped for at least 1 week. Bed rest is generally not necessary, nor is staying home from work or school. However, patients should be aware of their level of activity and take steps to avoid any activities that would elevate the blood pressure. Nose blowing should be minimized, and patients should be instructed to blow gently. Patients should also be instructed to avoid rubbing and picking at the nose. Finally, adjunctive therapy, including stool softeners and antitussives, should be considered in

If initial attempts to control epistaxis with these conservative medical therapies fail, a more comprehensive approach to the problem should be initiated. This may include specific investigations to evaluate the haemoglobin, platelet levels and coagulation function. An endoscopic examination, if not already performed, should also be considered. This subset of patients might also benefit from a CT scan to rule out the possibility of an occult tumor.

Endoscopic ligation of the sphenopalatine artery

External ligation of the ethmoid arteries

Medical Management

Nasal sponges Gelfoam

Nasal balloon

Silver nitrate

Laser cautery

Septoplasty

Septal dermoplasty

Traditional anterior pack

Traditional posterior pack

Endoscopic electrocautery

Nasal packing

Cautery

Surgery

Table 2. Management options of epistaxis.

administered to reverse the bleeding disorder.

selected patients.

Embolization Arterial ligation Second-line therapy is then indicated, including nasal packing, cauterization, and vessel ligation.

## **5.2 General treatment**
