Goroll_Primary Care Medicine, 8e

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SECTION XIV Ear, Nose, and Throat Problems

the posterior nose. Initial efforts should be made to bring the bleeding under control while awaiting an otolaryngologic con sult. Hematocrit, blood pressure, and pulse should be imme diately obtained, and, if necessary, a sample should be sent for type and cross-match. Blood pressure should be controlled, but care must be taken not to lower the blood pressure excessively in the face of blood volume loss. The patient should be instructed to sit up and lean forward , and if there has been a temporary interruption in the bleed ing, no treatment other than spraying the nose with a topical anesthetic and vasoconstricting substance, such as 4% cocaine or oxymetazoline 0.05% , should be attempted. The nose should be suctioned or blown clear only when the medical personnel present are prepared to deal with brisk epistaxis. Many cases of “posterior” epistaxis can be handled with the placement of laminated expandable nasal tampons . In other cases, expandable balloons with multiple ports may be placed for control of the epistaxis. After the bleeding has been stopped, short-term nasal packing (3 to 5 days) or surgical control of the bleeding may be attempted. With the advent of endoscopes, posterior epistaxis may be treated with directed cautery , obviating the need for extended periods of uncomfortable packing and possibly hospitalization. In rare cases, formal anterior–posterior nasal packing or operative transantral ligation of the spheno palatine artery may be required by otolaryngologic personnel. Finally, in particularly refractory cases, endovascular arteriogra phy with embolization may be required. Antiangiogenesis therapy is being explored to address the con dition’s underlying pathophysiology. The use of monoclonal antibody (e.g., bevacizumab) directed against vascular endo thelial growth factor (VEGF) has shown promise. Intravenous administration demonstrates the ability to reduce hepatic involvement and frequency of nosebleeds, but nasal application to avoid the adverse systemic effects of intravenous therapy has yet to prove effective in reducing frequency or duration of nosebleeds. The literature should be followed for more devel opments in treatment of this difficult condition. Etiologic Treatment of Bleeding due to Hereditary Hemorrhagic Telangiectasia

Anterior Septal Bleeding First Aid Measures

A few simple first aid measures suffice for most cases. The patient should sit up (this reduces venous pressure) and lean forward (which prevents the swallowing of blood if the bleeding is anterior). A small piece of cotton or cotton balls soaked in a vasoconstricting nose drop such as phenylephrine (Neo-Synephrine) or oxymetazoline (Afrin) is placed in the vestibule of the nose and pressed against the bleeding site for 10 to 15 minutes with manual compression of the anterior fleshy aspect of the nose (patients often mistakenly manually compress the bony upper two thirds of the nose). The temporary packing is then removed carefully and slowly to observe for rebleeding. This will stop almost all venous types of anterior nosebleeds. Humidification and a lubricant such as petrolatum ointment promote healing. Additional Measures If these remedies fail, the mucous membrane can be anesthe tized by applying cotton soaked with 4% cocaine or 4% lidocaine for 5 minutes. The nose is then carefully examined, especially along the anterior septum, to determine whether exposed vas culature is the cause of bleeding. A silver nitrate stick can then be applied to the bleeding site and to any prominent vessels. Silver nitrate cautery should be applied carefully, and patients with a previous history of septal or nasal surgery and patients who are taking antiplatelet agents as their mucosa may become extremely friable and apt to bleed more during cautery. Occasionally, a small artery in the septal mucous membrane will either fail to stop bleeding or rebleed a short time later. These episodes can usually be controlled by anesthetizing and recauteriz ing the area. This is followed by placing a small amount of oxidized regenerated cellulose (Surgicel) against the bleeding artery or a small packing of petroleum gauze strip or Merocel sponge soaked with oxy metazoline and/or thrombin solution, which is left in the nasal ves tibule for 48 hours. Patients with nasal packing require temporary antibiotic coverage directed against staphylococcal species. After cautery or packing, the patient should be placed on light activity, stool softeners, and humidification. Recently, an over-the-counter product for managing anterior epistaxis has become available (NasalCEASE). This is a specific calcium alginate product that has been shown to cause coagulation via platelet aggregation and plasmatic coagulation and can be applied in the physician’s office or even by patients at home. It has been shown to be both effective and cost-effective in the management of anterior epistaxis. A variety of materials that do not require formal packing or removal have become available for intranasal application. These include bovine gelatin-/human thrombin–type agents , which have proven effective in randomized controlled trials. Although they add significantly to initial cost, they offset the cost of follow-up removal of nasal packing. Patients with Bleeding Disorders Effective management entails treatment directed at the underly ing bleeding disorder (see Chapter 81). In addition, the imme diate control of bleeding requires being especially careful to prevent abrading mucous membranes, best achieved through the use of humidity, copious lubricants, and soft cotton tamponades wetted with long-acting vasoconstricting drops ( oxymetazoline 0.05% [Afrin] nasal solution). Packing should be avoided at all costs, but if it is unavoidable, it can be accomplished with a piece of oxidized cellulose , which does not require removal. Posterior Epistaxis Posterior epistaxis constitutes an inherently more serious problem because of the relative rapidity of blood loss and the relatively inaccessible and poorly visualized bleeding site in

PATIENT EDUCATION Prevention of Recurrences

Once septal bleeding is controlled in the office or emergency ward, several measures to prevent recurrences should be instituted: • • Instruct the patient on the need to avoid traumatizing the mucosa. Specifically, warn against habitual nose picking, constant rubbing with a handkerchief, and excessively forceful blowing. The fingernails of children should be trimmed short. • • Have the patient keep the septum well coated with petrolatum-based ointment such as zinc oxide, vitamin A + vitamin D ointment, or an antibiotic ointment until healed, usually in 3 to 5 days.

• • Teach the control of minor recurrent bleeding by the patient’s use of cotton pledgets soaked in a vasoconstrict ing nose drop (e.g., phenylephrine [Neo-Synephrine] or oxymetazoline [Afrin]) and pressed against the bleeding site. Consider the use of over-the-counter NasalCEASE. • • Explain the importance of humidifying the home envi ronment; have the patient keep a few windows partially open, place containers of water near radiators or stoves, or install a humidifier. • • Consider patient application of a water-based lubricant applied to the rims of the nostrils to maintain mucosal moisture. Copyright © 2020 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.