Posterior bleeding is much less common than anterior bleeding and usually is treated by the ear, nose, and throat surgeon (an otolaryngologist). Posterior nosebleeds involve bleeding from the back of the nasal cavity. Blood flow tends to be heavier than in anterior nosebleeds and hence needs early management. Posterior packing may be accomplished by passing a catheter through one nostril (or both nostrils), into the pharynx, and finally out the mouth. A gauze pack then is secured to the end of the catheter and positioned in the posterior nasopharynx by pulling back on the catheter until the pack is seated in the posterior aspect.
The procedure is done in the following steps:
- After adequate anesthesia has been obtained, a catheter is passed through the affected nostril, into the nasopharynx, and drawn out of the mouth with the aid of ring forceps.
- A gauze pack is secured to the end of the catheter using umbilical tape or suture material, with long tails left to protrude from the mouth.
- The gauze pack is guided through the mouth and around the soft palate using a combination of careful traction on the catheter and pushing with a gloved finger. This is the most uncomfortable (and most dangerous) part of the procedure; it should be completed smoothly and with the aid of a bite block to protect the physician’s finger.
- The gauze pack should come to rest in the posterior nasal cavity. It is secured in position by maintaining tension on the catheter with a padded clamp or firm gauze roll placed anterior to the nostril.
- The ties that protrude from the mouth (which will be later used to remove the pack) are taped to the patient’s cheek.
- Patients with posterior packs for epistaxis may be admitted to the ICU for continuous monitoring due to the risk of life-threatening events.
- The patient will require prophylactic antibiotics while the foreign body is in place. To prevent tissue infection, the packing will need to be removed within 48-72 hours.
- A potential complication of posterior packing that is kept in place for extended periods is toxic shock syndrome (a rare but serious medical condition caused by a bacterial infection).
- The risk of rebleeding and complicated bleeds from posterior nasal bleeds may require otorhinolaryngology consultation. Even when appropriate measures are taken to control a posterior nasal bleed, 25% will not stop.
An otolaryngologist may further perform endoscopic surgery to know the cause of the bleeding. When posterior bleeding is suspected, the general location of the source should be determined. This step is important because different arteries supply the floor and roof of the posterior nasal cavity; therefore, selective treatment may be required. Hot water irrigation has shown promise in reducing discomfort and length of hospitalization in patients with posterior epistaxis. More invasive alternatives include arterial ligation and angiographic arterial embolization.