Bleeding is typically more profuse than with anterior epistaxis and may be more difficult to control. Blood can often be seen flowing down the posterior oropharynx, or from both nares. The latter is thought to be more common with posterior epistaxis because the site of hemorrhage is closer to the choanae and blood is more likely to reflux to the unaffected side. Direct visualization of the bleeding site may require use of a fiberoptic nasopharyngoscope. Anytime an anterior pack has been placed, and the patient continues to feel blood trickle down the posterior pharynx, a posterior bleed must be considered. A complete set of vital signs, and a thorough head, neck, and naso/oropharyngeal exam should be performed. A general physical overview, searching for evidence of systemic coagulopathy is warranted.
Because posterior epistaxis patients are at greater risk for morbidity and mortality, lab evaluation is often appropriate. This should include hemoglobin and hematocrit, blood type and screening for a possible transfusion, INR/PTT, and any other baseline lab as indicated by the patient's underlying comorbidities. Finally, an intravenous line should be established.
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