Cautery (silver nitrate
Minor bleed with visible culprit vessel on anterior nasal septum/ speculum exam.
- Choose an appropriate (cooperative) patient
- Wash hands and wear gloves
- Establish haemostasis prior to use of silver nitrate stick; achieve with direct pressure, suction to remove any clot
- Anaesthetise the area to be cauterised with co-phenylcaine spray:
- Can spray directly onto septum, may be more effective to wet a cotton ball with the co-phenylcaine spray and apply this to the nasal septum (one side only) for 1-2 minutes, then remove and gently pat dry to maximise effectiveness of silver nitrate application
- Apply a paraffin barrier to enclose the area of treatment prior to performance of the cautery i.e. at entrance to nares:
- Moisture can cause the silver nitrate to drip and cause grey or black staining of the skin around the nares or upper lip
- This can be cosmetically troubling for patients
- If staining does occur, the stain will fade as the skin naturally exfoliates (1-2 weeks); gentle rubbing with some aqueous cream on a cue tip may hasten removal of the stain if used early (for use on intact skin, not the area of cauterised septum
- Do not rub or apply friction to the area of treatment
- Wet just the tip of the silver nitrate stick with some sterile water
- If it is too wet the risk of dripping and staining is increased
- If there is a pinpoint of active bleeding, the tip will not need to be moistened
- Note there is no role for AgNO3 for brisk, moderate or severe bleeding
- Gently roll the applicator tip over the mucosa or at the pinpoint bleeding site until a grey eschar forms or for a maximum of 5 seconds
- Do not perform prolonged, extensive or bilateral septal cautery (risk of necrosis/perforation
- Do not extend cautery to normal nasal mucosa
- Check that the bleeding has stopped: discharge with post cautery advice
Post-cautery
- Prescribe a nasal antiseptic moisturiser such as Nasopore
- Use paracetamol for discomfort
- No rubbing or blowing nose for a week
- Avoid boisterous play / contact sports / heavy lifting for a week
- Review by GP (post cautery patients do not require ENT follow up)
Links
- Epistaxis
- Floseal
- Rapid Rhino page
- Patient advice sheets
- Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. David E. Tunkel, MD, Samantha Anne, MD, MS, Spencer C. Payne, M. First Published January 7, 2020 Research Article https://doi.org/10.1177/0194599819889955