A 68-year-old man with hypertension (BP 160/95 mmHg) and on aspirin for coronary artery disease presents to the emergency department with brisk epistaxis from the right nostril for the past 2 hours. Anterior rhinoscopy reveals bleeding from the anteroinferior part of the nasal septum. After initial first aid measures fail, you proceed with cauterization. Which of the following is the MOST appropriate cauterizing agent for this patient?

Explanation

## Cauterization in Anterior Epistaxis **Key Point:** Silver nitrate is the gold standard cauterizing agent for anterior epistaxis, particularly in Little's area (Kiesselbach's plexus) on the anteroinferior nasal septum. ### Why Silver Nitrate? **High-Yield:** Silver nitrate (AgNO₃) stick (75–90% concentration) is preferred because: - Produces rapid chemical cauterization via protein denaturation - Creates a stable eschar that seals bleeding vessels - Safe for intranasal use with minimal systemic absorption - Effective even in patients on antiplatelet therapy (aspirin) - No significant contraindications in hypertensive patients ### Cauterization Agents Comparison | Agent | Mechanism | Indication | Limitation | |-------|-----------|-----------|------------| | **Silver nitrate** | Chemical cautery | Anterior epistaxis (Little's area) | Requires careful application; staining of mucosa | | Potassium permanganate | Oxidative cautery | Rarely used in modern practice | Weak hemostasis; not standard | | Hydrogen peroxide | Mechanical + oxidative | Topical hemostasis only | Temporary effect; not for cauterization | | Ferric chloride | Protein precipitation | Dental/surgical use | Not approved for intranasal use; risk of systemic absorption | ### Clinical Application **Clinical Pearl:** In this patient: 1. Anterior epistaxis from Little's area (anteroinferior septum) is the most common site (~90% of cases) 2. Silver nitrate stick is applied directly to the bleeding point under visualization 3. The cautery is held for 10–15 seconds to allow eschar formation 4. Aspirin use does NOT contraindicate cauterization; it is a local intervention 5. Hypertension should be controlled post-cauterization to prevent re-bleeding ### Technique 1. Anesthetize and vasoconstrict the nasal mucosa (lignocaine + epinephrine or cocaine) 2. Identify the bleeding site under good illumination 3. Apply silver nitrate stick directly to the vessel for 10–15 seconds 4. Pack the nose if needed (though cauterization alone often suffices) 5. Advise patient to avoid nose-blowing and hot foods for 24 hours **Mnemonic:** **SILVER** = Safe, Intranasal, Local, Vessel-sealing, Effective, Reliable [cite:Dhingra 8e Ch 6]