by Robert Adelson, MD, FACS
Nosebleeds, or epistaxis, is a remarkably common and particularly vexing condition for the Otolaryngologist. There is a 60% lifetime incidence of epistaxis and, amongst this group of patients, about 6% will seek medical attention for bleeding. Almost 1% of all visits made to an Emergency Department are for the treatment of epistaxis, making bleeding from the nose the most common condition for which an Ear Nose and Throat doctor will be urgently consulted. Epistaxis occurs most commonly when patient risk factors such as high blood pressure, prominent blood vessels, and the use of aspirin and other blood thinning medications are combined with environmental features that challenge the normally moist lining of the nose. Periods of low humidity, cold weather, and the use of forced air heating can dry the lining of the nose in much the same way that lips become during the winter. Dry nasal mucosa is more susceptible to small insults from blowing of the nose, forceful sneezing and digital manipulation of the nostrils with resultant minor trauma to the nasal mucosa and bleeding from the well-vascularized nasal lining. While nosebleeds are unfortunately common and highly concerning to both the patient and physician, they are also treatable and preventable.
What Can You Do?
The most important method of treatment for epistaxis is prevention. Humidification and moisturization of the nasal passages is the best defense against episodes of nasal bleeding. When nasal mucosa is moist it is less likely to develop small cracks and ulcerations in response to minor insults, and therefore less likely to bleed as a result of sneezing and forceful blowing of the nose. The generous use of nasal saline sprays should be considered during the cold and dry months of the year, and particularly when indoor heating further decreases humidity. Patients can consider using a humidifier in the room of their home during which they spend the most time and typically this involves running the humidifier in the bedroom while sleeping. Most directly, the use of intranasal moisturizers can help speed the process at the very front of the nose, which is the most common site of bleeding and an area of the nose that receives air at its coldest and driest moment during inhalation. I typically recommend lanolin nipple care cream (used by breast feeding mothers) as this widely available, safe to use in the nose, and not prone to dripping. Ponaris Oil and other over-the-counter nasal moisturizers are available and patient preference largely dictates the choice of emollient. Applying a marble-sized amount to the front of the septum every night is helpful in lubricating the area.
Despite careful prophylactic treatment and good blood pressure control, some patients will continue to experience nosebleeds. Should you develop a nosebleed, the initial step in management is to spray the nose with Afrin (oxymetazoline ) or to apply a generous amount of the same over-the-counter medication to a cotton ball, place the cotton ball inside the bleeding nostril, and then apply very firm pressure to the flexible portion of the nose for at least 5 minutes. Bleeding that persists after this treatment should be investigated by a physician, and on an emergency basis if the bleeding does not stop with this intervention.
How an Otolaryngologist Can Help
There is a step-wise approach to treating cases of epistaxis that persist despite good preventive measures, and this typically involves examination of the nose with a small fiberoptic scope in the office setting. At the same office appointment, prominent blood vessels within the nose can be treated with cautery techniques under local anesthesia. While this is usually successful, more than one cauterization procedure may be required to achieve a complete cessation of bleeding. Further episodes of bleeding that cannot be diagnosed or treated in the office may be addressed under anesthesia, using a more compete examination with endoscopic equipment and potentially the use of lasers or other energies to treat malformed or enlarged nasal blood vessels. Finally, there are instances of severe bleeding from the nose that require more aggressive measures, such as the placement of nasal packs to apply pressure and tamponade the flow of blood. While the use of such nasal packs for 3-5 days was quite common in the past, more modern approaches to the management of nosebleeds use these uncomfortable packs only as an emergency temporizing measure. After a patient’s bleeding has been stopped with a pack, the patient is offered endoscopic surgery using specialized sinus equipment placed through the nostrils and without any skin incisions that allows the identification and ligation of the large blood vessels deep within the nose that are responsible for about 90% of the blood supply to the nasal mucosa. Clipping these blood vessels is akin to “clamping off” 90% of the flow to the nose, and has a reported success rate between 85-100,% with less than 1% requiring revision surgery for epistaxis.
This graduated and conservative approach to the prevention and treatment of nosebleeds provides more effective and less invasive treatment with higher success rates and a reduced need for procedures under general anesthesia. When severe or recurrent bleeding occurs, the ability to avoid packing of the nose by instead using endoscopic equipment to selectively ligate blood vessels deep within the nose offers patients highly targeted surgical options with greater success rates and less pain, inconvenience, and cost when compared to the traditional techniques.