M2 ANATOMY

A 35-year-old lady awoke from sleep finding the side of her head in a puddle of blood on her pillow, with active bleeding from her right external nares. Upon arising she noticed persistent bleeding, although blood was now flowing down the back of her throat in addition to the nares. She pinched her nose between her index finger and thumb, and dressed with the assistance of her partner who drove her to the emergency department (ED). She was triaged immediately to a room in the ED outfitted for otolaryngologic emergencies.

In the ED the patient appeared pale and anxious yet in no distress. Her vital signs noted a BP of 90/60, HR 110, RR 20, temperature of 100.1 (oral) and pulse oximetry of 92% on room air. Brisk bleeding was observed from the external nares and posterior pharynx. The neck was otherwise supple, the heart rate and rhythm were tachycardic yet with a normal S1, S2 and no murmurs or gallops. The lungs were clear.

As an IV was being started, the ED physician had the patient express all clots from the nasal cavity. An active bleeding site could not be found while inspecting the anterior septal region, and the application of a topical vasoconstrictor diminished the flow of blood slightly but did not assist in revealing a bleeding site. The placement of an anterior nasal pack lessened bleeding from the nares but left the flow of blood into the pharynx unchanged. The emergency physician then placed a balloon-tipped catheter deep into the nasal cavity and after the balloon was inflated the bleeding stopped.