Internal Nasal Anatomy

The interior of the nose is divided in half by the bony cartilaginous septum and its mucoperichondrial covering. The septum thus makes up the medial wall of each nasal vault. The floor of the nose is formed by the palatal bone, sloping slightly downward as it goes back. The nasal cavity roof is made up of the sphenoid bone posteriorly, the cribriform plate (ethmoid bone), and the frontal bone anteriorly. Anteroinferiorly, the nostril opens into the nasal vault. The first 8 to 10 mm of nasal lining, going posteriorly from the nostril, is hair-bearing skin. The rest of the nose is lined with respiratory mucosa. The posterior extent of the nasal vault is the choana, or posterior nasal aperture, opening into the nasopharynx.

The most complex nasal anatomy occurs on the lateral wall of each vault, with three bony protrusions, the turbinates, extending into the nasal vault. The inferior turbinate is the biggest, and the superior one, the smallest. The nasolacrimal duct opens into the nasal cavity under the inferior turbinate. The maxillary, anterior ethmoidal, and frontal sinuses drain into the ethmoidal infundibulum, which opens under the middle turbinate. Posterior ethmoidal sinus cells open into the nose under the superior turbinate, and the sphenoidal sinus opens into the nose above and behind the superior turbinate.

Vascular Anatomy

Internal nasal tissue derives blood supply from both the internal and external carotid systems. The internal carotid artery supplies the anterior and posterior ethmoidal arteries via the ophthalmic artery. The external carotid artery supplies the nose via the internal maxillary artery and the facial artery. The sphenopalatine artery (branch of the internal maxillary), the superior labial artery (branch of the facial artery), and the anterior ethmoidal artery (branch of the ophthalmic artery) together supply Kiesselbach’s plexus in Little’s area of the anteroinferior septal mucosa. This rich vascular supply ensures plentiful bleeding when the mucosa is irritated or breached, resulting in epistaxis.

Nasal Physiology

The nose’s primary function is conditioning inspired air and conducting this air into and out of the pharynx. In a normal nose, air is warmed, humidified, and filtered of particulate matter before reaching the nasopharynx. The nose also contains sensor cells for olfaction in the superior nasal vault and improves vocal resonance.

Focal Anterior Bleeding

For spontaneous anterior bleeding from Little’s area, pinching the anterior nose firmly between the thumb and finger provides pressure that often controls the bleeding. Firm pressure is applied for 5 minutes without interruption and then is gently released. If bleeding persists, pressure should be applied for an additional 5 minutes. Pressure can be combined with a topical decongestant such as oxymetazoline or Neo-Synephrine to aid in bleeding cessation via vasoconstriction.

If there is a single identifiable anterior source such as a small laceration or varicosity, cautery with a silver nitrate stick or electrocautery may provide permanent cessation. For cautery, additional topical or injected anesthetic will make the patient more comfortable. This can be done by saturating a small cotton ball or pledget with a decongestant mixed with an anesthetic solution such as 4% lidocaine hydrochloride. The cotton ball or pledget should remain inside the anterior nasal cavity for 5 to 10 minutes. If additional anesthesia is needed, lidocaine with epinephrine (commonly 1% lidocaine in 1 : 200,000 epinephrine) can be injected into the mucosa under direct or endoscopic visualization without causing the patient much discomfort.

If silver nitrate cautery is used, the stick is applied directly to the oozing mucosa, cauterizing only the actively bleeding area. The mucosa touched by silver nitrate becomes black immediately. Once bleeding is well controlled, the mucosal area is gently rinsed with saline solution. If electrocautery is used, the grounding pad (if necessary with the unit) is applied to the patient and the oozing area cauterized. With both techniques, the “dose” of cautery used should be the minimum required to control bleeding, avoiding damage to nearby normal mucosa. A small piece of Gelfoam can be applied to the cauterized area. Antibiotic ointment is applied to the area twice a day for 3 to 5 days. Excessive cauterization should be avoided, since this can lead to inadvertent septal perforation.

A commercially available “pack” can also control anterior bleeding. These packs do not conform as well to the entire shape of the nasal vault in the way packing can and so may be less effective (depending on the exact site of bleeding). They are, however, quicker and easier to place than anterior packing, which is an acquired skill. Nasal tampons such as Merocel (Xomed) are generously coated with surgical lubricant then gently inserted into the nasal cavity dry and compressed. After the tampon is in place, it is expanded with saline to exert pressure on the nasal mucosa.

Middle Nose: Focal or Generalized Ooze

If bleeding originates slightly more posteriorly but still within the anterior zone, or if there is a generalized mucosal ooze, anterior packing can be used. The nasal cavity is firmly packed with ribbon gauze coated with petroleum jelly or BIP ointment (bismuth subnitrate, iodoform, paraffin). This approach applies pressure from inside the nose against the bleeding mucosa, much as bleeding from a facial laceration is controlled by holding pressure on the bleeding area.

Other options for controlling middle vault bleeding or generalized oozing include variations on anterior packing. The Rhino Rocket (Shippert Medical, Englewood, Colorado) is rolled polyvinyl alcohol foam on a tampon-like inserter. It unfurls when released inside the nose and has a string that remains outside, facilitating later removal. Various balloon nasal tamponades are available as well. Rapid Rhino is a pneumatic tamponade coated with a carboxymethylcellulose fabric, available in varying lengths used to control anterior and posterior epistaxis. It conforms to the nasal cavity better than compressed materials, is easy to insert and remove, and works within minutes.²

Posterior Bleeding: Generalized or Unidentifiable Source

The source of bleeding from the posterior half of the nose is more difficult to visualize. Direct digital pressure, which works well in the anterior nose, is not effective within the posterior bony nasal vault. So if bleeding is significant and sustained, if no nasal endoscope is available, or if blood flow obscures the endoscopic view, posterior/anterior packing is usually the first step.

Posterior bleeding cannot be controlled by anterior packing alone, because it is impossible to apply sufficient pressure. Trying to pack gauze into the posterior part of the nose is like trying to stuff a doughnut hole; as one packs more from the front, the gauze begins to fall out the back (i.e., into the nasopharynx). This is why posterior packing is used for a posterior hemorrhage.

Posterior packing provides a stable platform in the nasopharynx against which the packing inserted from anteriorly can be firmly placed. Traditionally, this is a roll of gauze placed through the mouth and guided into place in the nasopharynx by strings brought out through the nose, which then pull this pack into position and are tied around the columella.

When a patient is endotracheally intubated, firm pharyngeal packing using vaginal gauze can be used as a posterior nasal pack. Other alternatives to a posterior gauze pack include a Foley catheter and various nasal balloon devices. A Foley catheter placed transnasally into the nasopharynx and inflated can provide a similar firm nasopharyngeal platform. The commercially available balloon devices for posterior packing have an extended-length balloon or two balloons that are inflated separately, one for the nasal vault and the other for the nasopharynx.

After Packing the Nose

Even anterior packing of one nostril compromises nasal respiration and blocks sinus drainage into that nasal cavity. Posterior packing that obstructs both nasal cavities places patients at risk for hypoxemia. If seen as outpatients, all patients with posterior packs are admitted to the hospital for bed rest, oxygen supplementation (by face mask or face tent, not nasal cannula), hydration, and antibiotic therapy to prevent development of sinusitis or toxic shock syndrome. In the ICU setting, these supportive therapies should be provided for any patient requiring a nasal pack.

When a posterior gauze pack, Foley catheter, or other posterior packing material is secured at the anterior nares, traction on the columella or ala carries the risk of irritation and necrosis. Careful padding or devising methods of securing the packing are needed to prevent this complication. The key is spreading out the pressure over the columella or ala, rather than having a narrow string crossing these areas. Padding can be provided by folded gauzes, cotton rolls, and so forth. Alternatively, these ties can be attached to another tie that goes across the entire upper lip, over the ears, and behind the head. Umbilical clamps at the nasal openings can also be used to maintain forward pressure on the posterior packs. For a critically ill patient, to maintain pressure, one can also consider suspending the packing material to a halo device or other external fixed point (e.g., trapeze frame, ceiling, intravenous line stands).

Generalized Mucosal Ooze

Generalized mucosal oozing is usually due to a systemic clotting problem. In the critical care setting, clotting can be deranged on the basis of a coagulopathy (e.g., secondary to leukemia, an inherited disorder, or anticoagulation medications, disseminated intravascular coagulopathy, posttransfusion coagulopathy) or a systemic illness (e.g., renal or hepatic disease). If the systemic problem is easily correctable (i.e., stopping anticoagulants), nasal packing as described earlier can be used. If, however, the coagulopathy is ongoing, nasal packing can be a self-defeating approach. Although the bleeding stops when the pack is in place, the mucosal microtrauma of pack removal reinitiates bleeding. Use of absorbable hemostatic agents (Gelfoam, Surgicel, Avitene), thrombin-containing products (Floseal, Surgiflo) or fibrin glue can be helpful.³

Additional Treatment Options

If a bleeding point is identified but is too far posterior to cauterize at the bedside, the patient can be given general anesthesia in the operating suite. Endoscopically guided suction-cautery can be performed as far back as the choana. Sometimes infracture of the inferior turbinate is required to access a posterior bleeding point.

If bleeding is not controlled by packing, or if it recurs after packing is removed, control by arteriography and embolization or surgery is recommended.⁴ Surgical options include transnasal sphenopalatine artery ligation, anterior ethmoidal artery ligation, transantral internal maxillary artery ligation, and ligation of the external carotid artery in the neck.⁵ In the special case of hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), once conservative medical therapies fail, photocoagulation laser or septal mucosal dermoplasty may be required.⁶

Oxygen by Nasal Cannula

Oxygen supplied by nasal cannula dries the nasal mucosa. The dried mucosa is fragile and bleeds easily. Replacing the oxygen by nasal cannula with humidified oxygen via face mask or face tent will prevent this problem.

Once bleeding has occurred in this situation, the bleeding site can usually be identified on the anterior septum with a nasal speculum and headlight. If the bleeding consists of occasional spotting without active ongoing bleeding, gentle application of petrolatum or antibiotic ointment to this area several times a day will allow the mucosa to heal. If there is active bleeding, chemical or electrical cautery is sometimes needed.

Nasal Intubation

The largest cross-sectional diameter in the nasal vault occurs along the floor of the nose, which goes straight back from the nares. The best angle for passing a tube through the nose is found by elevating the nasal tip and passing the tube straight back. For smaller tubes such as nasogastric tubes, lubrication is usually all that is required for smooth passage through the nose.

Nasotracheal intubation is a common cause of epistaxis. Most such bleeding is mild and self-limited. If bleeding occurs during fiberoptic nasal intubation, it can obscure the endoscopic view. Measures that enhance smooth passage of the endotracheal tube through the nose and minimize bleeding include using a topical decongestant on the nasal mucosa before tube passage, generous lubrication of the tube, and thermo-softening of the tube in warmed water. Inspection of the internal nasal passages with a speculum or endoscope allows choosing of the larger side, the one with minimal narrowing by septal deviation, septal spurs, or turbinate hypertrophy. There is some evidence that routinely using the right nostril is associated with a lesser rate of epistaxis.⁷ Passage of successively larger soft nasal trumpets can assist with dilating the nasal passage (i.e., compressing the internal soft tissue) before intubation. Traumatic intubation can even result in inadvertent turbinectomy.⁸ Aspirin therapy increases the risk of epistaxis occurring with nasotracheal intubation, so being particularly gentle with patients taking aspirin may save having to deal with bleeding.⁹

Postoperative Epistaxis

Bleeding from the nose occurring after nasal or facial surgery must be reported immediately to the surgeon. Topical decongestants, pressure, cautery, absorbable hemostatic agents, or nasal packing may be required to control such bleeding. Occasionally the patient will need to return to the operating suite for vessel ligation.

Massive Facial Trauma

The occurrence of multiple facial fractures can cause epistaxis. Usually this type of bleeding ceases with nasal packing. Occasionally a displaced fracture tents open a lacerated vessel, and fracture reduction is required to stop the bleeding. Asch and Rowe forceps are used for this reduction, and a general anesthetic is usually required.

Vessel Problems

Rarely, massive epistaxis results from rupture of carotid aneurysms or carotid–cavernous sinus fistulas. Cerebral arteriography and embolization are required to control such bleeding.