epistaxis

Steven M. Houser MD
Rhinology/Allergy pages

Epistaxis or Nose bleeds

Epistaxis, or nose bleeds, can have many causes (e.g., dry mucosa, tumors, allergy, sinus disease). In most instances it is due to drying and cracking of the nasal mucosa. The drying may occur at one site more than another if a septal deviation is present: airflow over a deviation will preferentially dry one area and lead to bleeding. The following advice is what I ask patient to do after I have examined them and determined that their bleeding is due to dry mucosa, and not due to some more dangerous disease process. Note that most epistaxis is benign and originates in Little's area within the nose: the anterior confluence of vessels.

How to keep your nose moist to avoid nosebleeds:

1) Humidifier
A warm mist humidifier is the best, as it heats the water to form steam; bacteria and mold are killed in the process. The humidifier is most important in the bedroom, where you will sleep for 8 hours. Humidifiers on the heater are helpful, but they are usually not enough.

2) Saline nasal spray
Use the spray 6 to 10 times per day. Keep it in your pocket when you leave home. The effects are short-lived: about 1 hour. Some common brand names are: Ocean, AYR, Proetz
Ocean spray has a removable spray tip, allowing one to refill the bottle after making new saline. To make saline: boil 1 quart water, add 1 tablespoon of salt: pickling, canning, or regular, and add 1 teaspoon of bicarbonate to reduce any chance of stinging. Let the solution cool before use!
Saline can also be delivered into the nose by sniffing, using a baby�s nose bulb-suction, or with a Grossan irrigator (a special tip for a Waterpik; about $80.00 for both the Waterpik and irrigator, call Hydromed at 1-800-560-9007 to order if interested).

3) Saline gel
Use this twice per day: morning and evening. The effects are longer: 6 hours or so. To use the gel wash your hands, place a dab on your finger, and wipe it inside your nostrils. Alternatively, you may apply the gel with a Q-tip. Then pinch your nostrils closed to spread the gel, and sniff forcefully: this will spread the gel along your septum and throughout the nose. The gel is located in the pharmacy in the over-the-counter section near the saline sprays. Some common brand names are: AYR, Nose-better-gel, Ponaris

If conservative measures do not work, then further investigation is warranted. The patient may have a bleeding disorder, sinus disease, a tumor, etc. Packing may be required to temporarily control the bleeding. Surgery may be indicated to straighten a deviated septum or to cauterize vessels. An office evaluation can reveal septal deviation, or prominent septal vessels. When cauterizing the septum only one side at a time can be done, as we risk forming a perforation if both sides are treated at the same time. Sometimes the labial contribution to the septum (Little's area) can be cauterized by retrograde dissection into the columella - this is typicall done if the vessels are low in Little's area.

In extreme cases, a sphenopalatine artery ligation may be necessary to get posterior epistaxis under control. Radiological intervention to perform internal maxillary artery embolization can also be performed.

The picture above depicts a sphenopalatine artery ligation. This procedure is done endoscopically through the nostril. The patient awakes without packing. Recovery is fairly swift, and the results, in properly selected patients, are excellent.

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