Bleeding Nasal Polyposis and Septal Bleeding (Epistaxis)

Anatomy of the Septal Blood Supply

• Sphenopalatine artery - supplies the posterior and inferior septum (responsible for most severe posterior epistaxis)
• Anterior and posterior ethmoidal arteries (from the ophthalmic branch of the internal carotid) - supply the superior mucosa
• Superior labial branch of the facial artery - supplies the anterior mucosal septum

Causes of Bleeding in Nasal Polyposis / Septal Disease

Special note: Adolescent boys with recurrent epistaxis AND nasal obstruction should be evaluated for juvenile nasopharyngeal angiofibroma - a benign but locally aggressive tumor.

Clinical Assessment

1. Vital signs and airway - rare but possible compromise in severe bleeding
2. History - timing, frequency, laterality, trauma, medications (anticoagulants are a major risk factor for recurrence), comorbidities
3. Hypertension - commonly elevated during epistaxis due to anxiety; no proven causal relationship, but may be associated with persistent bleeding
4. Physical exam - have the patient blow the nose, then compress the cartilaginous nose for 10-15 min; examine with nasal speculum opened vertically (not laterally, to avoid obscuring the septum); oxymetazoline 0.05% (2 sprays) before pressure optimizes hemostasis and exam

Management - Step-by-Step

Step 1: First Aid / Pressure

• Bilateral compression of the cartilaginous septum for 10-15 minutes
• 2 sprays oxymetazoline 0.05% into the affected naris before pressure
• A nose clip is superior to manual pressure alone

Step 2: Identify and cauterize the source

• Apply topical anesthetic: 2% lidocaine + vasoconstrictive agent (e.g., 4% lidocaine + phenylephrine)
• Silver nitrate cautery - first-line if bleeding site is visible; effective with low re-bleeding rate
  • Cauterize from periphery to center, superior to inferior
  • Limit contact to <15 seconds to avoid septal damage
  • Do NOT apply bilaterally to the septum - may devascularize the septum and cause necrosis

Step 3: Topical hemostatic agents

• Absorbable gelatin sponge (Gelfoam)
• Absorbable knitted fabric (Surgicel)
• Topical tranexamic acid (500 mg IV solution applied to a nasal pledget or atomized) - moderate-quality evidence supports reduction in bleeding at 10 minutes and re-bleeding at 7-10 days; superior to anterior nasal packing in antiplatelet drug users

Step 4: Anterior nasal packing

• Polyvinyl acetal tampons (e.g., Merocel) or inflatable nasal balloons (e.g., Rapid Rhino - coated in procoagulant)
• Inserted along the floor of the nose, inflated with air
• For uncontrolled anterior bleeding: insert a second tampon into the opposite naris

Step 5: Posterior packing (if anterior packing fails)

• Double balloon catheter device - posterior balloon inflated first, seated by pulling anteriorly, then anterior balloon inflated slowly
• Alternative: Foley catheter into nasopharynx with 5-7 mL water in balloon, pulled anteriorly

Step 6: Specialist intervention

• Surgical ligation - traditional choice for intractable bleeding
• Endovascular embolization - success rate >80%; preferred in chronic coagulopathies and anticoagulated patients who cannot interrupt therapy

Key Considerations for Polyp-Associated Bleeding

• Nasal polyps are a recognized cause of epistaxis (listed in Box 58.6 of Rosen's Emergency Medicine)
• Polyps cause mucosal fragility and increased vascularity - any trauma or inflammation can trigger bleeding
• In HHT (hereditary hemorrhagic telangiectasia), recurrent septal bleeding is a hallmark; treatments include estrogen therapy, tamoxifen, thalidomide, and dermoplasty of the bleeding nasal septum
• Intranasal corticosteroids (used to treat nasal polyposis) can themselves cause epistaxis and, rarely, septal perforation
• Always consider malignancy (inverted papilloma, squamous cell carcinoma, lymphoma) when bleeding polyps are present, especially if unilateral or recurrent