Direct compression of the nasal alae (cartilaginous part) is first-line management for epistaxis as most anterior bleeds resolve after 10-15 minutes of compression without interruption. The patient should be sitting up and leaning forward to minimise blood entering the oral cavity and pharynx. A common misconception is that compression of the nasal bones controls bleeding.
This patient has an anterior septal bleed with a visible bleeding site at Little’s area (Kiesselbach plexus – anterior septal anastomoses of the anterior ethmoidal artery, sphenopalatine artery, greater palatine artery and septal branch of the superior labial artery). He is haemodynamically stable and there is no airway compromise.
If direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis, the next most appropriate management step in this patient would be nasal cautery as there is a visible bleeding site and this patient also suffers from recurrent epistaxis. He is calm and thus may be able to tolerate cautery. Before cautery, a topical anaesthetic spray and vasoconstrictor (lidocaine with phenylephrine) is usually applied to reduce pain and helps control bleeding respectively.
Cautery can either be chemical or electrical (thermal). Chemical cautery involves applying 75% silver nitrate sticks to the identified bleeding site for 3-10 seconds. Afterwards the cauterised area is dabbed with a clean cotton bud to remove excess chemical or blood and a topical antiseptic preparation such as Naseptin (chlorhexidine and neomycin) is applied to the nostrils 4 times daily for 10 days to reduce crusting and vestibulitis.
If nasal cautery fails or there isn’t a bleeding point identified or there is severe bleeding, nasal packing would be the next most appropriate management step to tamponade the local bleeding. Nasal tampons, inflatable packs and ribbon gauze impregnated with Vaseline can be used in nasal packing.
Aggressive therapies such as nasal balloon catheter and transnasal endoscopy with direct cautery/arterial ligation are reserved for patients with posterior bleeds and uncontrollable severe bleeding unamenable to nasal packing.