Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruffs plexus, a venous plexus situated in the posterior part of inferior meatus. Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth. Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Such bleeding is called "pseudoepistaxis" (pseudo + epistaxis). Examples include blood coughed up through the airway and ending up in the nasal cavity, then dripping out. Prevention
People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying petroleum jelly to the nasal nares. Treatment
Most anterior nosebleeds can be stopped by applying direct pressure, which helps by promoting blood clots. Those who have a nosebleed should first attempt to blow out any blood clots and then apply pressure for at least five minutes and up to 20 minutes. Pressure should be firm and tilting the head forward helps decrease the chance of nausea and airway obstruction as seen in the picture on the right. When attempting to stop a nosebleed at home, the head should not be tilted back. Swallowing excess blood can irritate the stomach and cause vomiting.
There are also several dissolvable packing materials that stop bleeding through use of thrombotic agents that promote blood clots, such as surgicel. The thrombogenic foams and gels do not require removal and dissolve after a few days. Posterior nasal packing can be achieved by using a Foley catheter, blowing up the balloon when it is in the back of the throat, and applying traction. Complications of nasal packing include abscesses, septal hematomas, sinusitis, and pressure necrosis. In rare cases toxic shock syndrome can occur with prolonged nasal packing. As a result, many forms of nasal packing involve use of topical antistaphylococcal antibiotic ointment. Tranexamic acid
Tranexamic acid helps promote blood clotting. For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein. Cauterization
This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding. Eventually the nasal tissue to which the chemical is applied will undergo necrosis. This form of treatment is best for mild bleeds, especially in children, that are clearly visible. A topical anesthetic (such as lidocaine) is usually applied prior to cauterization. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time. Surgery
Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose.