Anterior Nasal Packing


In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localise Ihe bleeding site, hi minor bleeds, from the accessible sites, cauterisation of the bleeding area can be done. If bleeding is profuse and/or the site of bleeding is difficult to localise, anterior packing should be done. For this, use a ribbon gauze soaked with liquid paraffin. About 1 metre gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor, and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front. One or both cavities may need to be packed. Pack can be removed after 24 hours if bleeding has stopped. Sometimes, it has to be kept for 2 to 3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome.


Posterior Nasal Packing

It is required for patients bleeding posteriorly into the throat. A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone. A rubber catheter is passed through the nose and its end brought out from the mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior nasal cavity is now packed and silk threads tied over a dental roll. The third silk thread is cut short and allowed to hang in the oropharynx. It helps in easy removal of the pack later. Patients requiring postnasal pack should always be hospitalised. Instead of postnasal pack, a Policy's catheter can also be used. The bulb is inflated with saline and pulled forward so that choana is blocked and then an anterior nasal pack is kept in the usual manner. These days nasal balloons are also available. A nasal balloon has two bulbs, one for the postnasal space and the other for nasal cavity.


Endoscopic Cautery


Posterior bleeding point can sometimes be better located with an endoscope. It can be coagulated with suction cautery. Local anaesthesia with sedation may be required.
Elevation of Mucoperichondrial Flap and SMR Operation
In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels. SMR operation can be done to achieve the same result or remove any septal spur which is sometimes the cause of epistaxis.


Ligation Of Vessels