Nosebleeds

Nosebleeds (epistaxis) is very common, so common in fact that almost everyone in the world would have had at least one episode during their lifetime. It is therefore very important to understand the basic steps to take if you have a nosebleed:

1. It’s understandably difficult, but try not to panic. Sit upright in a chair and lean forward. Apply pressure by pinching both sides of the ENTIRE SOFT part of your nose. Pinching the bone will do absolutely nothing.
2. You can spray an over-the-counter decongestant (Afrin, oxymetazoline, “12-hour nasal spray”, etc) before applying pressure. This will shrink the blood vessels and help slow or stop the bleeding.
3. Hold pressure for at least 10-20 minutes.
4. If bleeding persists after pressure, or seems too heavy and continuous at any time, call your physician’s office, an urgent care clinic, or plan to go to the emergency room.

Successful management of epistaxis is highly dependent on the underlying cause. After any sudden bleeding is controlled, all efforts should be directed at determining this. Several factors increase an individual’s risk of bleeding that should be considered, and controlled if possible:

• Nasal dryness – caused by weather, home environment, nasal sprays
• Inflammation – sinusitis, granulomatous disease (sarcoidosis, Wegener’s granulomatosis, rhinoscleroma, tuberculosis, syphilis)
• Trauma – self induced from nose picking (typically young children), facial or nasal trauma, surgery
• Tumors – benign and malignant (cancer)
• Septal abnormalities (spurs, deviations, perforations) – may disrupt normal airflow, resulting in local turbulence and persistent damage to the nasal lining
• High blood pressure – results in changes in blood vessel walls that both cause them to bleed more easily and have a more difficult time healing to stop bleeds 
• Clotting disorders – suggested by family history, easy bruising, or prolonged bleeding from prior minor injuries or surgery
• Blood thinning medications – plavix, aspirin (baby or full), Coumadin, lovenox, NSAIDS (including ibuprofen, advil, aleve, celebrex, etc)
• Chemotherapy – decreases body’s ability to manufacture new platelets
• Severe malnutrition – insufficient protein or vitamin K can result in deficiences of clotting factors.
• Liver disease – clotting factors are produced in the liver
• Kidney disease – elevated blood urea nitrogen (BUN) is a platelet inhibitor
• Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) – an inherited disorder involving formation of abnormal blood vessels that have very thin walls. These are easily damaged with even minor trauma and tend to briskly bleed.

Minor epistaxis may be of little consequence, but when frequent, can be a significant annoyance. Inconvenience or fear of bleeding in public may lead to reduced quality of life or even self withdrawal. When episodes are repeatedly heavy, blood transfusions may be necessary, particularly in elderly or already anemic patients who cannot tolerate much blood loss.

In select cases, office evaluation and management of active or recurrent bleeding is quite effective. Nasal endoscopy can help determine where exactly bleeding is coming from, and can also evaluate for abnormalities such as inflammation, septal abnormalities, and tumors including cancer. Anytime bleeding is exclusively from one side, the presence of a tumor should be excluded.

Management options can include any combination of moisturization, cautery, and packing. Some forms of packing are absorbable, meaning they do not have to be removed. Any nasal procedure is performed with topical anesthesia for patient comfort.

If these measures fail to result in improvement, you may benefit from a minimally invasive procedure to reduce the majority of blood supply to areas of the nose that frequently bleed. This procedure is termed “sphenopalatine artery ligation” and is done under endoscopic visualization.