by Dr. Christopher Chang, last modified on
Epistaxis (also known as nosebleeds) which can happen at any time, most often occurs when the air suddenly turns cold and dry, especially in the winter season. The source of the nosebleeds usually is in the very front of the nose on the septum where the air entering the nose is at its most dry state. The septum is a wall that divides the right and left nasal cavities. Note that epistaxis is a particular problem in individuals with a deviated septum (correctable by a surgical procedure known as septoplasty) due to turbulent nasal airflow which creates a further drying effect (click here to read more about this situation). Sinus infections and allergies may also exacerbate nosebleeds.
What do I do if I have a nosebleed?
(To watch how cauterization or nasal packing is performed for nosebleeds, skip to below to watch videos.)
Pinch your nose firmly NOT over the bone, but just below it as shown below. One should keep the nose pinched for at least 10 minutes as that is how long it takes to create a scab. Should this measure fail, using a nasal decongestant such as Afrin may help before pinching the nose for another 10 minutes.
What do I do after a nosebleed?
There are some conservative measures one can try first before going to see a physician.
- NO nose-blowing for at least 2 weeks (blowing the nose just rips the scab off causing it to bleed again). It is OK to dab at the nose or gently pinch the nose to milk out secretions.
- NO nose-picking which may also rip scab off resulting in bleeding.
- Sneeze out the mouth (do NOT sneeze out your nose).
- If at all possible and medically safe, stop taking any blood-thinners you may be on including aspirin, ibuprofen, coumadin, eliquis, plavix, etc.
- Check your blood pressure to ensure it is not too high. If it is, contact your primary care doctor. A high blood pressure exacerbates any nosebleed.
- Keep a humidifier going in the bedroom with the door closed to raise the ambient humidity. Saline flushes may be helpful as well if significant crusting is a problem.
- Use a nasal emollient like ponaris (akin to chapstick for dry cracked lips, but made for the nose). This product is highly recommended. Watch video on how to use ponaris.
- Alternatives to the nasal emollient include:
- Gently apply a saline or other oil-based gel (ie, Nasogel, vaseline, or equivalent) around the inside entrance of your nose with the pinky finger 3 times per day. Make sure you apply far enough deep into the nose otherwise this method may not work (typically, at least up to the first knuckle of the pinky finger).
- Use a saline nasal spray every 2 hours to keep things moist in the nose. If the nasal mucosal lining is chapped, this treatment will not work.
- Use a nasal decongestant (ie, Afrin) for no more than 3 days. Do NOT use for more than 3 days due to risk of addiction (rhinnitis medicamentosa)
- Other products to help with nosebleeds shown here.
What options can our physicians provide for epistaxis?
- Silver nitrate cauterization or electrocauterization. May need to be repeated up to 3 times spaced 2 weeks apart (see below for more info and to watch videos). Keep in mind this method does not work very well if your blood is thinned out with medications.
- Nasal packing (see below for more info).
- Prescribing Premarin cream, especially to females, which causes hypertrophy of the nasal mucosa and recession of superficial blood vessels.
- Surgical treatment (septoplasty, surgical cauterization, interventional embolization, etc).
- Studies (CT/MRI scans, nasal endoscopy, etc to look for more sinister causes of nosebleeds).
When all these options have failed or is contraindicated, a procedure called embolization can be performed of the vessels going to the nose. Embolization is when a catheter is threaded from an artery in the groin to the face where arteries going to the nose are deliberately clotted off preventing blood flow and hopefully permanently stopping the nosebleed from the inside (rather than outside as with cauterization or nasal packing). This procedure is performed by an interventional radiologist.
What are the differences among the different methods of epistaxis control?
Silver Nitrate Cauterization: This method uses a chemical called silver nitrate to create a superficial burn to the nasal lining where the bleeding is coming from. The silver nitrate is found on the tip of a wooden stick and rolled over the affected nasal lining after application of local anesthesia. Read the chemistry behind this.
- Pros: Reasonably effective for mild nosebleeds due to superficial capillaries. Can be done in the office with minimal discomfort. Children as young as 5 years tolerate without difficulty.
- Cons: Of all the different methods, this procedure offers the lowest chance of stopping a nosebleed. Does not work very well if a patient is taking blood thinners. Minimally effective for a nosebleed due to an arteriole. May cause upper lip staining (can't be washed off easily, but is temporary and usually fades away in about 5-7 days).
Electrocauterization: This method uses electricity to create a burn not only to the surface lining (as found with silver nitrate cauterization), but also deeper underneath the lining to create a more thorough burn and therefore scarring. This can be done after local anesthesia as well.
- Pros: Greater chance of nosebleed control compared to silver nitrate cauterization due to a deeper burn.
- Cons: Much more painful. May require general anesthesia in the operating room for comfort reasons. Does not work very well if a patient is taking blood thinners.
Nasal Packing: This method is when a tampon like device is inserted into the nose to exert continuous pressure over the site of bleeding. With continuous pressure, the blood vessels "collapse" and hopefully remains that way preventing future bleeds. The longer the packing stays in, the less the chance that a repeat nosebleed will occur. Ideally, 5 days of packing is optimal though 3 days is often sufficient. Click here to read more about nasal packing.
- Pros: Offers the best chance of nosebleed cure that does not require further intervention.
- Cons: Uncomfortable. Packing can be seen on the face.
Surgery: This invasive method is performed under general anesthesia whereby the nasal lining is lifted away and blood vessels cut. Typically, the surgery performed is called septoplasy since a septal deviation is also the basic reason why nosebleeds occur (read more on this here).
- Pros: Offers the best chance of long-term cure if anatomic deformities present.
- Cons: Highly invasive. Can only be performed under general anesthesia in the operating room. Usually about 1-3 weeks of recovery. Reduced effectiveness if a patient is on blood thinners.
Interventional Embolization: This invasive procedure attempts to stop bloodflow to the nose by blocking up the blood vessels. This is accomplished by threading a catheter in the groin up into the nasal area. Once the catheter is in position, material is injected into the blood vessel causing it to clot off thereby stopping bloodflow.
- Pros: No packing or surgical recovery required. Offers best chance to stop a nosebleed if nasal packing fails, especially if patient is also on blood-thinners.
- Cons: Highly invasive. Small risk of stroke present. This method will not work if nosebleed coming from the ethmoid arteries.
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