Ear, Nose, and Throat Emergencies
Epistaxis
1. Epistaxis is a common problem in travelers.
2. Reduced humidity in airplanes, cold climates, and high-altitude environments can produce drying and erosion of the nasal mucosa.
3. Other major causes include infections, inflammatory rhinitis, inhaled medications, mucosal breakdown caused by infiltration by malignancy or granulomatous disease, and nasal trauma.
4. Daily applications of a small quantity of petroleum jelly (Vaseline) to the septum can help to keep the nasal mucosa moist.
5. Although most cases of epistaxis are minor, some present life-threatening emergencies.
6. Ninety percent of nosebleeds are anterior, and exhibit unilateral, steady, nonmassive bleeding. Ten percent are posterior and may present with massive bleeding.
7. A posterior source of the bleeding should be considered when epistaxis is bilateral, brisk, and not controlled with pinching the nostrils or with an anterior nasal pack.
Treatment
1. The existing clot should be completely cleared, usually by having the patient blow his nose.
2. One or two sprays of a topical nasal vasoconstrictor (e.g., oxymetazoline [Afrin] or phenylephrine [Neo-Synephrine]) should be inhaled into the affected nostril.
3. The patient should be kept sitting (i.e., keeping the head elevated and still).
4. The patient should be instructed to grasp and pinch his entire nose, maintaining continuous pressure against the septum for at least 15 minutes. If this maneuver does not control the bleeding, nasal packing may be required.
5. Anterior epistaxis nasal pack
a. Soak a piece of cotton or gauze with a vasoconstrictor such as oxymetazoline nasal spray, and insert it into the nose, leaving it in place for 5 to 10 minutes.
b. Petroleum jelly–impregnated gauze or strips of a nonadherent dressing can then be packed into the nose so that both ends of the gauze remain outside the nasal cavity (Fig. 33-1). This prevents the patient from inadvertently aspirating the nasal packing.
c. Complete packing of the nasal cavity of an adult patient requires a minimum of 1 m (3.3 ft) of packing to fill the nasal cavity and tamponade the bleeding site. When placing the gauze, it should be started as far posteriorly as is possible.
d. Expandable packing material such as Weimert Epistaxis Packing, Merocel nasal tampon, Rapid Rhino, or the Rhino Rocket is available commercially. The packing material can be lubricated with K-Y jelly or water before insertion. A tampon or balloon tip from a Foley catheter can also be used as improvised packing.
e. Anterior nasal packing blocks sinus drainage and predisposes to sinusitis. Prophylactic antibiotics (see Sinusitis, later) are recommended until the pack is removed in 48 to 72 hours.
6. Posterior epistaxis nasal pack
a. If the bleeding site is located posteriorly, use a 14- to 16-French Foley catheter with a 30-mL balloon to tamponade the site (Fig. 33-2).
b. Prelubricate the catheter with either petroleum jelly (Vaseline) or a water-based lubricant.
