Management of Nasopharyngeal Bleeding

Initial Assessment and Triage

For active nasopharyngeal bleeding, the American Academy of Otolaryngology-Head and Neck Surgery recommends immediately applying firm sustained compression to the lower third of the nose for at least 5 minutes while simultaneously assessing for airway compromise and hemodynamic instability, which would require emergent hospital evaluation 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery suggests that emergent hospital evaluation is required for patients with active bleeding and signs of airway compromise, hemodynamic instability, bleeding from both nostrils or from the mouth, bleeding duration >30 minutes over 24 hours, history of hospitalization or transfusion for nosebleeds, or >3 recent bleeding episodes 1, 3, 4, 5, 6
The American Academy of Otolaryngology-Head and Neck Surgery recommends that an ambulatory setting is acceptable for patients with minor active bleeding without airway or hemodynamic concerns, or no active bleeding with history of only minor prior bleeding 1, 7, 8

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying firm sustained compression to the lower third of the nose for 5 minutes or longer as the first-line intervention for nasopharyngeal bleeding 2, 9
After any blood clot removal, the American Academy of Otolaryngology-Head and Neck Surgery suggests performing anterior rhinoscopy to identify the bleeding site, and if the source cannot be identified or bleeding is difficult to control, performing or referring for nasal endoscopy to examine the nasal cavity and nasopharynx 1, 7, 9
The American Academy of Otolaryngology-Head and Neck Surgery recommends treating the identified bleeding site with one or more of the following: topical vasoconstrictors, nasal cautery, or moisturizing or lubricating agents 1, 3, 5, 9
If bleeding persists, the American Academy of Otolaryngology-Head and Neck Surgery suggests proceeding with nasal packing, using resorbable packing for patients with suspected bleeding disorders or those on anticoagulant/antiplatelet medications, and standard packing for other patients 1, 3, 9

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting factors that increase bleeding frequency or severity, including personal or family history of bleeding disorders, anticoagulant or antiplatelet medication use, intranasal drug use, prior nasal/sinus surgery, nasal trauma, nasal cannula oxygen or CPAP use, chronic kidney or liver disease, hypertension, cardiopulmonary disease, and anemia 1, 3, 5, 10

The American Academy of Otolaryngology-Head and Neck Surgery suggests that in the absence of life-threatening bleeding, first-line treatments (compression, cautery, packing) should be initiated before transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 3, 9

The American Academy of Otolaryngology-Head and Neck Surgery recommends evaluating candidacy for surgical arterial ligation or endovascular embolization for persistent or recurrent bleeding not controlled by packing or cauterization 1, 6

The American Academy of Otolaryngology-Head and Neck Surgery suggests educating patients with nasal packing about the type of packing placed, timing and plan for removal, post-procedure care, and warning signs requiring prompt reassessment 3, 4, 10
The American Academy of Otolaryngology-Head and Neck Surgery recommends educating all patients about preventive measures, home treatment techniques, and indications to seek additional care 1, 7

The American Academy of Otolaryngology-Head and Neck Surgery suggests assessing for hereditary hemorrhagic telangiectasia (HHT) in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds by examining for nasal and oral mucosal telangiectasias 1, 6
The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting outcomes within 30 days or documenting transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 9