Having an occasional bloody nose (epistaxis) is a fairly common event. It is even estimated that up to 35% of all people will seek medical attention for a bloody nose at some point in their life. Luckily most episodes of epistaxis are short-lived and resolve with either no treatment or very simple treatment such as applying localized pressure for a few minutes. Commonly, these types of events occur with some sort of identifiable cause- for example, trauma or exposure to a very dry environment. However, occasionally epistaxis becomes frequent or does not stop with simple treatments and requires treatment by a specialist even if it is just because it has become a social nuisance.
Dr. Jerome Hester is a San Francisco Bay Area ear, nose, and throat specialist with decades of experience and he obtained his training in Otolaryngology/Head and Neck Surgery at Stanford University. He takes a comprehensive approach with every patient for the best level of care, always assessing the entirety of the symptoms and performing a thorough anatomic inspection of the nasal passages and sinuses as well as a complete history of the individual’s symptoms in order to create a personalized treatment plan. As mentioned, these symptoms can be signs of a chronic sinus infection.
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The reason epistaxis is such a common problem can be traced to the anatomy of the nose, particularly the anterior septum- the wall that separates the nose into right and left compartments. This anatomical design is there for a reason. One of the major roles of the nose is to heat and humidify the air that we breathe in. The body’s best heating system is the fact that our core temperature itself is around 98.6 degrees Fahrenheit. The anterior portion of the septum has a large collection of blood vessels (called Kiesselbach’s Plexus) under a thin layer of skin (mucosa). Therefore, any air entering the nose is in very close proximity to the warm blood in these vessels. However, this also means that if the thin mucosa is violated in any way, the vessels are then exposed and can bleed.
The most common cause of bloody noses, especially in the pediatric age group is “digital trauma”- picking one’s nose. Repeatedly picking at this site not only is a social issue, but can cause the mucosa to wear down and chronically expose the collection of blood vessels underneath leading to recurrent bleeding episodes.
Dry conditions with low humidity can cause this area of the nose to dry and crack much like skin in other parts of the body. This can be a problem even in the winter as more time is spent indoors and the heating system is used to keep us comfortable. Without the use of a humidifier, this produces a very dry environment.
Various medications, both prescription and over the counter can have the unwanted side effect of increasing the risk of epistaxis. Topical decongestant nasal sprays as well as those sprays used for allergies can irritate the lining of the nose and cause bleeding. This is especially true if they are used on a chronic basis, or used more frequently than recommended. Over the counter pain medications such as aspirin and ibuprofen cause problems using a different mechanism. Instead of directly damaging the lining of the nose, these medications can make the patient’s blood not clot as well. In this case, a small area of irritation inside the nose can be more likely to bleed and take longer to stop bleeding due to this side effect. Finally, there are some medications prescribed specifically to “thin” a patient’s blood to prevent unwanted clots from forming in the body. These will however also make it more difficult for the body to stop bleeding if a nose bleed were to start.
Any illicit drug that is taken through the nose can also lead to an increased risk of nose bleeds. This can be due to the exact action of the drug itself, or by damage to the lining of the nose from other chemicals that can be added to the drug.
Finally, certain medical conditions can be a factor. For example, if the septum itself is significantly crooked (a “deviated” septum) the turbulent airflow that then occurs can cause localized drying and trauma to the septum and lead to epistaxis.
Certain abnormal growths, both cancerous and benign, can also bleed. The diagnosis of such lesions requires a thorough exam by a specialist.
Finally, disorders that cause abnormal growth of blood vessels, such as Osler-Weber-Rendu (also known as Hereditary Hemorrhagic Telangiectasia) are rare but can cause very serious recurrent epistaxis. Once again, the diagnosis requires an expert in the examination and knowledge of these types of disorders.
Treatments for Epistaxis
Treatment of an Acute Nosebleed
During an acute nose bleed, the most effective treatment is to apply pressure on the area that is bleeding. As was discussed previously, most cases of epistaxis occur at the front part of the septum. To apply pressure to this area, one simply pinches the soft part of the nose between the thumb and forefinger. It is important to keep constant pressure there for at least 5 minutes. A common mistake is to hold pressure for a short period of time – for example – 30 seconds- then release pressure to “take a look.” This does not allow enough time for a clot to occur. Likewise attempting to put pressure over the bridge of the nose will not be effective as it is not possible to compress the bones in this area, and therefore no pressure is placed on the area that is bleeding. If the patient wishes to sit down, especially if they feel lightheaded, that is appropriate, however, one should not put one’s head between your knees or in any other dependent position as this will increase the amount of blood in the head and increase bleeding. If excessive bleeding continues despite this treatment or if the patient has other complicating factors such as chest pain, emergency care should be summoned by calling 911.
If pressure does not control the bleeding and there is not a medical emergency present, further treatments can be initiated by an expert. The placement of packing would be the next step. Packing is a material that can be placed in the nose to increase the pressure on the area that is bleeding. This can be gauze or other materials which are then removed after a few days, or one of several dissolvable devices that slowly soften over a few days that they can be rinsed out of the nasal cavity. The physician may also cauterize the spot if the exact spot of bleeding can be visualized. Dr. Hester may use small endoscopes to examine the nose to find this source. That then allows him to use chemicals (such as silver nitrate) or heat energy to close the wound and stop the bleeding. In difficult cases, both cautery and packing can be used.
Finally, in very serious cases, the artery supplying the vessels involved may need to be treated. Interventional radiologists use X-ray guidance and the placement of a small coil inside the artery to occlude it and stop the bleeding. Although this can avoid surgery, it must be performed in an institution that has the equipment and doctors trained in this field. The alternative is to surgically find the artery and ligate (tie it off) it. This procedure is reserved for the rare case of epistaxis that cannot be treated more conservatively.
Treatment for Chronic Epistaxis
The vast majority of cases do not require aggressive treatment. Rather, they may reoccur causing social issues. In these situations, primary treatment includes moisturizing the offending area and eliminating any chronic trauma to that region. The use of petroleum jelly or any moisturizing protective creams or ointments once or twice a day is usually very helpful to allow the skin over the exposed blood vessel to heal. If one’s indoor environment is dry common when the use of heating or air conditioning is prevalent, the addition of a humidifier at least by the bedside can also helpful.
Along with moisturization, the avoidance of trauma is necessary to allow an area to heal. This is most commonly a problem in youngsters when constant “picking” at the area compounds the issue. However, even adults must sometimes be reminded not to constantly touch an area that is trying to recover.
As was mentioned above, various drugs, both therapeutic and illegal can cause chronic epistaxis. Avoidance of these medications where possible, especially if an alternative can be safely suggested by one’s physician, is the best solution. If not, the use of moisture can sometimes combat the side effects.
Minimally Invasive Treatment
Dr. Hester will review your history looking for causes and perform a complete examination to identify the site of bleeding. Commonly the site can be identified. In this case, cauterization can be performed. Silver nitrate is a chemical compound that causes the surrounding tissue to liquify and essentially form a cap over the identified blood vessel. This “cap” lasts a few days much like a scab. If left undisturbed, it will allow healthy tissue to grow over the vessel, stopping the bleeding. This is a procedure that can be performed in the office without even local anesthetic and results in only a temporary mild stinging discomfort. Afterward, the patient can return to normal activities with only minimal limitations and instructions to keep the area moist for a few days. This simple technique can also be safely repeated if the problem recurs.
Cauterization can also be performed that uses an external energy source such as heat to coagulate the area and again allow new tissue to ultimately grow over the vessel. In the office setting the most common technique is the use of electrocautery. This is the most common method that surgeons use in the operating room to stop bleeding and is very effective. However, due to the heat energy being delivered, it can be mildly uncomfortable. Typically, the application of a liquid local anesthetic on a small piece of cotton is placed over the area to be treated. The cauterization only takes seconds, and although uncomfortable, is usually tolerated well. If there are concerns regarding the procedure, mild sedation can be used. Once again, the patient is able to return to essentially normal activity immediately although in cases with a history of more significant epistaxis, they may be advised to avoid vigorous exercise for a few days.
Finally, for conditions such as Hereditary Hemorrhagic Telangiectasia, various types of lasers may be used to cauterize. A specific light energy wavelength is chosen to obtain the best results of cauterization with minimal damage to surrounding tissues. This is important in this type of disorder due to the fact that the areas causing epistaxis may be much more diffuse.
As described previously, placing a device or material inside the nasal cavity to apply pressure on the area which has been bleeding is known as “packing.” Packing, whether it consists of material that dissolves or needs to be removed after a few days, is more commonly a treatment for an acute episode of epistaxis rather than a treatment for the chronic condition.
Correction of a deviated septum (Septoplasty)
Although a septoplasty is more commonly performed to straighten the septum and therefore provide improved breathing (see nasal obstruction), if it is felt the deviation is leading to an area of drying and subsequent bleeding, surgery to correct this may be recommended. The surgery itself is performed through the nasal cavity without external changes in the appearance of the nose and has the patient back to normal activity in a few days.
In chronic conditions where the frequency or severity of the bleeding is considered serious enough, the larger blood vessels supplying the area can be identified and ligated by placing a suture or a clip around the vessel which stops the blood flow. Many times, this surgery can be performed using a small endoscope to visualize the area without any significant incisions. Care is taken to identify the site on the blood vessel that will stop the epistaxis without causing a lack of blood flow to other areas.
An alternative to arterial ligation is embolization. Embolization is the placement of a small device to block blood flow from the inside of the vessel, similar to a clogged water pipe. This procedure is typically performed by a specialist (interventional radiologist) who is trained to be able to thread a small catheter through a blood vessel and then by using a real-time X-ray, find the spot that is bleeding and placing the “plug” at this site. This procedure can avoid a surgical incision, but does need to be performed at a medical center that has both the technology and specialist to perform it safely.
Epistaxis can be worrisome when the cause and location of the problem are not known. Dr. Hester has decades of experience in not only identifying the answers to these questions through taking a thorough history and performing a complete examination but also in outlining for you the appropriate treatment choices to solve your epistaxis.
Improve Your Quality of Life with Freedom from Nosebleeds
Epistaxis can be a chronic condition that dramatically affects one’s quality of life. Dr. Jerome Hester can perform a complete evaluation of your nasal and sinus issues and then provide a detailed description of all treatments that are available. Together, we can find the option that is right for you.