People of all ages experience nosebleeds, or epistaxis, especially young children and older adults. In many cases, a nosebleed is not serious and can be treated at home. But some nosebleeds can be quite frequent and not readily subside with conventional therapies provided by your ENT doctor or another healthcare provider. Rarely are they a symptom of a more serious health condition, but specialized treatment is available for any kind of nosebleed.
If you experience frequent or severe nosebleeds, your primary care physician may refer you to an ear, nose and throat specialist, or an endovascular neurosurgeon – a specialist in medical issues pertaining to blood vessels – for diagnosis and treatment.
What Is Epistaxis?
Epistaxis has one obvious symptom – blood dripping from one or both nostrils. In some situations blood may also drip down the back of the throat. There are two types of epistaxis: anterior, which originates in the front part of the nose, and posterior, which occurs higher up in the nasal cavity.
Anterior Epistaxis
Anterior nosebleeds are the type that many people experience during a lifetime and that parents of small children are very familiar with. This kind of nosebleed begins in the lower part of the septum – the “wall” between the two nostrils. The septum is rich in small blood vessels, which are close to the skin and easily broken by things such as a blow to the nose or even a scratch from a fingernail.
Anterior nosebleeds are also common in dry climates or during winter, when people spend most of their time indoors in heated air. Under these dry conditions, the nasal membranes can become cracked and bleed. Crusts can form in the nose, too, causing bleeding when they separate.
This kind of nosebleed can generally be treated at home with simple steps, such as pinching the soft parts of the nose and leaning forward to keep blood from draining into the back of the throat. Some people experience a single episode of an anterior nosebleed, while others, particularly young children or elderly people, may have them more frequently.
Posterior Epistaxis
A nosebleed can also begin higher and deeper within the nasal cavity. During a posterior nosebleed, blood flows out the front of the nose or toward the back of the mouth and down the throat, even if the affected person is sitting or standing. Like the anterior kind, this nosebleed may have relatively minor causes like allergies or chemical and environmental irritants. But it can also be caused by more serious conditions such as a blood clotting disorder, a tumor in the nasal passages or sinus cavities, or certain inherited vascular disorders. People who use blood-thinning drugs such as Warfarin or aspirin may also be prone to this type of nosebleed.
Although routine first aid measures may stop a posterior nosebleed, this kind of epistaxis can cause large amounts of blood to drip down the back of the throat, even if blood stops flowing from the nose itself.
Diagnosing Epistaxis
Your primary care physician or emergency room physician is likely to refer you to a specialist who has the skills to diagnose and treat the cause of your nosebleeds correctly.
Your primary care doctor may first refer you to an ear, nose and throat, or ENT, specialist for a thorough examination of your nose and throat using instruments to view the nasal passages and the back of the throat. For further diagnosis and treatment, the ENT specialist may then refer you to an endovascular neurosurgeon – a specialist in treating conditions related to the vascular, or blood vessel, system. If a nosebleed requires hospital care, an emergency room doctor may be seeing you first and then call other specialists if the bleeding continues. Typically, an ENT doctor will evaluate the patient first and will then determine if an endovascular specialist is needed.
Diagnosing epistaxis will include performing a number of tests and taking a general health history. The endovascular surgeon will typically ask questions about your medical history and any medications you may be taking. Blood tests will be performed to diagnose or rule out any kind of bleeding abnormalities that might be contributing to the problem and to determine if your nosebleeds have caused anemia or other issues. You may also undergo imaging tests, such as a CT scan or MRI, to view the sinuses and nasal passages.
In some cases of extreme nosebleed, an angiography might be needed to precisely locate the cause of bleeding. In this test, a dye is injected into the body through a catheter, allowing doctors to view the vessels more clearly and track the flow of blood in the affected area. Because posterior nosebleeds can have many causes, these tests can help doctors make a precise diagnosis. These causes can include:
Blood clotting disorders
Diseases and disorders affecting the blood’s ability to clot, such as hemophilia, may also be underlying causes of posterior nosebleeds, but also-in the appropriate context -blood thinning medications such as Coumadin, Eliquis, Xarelto, Pradaxa and also Aspirin, Plavix and Brilinta.
High blood pressure
Hypertension can cause nosebleeds, especially in a situation called hypertensive crisis, or a sudden, rapid increase in blood pressure. Severe high blood pressure can also worsen a nosebleed that occurs from some other cause.
Tumor in the nasal cavity
Although other symptoms like headaches and persistent nasal drainage are often present, frequent or severe nosebleeds may be the only sign of a mass in the nasal cavity.
Hereditary hemorrhagic telangiectasia
Also known as Osler-Weber-Rendu disease, hereditary hemorrhagic telangiectasia is a genetic disorder that causes abnormal blood vessels to form in certain organs, the skin and the mucous membranes, including the nasal passages.
Treatment Options for Epistaxis
Depending on the cause and severity of a nosebleed, treatment options can range from relatively simple procedures designed to stop the bleeding to more complex surgical interventions.
Both anterior and posterior nosebleeds can be stopped by using basic first aid strategies like bending forward and pinching the soft part of the nose to stop the bleeding. But, when those measures don’t work or bleeding is profuse and draining down the throat, it’s necessary to seek immediate medical care. Severe blood loss can result in anemia or cardiac problems, as well as an overall decline in health. And, when blood runs down the throat, it can cause gastric symptoms, including nausea, vomiting and diarrhea.
At the emergency room or hospital, doctors will work to stop the blood flow and stabilize the patient. At this time, your nose might be packed with gauze or foam to create pressure and stop the bleeding. While in the hospital, you might see an ear nose and throat, or ENT specialist, or an endovascular surgeon, for additional treatment options.
Even after bleeding from the nose has stopped, blood can still continue to drain down the back of the throat in cases of posterior nosebleed. So, if you continue to taste blood or have symptoms of blood loss, or if your nosebleeds are frequent and severe when they do occur, it’s essential that you see your doctor.
Nonsurgical Procedures for Epistaxis
Nonsurgical procedures can be performed to stop severe nosebleeds and keep them from recurring. These include:
Nasal Packing
To stop either a severe anterior or posterior nosebleed, nasal packing can be used to apply pressure and absorb blood. In many cases, doctors can stop bleeding simply by inserting a nasal tampon or balloon that expands and puts pressure on blood vessels to help stop bleeding.
For bleeding that is severe and difficult to control, nasal packs made of gauze may be introduced through a catheter into the nasal cavity. Nasal packing is typically left in place for several days. Although packing can effectively stop bleeding, it can be uncomfortable and require medication to help with comfort.
Cauterization
Nasal cautery can be used to seal the blood vessels at the point of bleeding and promote the development of scar tissue on the site to prevent recurrences. With the use of local anesthesia to reduce discomfort, doctors apply either an electric current or a silver nitrate swab directly to the mucous membranes inside the nose.
Surgical Procedures for Epistaxis
Surgical options for treating epistaxis depend on the cause and severity of the condition, and these treatments are typically used when less invasive measures like packing and cauterizing are not appropriate, or if those procedures have been tried and have failed to stop the problem. These highly specialized and invasive procedures include:
Ligation
In some situations, doctors may tie or close off an artery that supplies blood to the nose with a clip to prevent further bleeding. This is a very specialized kind of procedure that is not routinely performed by ENT specialists. Ligation involves an incision either into the orbit of the eye or the sinus cavity so that the clips can be placed on the affected artery.
Embolization
If ligation or nonsurgical interventions are not appropriate for your situation, or if they have been tried and failed, your ENT physician may refer you to an endovascular neurosurgeon for embolization to completely eliminate the epistaxis.
Embolization is a minimally invasive procedure that involves inserting materials such as sponge particles, gel foam, metal coils or fiber into a blood vessel to completely block its blood flow. An embolization procedure is performed in a hospital setting, and it requires only a single, small incision in the large femoral artery in the groin.
Using contrast dye and sophisticated X-ray imaging, the endovascular surgeon directs a catheter through the groin incision to the site of the bleeding. Then, the surgeon threads a microcatheter through the larger catheter tube to the site. Through this catheter, sponge particles or other embolization material can be released into the affected artery. Once the sponge particles are in place, the catheters are withdrawn, and the incision is closed.
Embolization treatment for epistaxis is not permanent. The skin in the nose renews itself, and within about six weeks, all the sponge particles placed in the nose are absorbed by the body. But that time period is enough to ensure that the bleeding is permanently stopped in nearly all cases.
An embolization procedure for epistaxis takes about an hour. After the procedure, you will need to lie flat with your leg extended for four to six hours to be sure that the bleeding is controlled. Without complications, you can expect to remain in the hospital overnight for the monitoring of your groin incision and recovery of your nose bleeding. Most people go home the following day.
Recovering From an Embolization Procedure
Recovering at home from an embolization procedure takes about a week. You can expect to leave the hospital with detailed instructions on how to care for your groin incision and a set of do’s and don’ts that may include restrictions on bathing and swimming, lifting, and strenuous chores and exercise. You will gradually be able to resume normal activities and return to work or school in around five to seven days.
Managing Your Recovery
After an embolization procedure, you may be given pain medication for your incision, but no other medications specific to the surgery are needed. If you have been diagnosed with hypertension, it’s necessary to take blood pressure medications as prescribed, since excellent blood pressure control is essential to your recovery. Because blood thinning medications can contribute to epistaxis, they are usually discontinued when the bleeding starts. But, if they are needed, they can generally be resumed the day after your procedure, depending on your doctor’s recommendations.
Your ENT specialist may also prescribe other medications, such as nasal sprays and moisturizing gels, to help relieve conditions that contribute to nosebleeds, and it’s important to take these as prescribed after an embolization procedure.
After Your Recovery
In the weeks following your embolization procedure, you can expect to see your doctor for follow-up appointments to check your groin incision and monitor your overall recovery. Without complications, you can resume all aspects of daily life as your recovery proceeds. A successful embolization procedure resolves bleeding completely, with no need for additional treatments.
Patients typically consider endovascular surgery for epistaxis after trying a number of other treatments, such as packing or cauterization. If you had a balloon or nasal packing in place at the time of your endovascular embolization, it can be safely removed the day after the procedure.
You can expect to experience a clear discharge while the inner layer in the nose renews itself, but no frank blood should be appearing anymore. Because nasal packing is uncomfortable, it is typically a great relief to have it removed.
Benefits of Embolization Surgery
Embolization for epistaxis can completely resolve frequent severe nosebleeds in most cases, with a low risk of complications. Because this procedure is minimally invasive, it requires a short hospital stay and recovery time, with few, if any, special considerations during recovery. When embolization is successful, there is no need for treatments like cauterization or packing.
Embolization Risks
As with all surgeries, embolization is not without some risks. These include allergic reactions to contrast dyes used for imaging during the procedure, and to anesthetics and analgesics. Bleeding or infection at the incision site can also occur. In some cases, arteries can be damaged during placement of the catheter.
Patients who undergo embolization also commonly report experiencing headaches, a mild numbness in the inner gums, and a slight pain in the jaw. These symptoms are temporary and usually resolve themselves within three to six weeks.
Embolization can be an effective procedure for stopping nosebleeds, but in some cases, the bleeding comes from a branch that arises from the eye artery and then courses down the eye. Those branches cannot be treated with the embolization procedure.
Things to Consider Before an Embolization Procedure
Before your embolization procedure, you can expect to meet with your endovascular neurosurgeon for a pre-procedure exam and to schedule your hospital stay. During this time, talk to your doctor about any medications you may be taking, especially if you use blood thinning medications or medications for controlling hypertension. Your doctor may recommend that you stop taking these medications or change your normal dosing in the days before the procedure.
You also need to let your doctor know if you have kidney or liver problems, any allergies to contrast dyes or anesthetics, or other substances used in medical procedures, such as latex. If it is determined that you have packing or other materials in your nose from previous treatments, ask about how and when those materials will be removed.
Your doctor will provide pre-surgery directions, including any restrictions on eating and drinking in the hours before your procedure. Because an embolization procedure typically requires an overnight hospital stay, you should make plans for missing work or school, taking care of responsibilities at home and your recovery at home.
Nosebleeds can have many causes, and they can often be treated at home. But, when epistaxis is frequent or severe, or nonsurgical alternatives such as packing don’t resolve the bleeding, your doctor may recommend embolization – a minimally invasive and effective procedure that, in most cases, can resolve the bleeding completely. Your neurosurgeon will work with you to create a treatment and recovery plan for your unique circumstances.
