A Work In Progress

By Shadeh Ghaffari-Rafi, Neurobiology, Physiology, & Behavior, ’16

At first, Jerry’s expected springtime pollen allergies didn’t bother him or seem unusual. His allergies caused mild nosebleeds, which he would stop by pinching his nose for five minutes. This past year, however, the bleeding didn’t stop.

Five years ago, Jerry relocated to Iowa for work, as the company he worked for in California closed. For the past five years, everyday, Jerry has been taking two pills, one to alleviate his heart rate, blood pressure, and heart strain and another to lower his blood cholesterol. His doctor recommended that Jerry occasionally take low dose aspirin so his blood would flow more easily, he would feel less chest pain, and avoid blood clots and severe headaches. Although he hiked and went to the gym regularly, for a 5’5’’ 56 year old man, he was slightly overweight at 165 lbs.

A nosebleed, or epistaxis, can range from mild to severe, and sometimes lead to life-threatening consequences, depending on the flow (Fried 2013). The bleeding is due to rupture of small blood vessels inside the nose. Professor of head and neck surgery at Albert Einstein College of Medicine, Dr. Marvin Fried describes minor bleedings tend to occur “more frequently in children and adolescents” and most are easily treatable, while more severe, rarer cases occur in patients over 50, with blood oozing down the back of the throat, and generally require emergency treatment. Epistaxis may result from mild conditions, including nose picking, mild allergies to pollen or environmental irritants, and moderate conditions such as trauma or prior nasal surgery. In some cases, epistaxis can occur due to life threatening conditions such as leukemia. Family history of severe or heavy bleeding tends toward more severe cases and patients at risk of cardiovascular disease tend to have severe nosebleeds. Dr. Fried emphasizes “epistaxis can be either short-term and disappear quickly or it can also occur in sudden episodes”. In some instances, epistaxis occurs with other symptoms, such as fever, headache, and dizziness.

Diagnosing epistaxis involves understanding the patient’s medical history and a physical examination, especially of the nose, to help determining possible underlying diseases. Because epistaxis may be short lasting, a diagnosis and its cause can be missed so a clinical examination can be recommended. Understanding if a patient uses aspirin is critical to diagnosis, as low-dose aspirin lowers the risk of cardiovascular disease, it also increases the risk of epistaxis, making the bleeding last longer and harder to stop (Kasperek and Pollock 2013). Pinching the nose for five minutes while sitting upright can normally control the bleeding.

Last Spring when his nose bled, Jerry pinched his nose to stop the bleeding, but it only  stopped temporarily. However, unusually, he experienced another nose bleed the same day, and inconveniently, during the week, he continued to have nose bleeds not only at home, but also at his office, while driving, and at dinner with friends. Each time he repeatedly pinched his nose stopping the nose bleed.

At the end of that week, Jerry and his friend were planning to go hiking, but even before beginning the hike, his nose started to bleed. This time, he felt blood rushing down into his stomach and thought blood vessels “were damaged deep inside his nose”. Concerned, Jerry and his friend rushed to the emergency room.

The physician assistant (PA) questioned Jerry regarding his aspirin usage, and reviewed his medical history, learning he had no prior bleeding disorders, took aspirin occasionally, and had prior treatment for nosebleeds as a child. After the physical examination, the PA dried his nostrils and stopped the nosebleed by inserting a stick coated with silver nitrate against the source for less than five seconds burning the nose tissues. Afterwards Jerry and his friend left the hospital and stopped at a Thai restaurant for dinner. After the first few bites, his nose bled all over the table including his spicy eggplant dish. Shaken and extremely worried, Jerry went back to the hospital, where another PA reviewed his prior treatment and medical history and examined his nose. Then, the PA inserted a balloon into his nose and pumped air to expand the balloon, applying direct pressure to the nostrils, to decrease and stop what Jerry recalled as “nonstop bleeding”. The PA warned him to stop aspirin usage and not eat spicy food, otherwise the bleeding would continue. Jerry rested for a week and the PA referred him to see a nose specialist in three days.

In more severe cases of epistaxis, if the bleeding doesn’t stop, the site next to the bleeding vessel can be burned, cauterized, with “silver nitrate on an applicator stick” (Fried 2013). Cauterization has a success rate of more than 80% of blood stoppage. Although complications with this procedure are uncommon, many patients report nerve damage and breathing obstruction post treatment. In many cases, breathing obstruction can be surgically fixed by straightening the nasal septum, which divides the left and right airways in the nose, also known as septoplasty. In the few cases in which cauterization fails, a balloon or pack is used to absorb the blood. If the patient doesn’t experience re-bleeding in the following appointment, the pack should be removed. However, in many cases, nasal packing is not the first choice of treatment, as it not only leads to physical discomfort, but often emergency surgery.

At his appointment, the specialist slowly pulled the balloon out of his nose.  To the doctor’s surprise, immediately, blood started to flow out. The doctor told Jerry to pinch his nose and go to the hospital where the doctor would surgically close off the artery to stop the bleeding. Post-surgery, Jerry stayed overnight in the hospital and rested at home for a couple of weeks. The doctor recommended Jerry not to consume spicy foods, or take aspirin for a few weeks; however, he could continue to use his other medications. The doctor prescribed painkillers to use when needed to suppress the heavy pain he felt from the surgery and balloon. Over the next three days, the blood diluted and oozed into a gauze inside his nose.  Every three hours, during those three days, Jerry replaced the gauze until the bleeding stopped.

Two weeks after surgery, Jerry told the doctor he wasn’t able to breathe easily. After an examination, his doctor confirmed the breathing obstruction that resulted from the tissue damage accumulated during cauterization. The doctor then surgically repaired the damaged cartilage through septoplasty. To prevent future nosebleeds, the doctor recommended using a nasal spray to keep the nose moist until it improves.

In the rare case that epistaxis cannot be controlled after cauterization and nasal packing, a surgical method to constrict the blood vessels, ligation, is done to control the bleeding (Flint et. al. 2010). In this procedure, the surgeon clips the artery responsible for the epistaxis using endoscopic guidance. With success rates of 93%, this procedure is not associated with any serious complications except continued epistaxis after the surgery due to the failure to clip all the arterial branches.

This traumatizing event led Jerry to make lifestyle changes to avoid taking aspirin. Following surgery, he educated himself on the causes of blood clots and the precautionary measures he can take to avoid one. He began incorporating simple changes, including avoiding salt on his food, fat content milk, and high fructose foods. Over the months, Jerry reduced his calorie intake and exercised two hours a day. After five months, his weight dropped from 165 lbs. to 132 lbs. and at his next appointment, his cardiologist was amazed as all his numbers drastically improved for good/bad cholesterol and triglycerides(fat). Since this event, Jerry has had no nose bleeds and inspired his family to make healthier decisions.

References:

Flint P, Haughey B, Lund V, et. al. 2010. Cummings Otolaryngology – Head and Neck Surgery. Philidelphia (PA): Mosby Elsevier. 2956 p.

Fried M. 2013. Epistaxis. The Merck Manuel. [cited 2014 May 16]. The Merck Manuel [Internet]. Merck Sharp & Dohme Corp. [2010-2013]. Available from: http://www.merckmanuals.com/professional/ear_nose_and_throat_disorders/approach_to_the_patient_with_nasal_and_pharyngeal_symptoms/epistaxis.html?qt=nosebleed&alt=sh

Kasperek Z, Pollock G. 2013. Epistaxis. Emergency Medicine Clinics of North America. [cited 2014 May 16]; 31(2): 454. In Academic Search MD Consult [Internet]. Saunders Company [2013]. Available from: http://www.mdconsult.com/das/article/body/447292157-2/jorg=clinics&source=&sp=26235393&sid=0/N/1160691/1.html?issn=0733-8627

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