Epistaxis – or everything you ever wanted to know about nosebleeds

It is winter and to my practice that means several daily calls with the complaint of nosebleeds, otherwise known as epistaxis. It is truly amazing how much blood can come out of a person’s nose. Perhaps, amazing is not a word most people would use to describe it. Words like scary, terrifying, alarming may be more appropriate. This is what I remind myself whenever I see a patient with a bleeding nose. They are scared. They want the bleeding to stop, and they want to make sure that the nosebleed is not an indication of “something more serious.” My job is to provide reassurance and make them feel at ease, while I begin my investigation – the same series of questions I ask each one of them. They are memorized: 

1. When did the bleeding start? 
2. Which nostril?
3. How long does it last?
4. Any bleeding from the mouth?
5. How often do you bleed?
6. What do you do to make it stop? 
7. When was the last episode? 
8. Are you on any medications or supplements that could then your blood?
9. Any family history of bleeding disorders?
10. Any easy bruising or bleeding gums?
11. Do you have allergies and need to blow your nose often? 
12. Any difficulty breathing through one or both nostrils?
13. Do you use any allergy nasal sprays?
14. Have you ever required nasal packing or blood transfusion because of a severe nosebleed?
15. What ‘home remedies’ have you tried for prevention?

There may be additional follow through questions based on the answers to above.  However, most of the time this list results in a thorough history and gives clues as to why the nosebleed started. 

Examination will include a complete head and neck examination with detailed focus on the nose, using a nasal endoscope. An endoscope allows ENT docs to fully evaluate the internal anatomy of the nasal cavity and the entry points into the nasal sinuses and skull base. The majority of the time an endoscopic exam reveals the source of bleeding to be the nasal septum. This structure, which divides the right from left nasal cavity, is made of cartilage and thin bone with surface lining on each side called mucosa. The nasal septal mucosa is a sensitive and powerful anatomical structure with a rich supply of blood. The multiple veins, venules, arteries, arterioles, and capillaries create a lattice of intricate vascular anatomy. These vessels are responsible for bringing nutrients and oxygen to the nasal septum. They are also the main culprits behind a nosebleed.

Bleeding capillaries tend to be the most common offenders.  Fortunately, these bleeds are brief and not very severe. On the other hand, arterial nosebleeds are rare, usually due to trauma or even surgery, but often require an intervention like nasal packing or surgery. Venous bleeding is much more common than arterial bleeding, and because it can be persistent, it is the most common etiology that results in a visit to the doctor’s office.  It can range from self limiting to severe enough to require an intervention.  Luckily, most of the time that intervention can be done in the office and will not require packing or surgery.

One of the most common and effective methods to stop a nosebleed is via cauterization.  Your doctor will use a chemical called silver nitrate to “burn” the offending vessel. This cauterization results in the destruction and devolution of that blood vessel.  Further wound care will ensure that the septum will heal without that vessel causing further issues.

Occasionally the patient may require placement of a material inside the nose to tamponade the bleeding. This packing can be absorbable or removable. The comfort or discomfort of the nasal packing is directly proportional to its size. Absorbable packing is less painful. Therefore, smaller absorbable packing is always preferred. 

Regardless of the severity of the bleeding, there are multiple solutions and treatments.  Despite this reassuring fact, it is common for patients to ask, “why did this happen?”

The reasons behind nosebleeds are important to recognize, as that knowledge will result in the best treatment of all: prevention. The most common reason for a nosebleed is trauma to a dry nasal lining. Trauma can be injury, aggressive nose blowing, nose picking- euphemistically called digital trauma in your doctor’s note. Dry nasal passages can result from climate, environment, and drying medications, or a history of radiation therapy.  Add trauma to that in the setting of use of a “blood thinner”, a medication that slows down clotting, then you have the triad for epistaxis. A patient on baby aspirin with severe allergies during the winter is the ” typical” nosebleed patient.

Understanding all of this can give us a clear blueprint for prevention.

1. Combat dryness by limiting medications that can be drying to the nose. If you need to use these medications, such as nasal steroid for allergies, then use them as prescribed. 
2. Nasal saline sprays are an easy way of adding moisture to the nose. A nasal saline gel is a better option. Surgical lubricants like KY Jellyare an excellent way to add a high volume of moisture without drowning in nasal saline.
3. A humidifier during the winter can be a great way to help with the environmental factors.
4. Blood thinning medications can be stopped under the supervision of your prescribing physician.  However, these medications are commonly given in patients with cardiac risk factors or for stroke prevention. Therefore, it is always preferable to continue the medications and focus on the other prevention tips or treatment of the nosebleed.

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There you have it. The longest piece of writing you will ever have to read about a bleeding nose. Hopefully, it provided some guidance and insight. It does not, however, replace being evaluated and treated by your ENT doctor in person.

Tags: nosebleeds, epistaxis