No lifting greater than five pounds
Sneeze with your mouth open
No nose blowing
Sleep with your upper body elevated
Do not bend over to tie your shoes - Use slippers or loafers
Cool diet - Liquids or food at room temperature or cooler
Use a cool mist humidifier with a filter
Saline mist nasal spray - Two sprays to each nostril four times each day
Epistaxis/Nose Bleed Information
The nose is the filter and heat exchanger for your lung. To perform
these functions, the nose is full of blood vessels and will crust up as
it filters out the dirty particles in the air. We need to clean out our
nose, the filter. During the cleaning process (blowing your nose or
digitally cleaning your nose), a blood vessel can break and bleed. A
blood clot and scab form to stop bleeding. If you remove the blood clot
or scab too early, the nosebleed comes back. Several nosebleeds within
a few days are the result of the same broken blood vessel from the scab
falling off too early. In essence, it’s one nosebleed. It takes about 2
weeks for the broken blood vessel to heal. The best treatment option is
conservative medical care for 2 weeks. Let your body heal naturally and
spontaneously. If this does not resolve your Epistaxis, each additional
treatment method carries increasing discomfort and risks.
Conservative Medical Treatment: 1. Moisturize your nose -
• Use saline nasal spray followed by ointment, e.g.
Vaseline petroleum jelly or antibiotic ointment applied five times a
day for 2 weeks. Use a kidney bean sized amount of ointment at the
nostril opening. Sniff the ointment into the nose.
• Drink plenty of water.
• Use a humidifier or vaporizer at your bedside. 2.
No nose blowing, rubbing, or picking for 2 weeks to allow the broken
blood vessel to heal. 3. Sneeze with your mouth wide open. 4. Elevate
the head of your bed at all times. 5. Avoid Coumadin/Warfarin, aspirin,
ibuprofen (Motrin), Naproxen and Aleve, which can prolong bleeding,
unless these are medically necessary. Discuss this with your primary
care provider. Do not stop Coumadin or Warfarin on your own without
your primary care doctor’s permission. 8. Your blood pressure needs to
be well controlled. If not, contact your primary care provider.
Cauterization: If conservative medical treatment does not work, a
numbing spray can be applied to your nose. It stings a little as the
spray works to numb your nasal membrane. A silver nitrate cautery stick
is then applied to burn the bleeding vessel area. This technique does
not work well when you are actively bleeding. The cauterized area will
form a large scab. You still need to do conservative medical care for
next 2 weeks. If you disturb and knock off this scab too early by
cleaning or blowing your nose, you may suffer a much larger nosebleed.
Once this cauterized area heals, the nosebleed will go away. This is
not a permanent cure. The cauterized blood vessel will grow back in a
few months or another blood vessel will break. There is no permanent
cure for nosebleeds.
Nasal Packing: If cauterization does not work, you will need nasal
packing to put pressure on the bleeding area. This is achieved by
inserting a Merocel pack into the bleeding nostril. This process is
painful but necessary to stop a larger nosebleed. This process also
abrades more nasal mucosa and can cause more nosebleeds unless the
packing is left in the nostril for 3-5 days. You may continue to have
minor bloody drainage around the packing for 48 hours after insertion
of Merocel nasal packing. This is normal. If Merocel packing fails,
Epistat balloon packing may be placed. This type of packing is very
painful compared to Merocel packing. After removal of nasal packing,
you still need to do conservative medical care for the next 2 weeks.
Blowing your nose right away after the packing is removed may start up
the nosebleed again and require anther packing for 3-5 days.
Arterial Embolization: If your nosebleed continues after failed nasal
packing, the nosebleed is now considered severe. You will probably need
to stop coumadin/warfarin if you are taking these medications. You may
also require a blood transfusion at this time. Your doctors will
discuss these issues with you. There is usually no time to arrange for
autologous or designated donor blood. Banked blood is usually the best
choice. You may check blood transfusion information in the Pre Op area
of my website for further information on blood transfusion.
The best option to stop your nosebleed at this time is to perform an
arteriogram to identify the bleeding vessel and embolize (clot off) the
blood vessel if possible. There are 2 groups of blood vessels feeding
into your nose. The posterior group is amenable to embolization. The
superior group feeds the nose through the brain and the eye and is not
amenable to embolization.
Embolization requires a puncture on the femoral artery in the leg. A
catheter is threaded to the aorta and carotid arteries. A dye is
injected to identify the major blood vessel feeding the nosebleed,
usually the internal maxillary artery in the posterior group of blood
vessels. Clotting materials are injected to clot off the artery. The
risk of this procedure is bleeding from the leg artery puncture and a
small risk of strokes from the clotting materials
injected. You may also have chronic facial pain from reduced blood
supply to your face. After the embolization, you still need to do
conservative medical care for the next 2 weeks.
Surgery: If your nosebleed is from the superior group of blood vessels
(ophthalmic artery feeding into ethmoid arteries), the only technique
to control your nosebleed is by surgery. A cut is made between the eye
and the nose to expose the ethmoid arteries. Surgical clips are used to
tie off the arteries. After surgery, you still need to do conservative
medical care for the next 2 weeks.
Summary: Most nosebleeds are minor and do not cause any serious health
issues. Nosebleeds are especially common in children. My head and neck
surgery colleague commented that he can not have a pool party without
one of the invited children having a nosebleed. Nosebleeds are also
common in adults. We just do not discuss them at social gatherings.
There is no convenient time to have a nose bleed. Luckily, most
nosebleeds are stopped with conservative medical treatment. Few
patients need cauterization. Much fewer patients need packing. Rarely,
patients need embolization and surgery.
Patients on coumadin/warfarin or nasal oxygen are also at higher risk
for nosebleeds. These patients may need to learn how to live with minor
nosebleeds and manage them conservatively because the alternative is to
stop coumadin/warfarin or oxygen. This alternative tends to put these
patients at serious health risks. Please discuss these issue with you
primary medical doctor.