Ear, Nose and Throat - U.S.A.  (ENT USA) Epistaxis - Nasal Bleeding
Nose Bleeds - Epistaxis
Treatment of Nose Bleeds and Epistaxis
   
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Nose Bleed - Epistaxis

 
One of the most common problems an individual may develop is a nose bleed (epistaxis). In the child nose bleeds are usually the result of nasal drying but in the adult they may be a warning sign of high blood pressure.  Rarely, nose bleeds may be the presenting sign of a bleeding problem, a nasal growth or cancer, or even leukemia. Thus, any nasal bleeding which persists, recurs, or is severe needs to be evaluated by a doctor.         Search PubMed for Epistaxis   

   View Nasal Cautery Video #1         View Nasal Cautery Video #2 

 

  

In children, many doctors feel that nasal drying is a common cause of nose bleeds. 
Nasal drying is common in the winter during cold dry weather and in the summer with air-conditioning.  If due to nasal drying, nose bleeds can sometimes be prevented by placing KY Jelly about 0.5 inches into the nose using a Q-tip. This should be done two to four times a day. Placing a humidifier in the home will also help. However, this will also promote the growth of molds and other allergens. Do not use Vaseline.  Vaseline is petroleum-based and thus will dry, not moisten the nose.

However, children with nose bleeds will often have a wet nose from a
rhinitis (inflammation of the inside of the nose).   The inflammation from the rhinitis promotes vascularization (blood vessel growth) in the anterior part of the nose.  These vessels are usually prominent and bleed easily.   Treatment of the allergy with antihistamines or Astelin nose spray will often eliminate the nose bleeding. 


If the bleeding does not stop, nasal cautery may be required.  There are two types of cautery which are commonly used, chemical cautery using silver nitrate and electrocautery.  The picture on the right shows a septal bleeding point being controlled with silver nitrate cautery.   Below is a link to videos demonstrating electrocautery of a bleeding point on the nasal septum

Silver Nitrate Cautery of a Nose Bleed

   
 
 


Do not use
steroidal nose sprays in the treatment of nasal allergies associated with nose bleeding since nasal steroids can make the bleeding worse.

In adults, nose bleeding may be severe. It can be
anterior but often is posterior
or from the back of the nose.  The bleeding is usually associated with high-blood pressure.

Posterior Nose Bleed
This picture shows a
posterior nosebleed (epistaxis).  This type of nosebleed usually occurs in adults with high blood pressure.  Note the blood coming  out from under the middle turbinate.

Anterior Septal Vessels - Kiesselbach's Plexus
This picture shows prominent
anterior (up-front) septal vessels which will bleed easily.  This type of nosebleed (epistaxis) usually occurs in children.

Large posterior nasal vessel which can cause nose bleedingThe picture on the right shows blood vessels in the back part of the nose.  It is not hard to imagine that these vessels could easily start to bleed.  Larger vessels deep to the smaller vessels shown can rupture and cause severe bleeding.




The pictures below are from a 45 year old patient with a minor but bothersome nose bleed.  The nose had an
anterior  pack placed with did not control the bleeding.  Nasal endoscopy found a bleeding source high up and deep in the nasal cavity.  Since there had been no active bleeding for 24 hours Gelfoam packing was placed.  Gelfoam is an absorbable packing which does not need to be removed.  It also promotes clotting. 
  

To view video of placement of a Gelfoam nasal pack click on button:      

Posteror Nose Bleed  Gelfoam Packing of a Posterior Nose Bleed  Gelfoam Packing of a Posterior Nose Bleed
Mouse Over Picture to Label Structures


The two patients below have a solitary bleeding point on the anterior nasal septum.   Click on the pictures to enlarge:
 
Epistaxis caused by a bleeding point on the nasal septum.The picture on the left shows a nipple like structure which has a central blood vessel, located on the mid
nasal septum .  This patients also smoked two packs per day for fifty years and has a chronic rhinitis with very dry nasal mucosa
.


        
   View Nasal Cautery Video #1         View Nasal Cautery Video #2 

 

 


Nose bleed caused by a ruptured vesses on the anterior nasal septumThe picture on the right shows an elevated collar of the
nasal mucosa round a small central ulcer located on the anterior nasal septum.  The mucosa is trying to heal over the bleeding point, but the bleeding point keeps breaking through the mucosa.  This forms a small volcano-like structure.









  
Treatment - First Aid:  If the nose is actively bleeding, pinch the nostrils and lean forward.  If you do not have hypertension or diabetes, you may want to try to use a
nasal decongestant nose spray.  These nose sprays constrict blood vessels and will sometimes stop bleeding. Since, nose bleeding in children often occurs in the front part of the nose, moistening a piece of cotton with a decongestant nose spray and placing it in the front part of the nose may also stop the bleeding.   In children, nose bleeds may be caused by the inflammation produced from an allergic rhinitis.  Treatment of the allergy with antihistamines or Astelin nose spray will often eliminate the nose bleeding. 

In adults, nose bleeding may be severe. Often caused by high-blood pressure. Decongestants should be used with caution since they  may aggravate existing high-blood pressure.  Prescription steroidal nose sprays can over time thin the lining of the nose and cause nose bleeding. These medications should be discontinued if bleeding develops. Oral antihistamines or Nasalcrom should then be used to control the allergic symptoms. 

Treatment - Medical:  The treatment of severe nasal bleeding in the adult can be very difficult.  Repeated nasal packing is sometimes required.  Nasal cautery can control the bleeding but only if the bleeding point can be seen either directly or with a fiberoptic endoscope.  Often the bleeding site is in the back of the nose, hidden within the many sinus passageways.  In this case, only nasal packing or ligation (tying off one of the nasal arteries) can be used to stop the bleeding.  Nasal packs are usually left in the nose for a minimum of three days.  Antibiotics should always be given to prevent toxic-shock syndrome.  

Nasal packing used to control nose bleedsNasal tampon used to control nose bleedsThere are two types of
nasal packs:  1) An anterior pack which is placed in the nasal cavity.  An anterior pack may be made of cloth or a nasal tampon.  If the bleeding is severe a nasal balloon can also be inserted.  However, nasal balloons can exert a significant amount of pressure and damage to the inside of the nose from pressure necrosis may take place.  The pictures on the right shows a tampon pack and 1/2" gauze which can be used as an anterior pack.

2) A
posterior pack refers to a large pack which is placed in the nasopharynx and is used to completely plug the back part of the nose.  (note it is NOT the small gelfoam pack placed in the above video.)   An anterior pack is always placed with a posterior pack.  Posterior packs have been associated with breathing complications (even strokes and heart attacks caused by lack of oxygen at night) and are difficult to place and very uncomfortable for the patient.   For this reason, many patients will want to have one of the nasal arteries ligated instead of having the placement of a posterior
pack.

Nasal Alar Necrosis from Placemnt of a Posterior PackIf a nasal pack is placed too tight, it can cause tissue death and scaring.  This complication is most commonly seen in inflatable balloon packs and in posterior nasal packs.  To the right is a picture of a nose which has a through and through area of tissue necrosis on the lower part of the right nose.  The patient had a tight balloon pack which had a clamp on the outside to hold the pack in place.  The clamp was next to the skin and prolonged pressure caused the skin and underlying tissue to die. 
 
 

 

   


    
   

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