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Nosebleeds

Nosebleeds, or epistaxis, is one of the most common problems that require urgent or emergent ENT attention. Risk factors for nosebleeds include excessive nasal dryness, high blood pressure, the use of medications that impair clotting such as aspirin, clopidogrel (Plavix®) or warfarin (Coumadin®), and repeated digital trauma to the nose (particularly in children).

First aid for nosebleeds usually begins and ends with direct pressure. The head should be kept in a neutral position (not tipped back) as the soft front of the nose is firmly grasped between the thumb and forefinger for 10 to 20 minutes. The pre-treatment of the nose with topical over-the-counter oxymetazoline (Afrin®) or phenylephrine (Neosynephrine®), best applied to the front of the nasal cavity with a stretched cotton ball partially inserted into the affected nostril, can improve the results achieved with direct pressure. Over-the-counter hemostatic products such as BleedArrest® can also be helpful, especially for patients on blood thinning medications.

Patients who have bleeding that fails to respond to first aid, or who have been experiencing repeated episodes of bleeding, require the attention of an ENT physician. Methods of controlling bleeding can include cauterization of the bleeding site (best results in patients not on any blood thinning medication) and nasal packing. Patients with poorly controlled blood pressure may require medical attention in a hospital/ER setting. Nasal packing is usually kept in place for 48 to 72 hours, while antibiotics are used prophylactically.

Nasal healing from excessive dryness or after cauterization is facilitated by using nasal moisturizers such as saline nasal mist or gel (preferably the latter), while other products such as Ponaris® nasal emollient can be used as well. Topical antibiotic ointments such as Bactracin, Neosporin® or Triple Ointment can also be lightly and gently applied into the nose, especially for noses that are especially raw after packing or cauterization.

Coumadin®/Warfarin Patients: The INR test is used to measure the degree to which the medication is thinning the blood. The normal value for INR in patients on no such medication is 1. Anti-coagulated patients are generally dosed to maintain an INR in the therapeutic range of 2 to 3. This means the patient is more likely to bleed, but with an acceptably low risk for severe bleeding.

Pediatric nosebleeds are common, and usually arise from prominent veins at the front of the nasal septum near the floor of the nasal cavity. These often require cauterization in the office, with the nose being pretreated with a topical anesthetic.

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