What are the indications for cauterization in the management of epistaxis, and how should it be performed?

Indications for cauterization in epistaxis management:

• Cauterization is considered when bleeding does not stop after 10–15 minutes of applying nasal pressure.
• It should be performed if the bleeding point can be clearly identified, typically within Kiesselbach's plexus, appearing as a small red dot less than 1 mm, even if not actively bleeding.
• The procedure is suitable for adults and older children who can tolerate it, but not recommended for younger children under 4 years old.
• Appropriate expertise and facilities must be available, including good lighting, topical anaesthetic spray, and a nasal speculum.

Recommended procedure for performing nasal cautery:

• Ask the patient to blow their nose to clear clots, which may restart bleeding.
• Apply a topical local anaesthetic spray combined with a vasoconstrictor (e.g., lidocaine with phenylephrine such as Co-phenylcaine®) and wait 3–4 minutes for full effect.
• Identify the bleeding point precisely to avoid excessive tissue injury.
• Lightly apply a silver nitrate stick to the bleeding point for 3–10 seconds until a grey-white colour develops.
• Only cauterize one side of the nasal septum to prevent septal perforation and avoid touching non-affected areas such as facial skin.
• After cautery, dab the area with a clean cotton bud to remove excess chemical or blood.

This approach is recommended as first-line treatment over nasal packing due to better tolerance and effectiveness, despite low-quality evidence supporting it.

Patients should be advised to avoid activities that increase re-bleeding risk for 24 hours, such as nose blowing, picking, heavy lifting, strenuous exercise, lying flat, and consuming alcohol or hot drinks.

If bleeding restarts and does not respond to first aid, urgent medical advice should be sought.

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