ENT docs see a lot of folks with nosebleeds this time of year when the weather is hot and dry. Bloody noses are also common in winter, where indoor heat dries the air. For those with recurrent nosebleeds, we often can treat this in the office setting. Many patients know beforehand that cautery will be done. But some have misgivings about the procedure, how painful it will be and how they’ll recover, often from faulty information found on the internet. Naturally, quite a few worry about the whole ordeal behind nasal cautery, especially youngsters. This concern arises often, where a few patients are scared to death they’ll suffer with unsurmountable pain lasting hours if not until the next day, or will be unable to resume normal activity or sports for a week or more.
This post is meant to allay those fears and misconceptions. I’ve suffered nosebleeds myself, often when exercising, and a few times in the middle of a workday seeing patients. I’ve packed my nose and resumed seeing patients; the mask-mandate during the COVID pandemic made that easy, as the mask hid the Kleenex sticking out from my nose. Sans mask, I must do some explaining when I walk into the exam room. But heck, docs are human too.
There are a few relatively simple measures you can perform upon yourself or your child to treat a nosebleed.
However, for more frequent, recurring nosebleeds needing a doctor’s treatment, nasal cautery is the one of most common procedures in the office setting. This is done with the patient sitting up in an exam chair. Before I whip out the instrument of “torture” though, I first prepare the patient (mentally) and their nose (literally).
First,
I explain we examine the nose with a speculum and headlight. When I’ve
mentioned speculum before, a few women were shocked, imagining the large,
vaginal speculum used by their OB-gyn docs.
Their fears are allayed--in the midst of a “whew!” and sigh of relief--once
I bring out the much, much smaller device.
 |
| Nasal Specula |
As
you can see, this is a relatively benign-looking device. For fearful kids (and some adults), I demonstrate
how this is used--that this little guy will not pinch, stab or poke them--by spreading
the device between their fingers.
Bringing it to their nose is an entirely different matter.
 |
| Viewing inner nose with nasal speculum and headlight |
But as you can see, the patient being examined with the nasal speculum is not suffering at all—see the smile? She’s having a wonderful time.
After the nose is examined with the speculum and the aid of a headlight, the nose is then sprayed with oxymetazoline (Afrin) or neosynephrine to shrink (decongest) the nasal tissues. This helps to reveal the source of bleeding, which sometimes is difficult to detect. Next, lidocaine solution is sprayed, an anesthetic that numbs the inside of the nose and makes the procedure more tolerable. I warn the patient that the lidocaine often drips down the back of their throat, which will render their throat numb for a 1/2 hour or more. I’ll then saturated a few cotton pledgets with the decongestant and anesthetic and place one in the nose as a compress to further open and anesthetize it.
Silver nitrate (AgNO3) is a chemical cautery agent that seals blood vessels, and is the most common cautery agent used, both in the ENT office, ER and urgent care setting.
Cautery
in this manner does not “burn” the tissue as some folks are led to
believe. There are no large “sparks,” no
sizzling, smoldering flesh, and no plumes of dense smoke arising from their
nostrils, though this is a disappointment to some (of the stranger ones). I reiterate the AgNO3 is meant to seal the
blood vessel(s). When I show the patient
the silver nitrate applicator (a wooden stick with an oval head of the chemical
at one end), I’ll press it against their hand or arm, since it will not
activate on dry tissue. I tell them they
will feel some pressure as I apply and push it onto the vessel, and they may
feel a sting or a burning sensation, but there is no actual “burning” per se,
even though the darn thing looks like a long matchstick. Many don’t feel a thing other than the pressing
of the stick in their nose.
Usually I keep the cotton pledget in the nose and shift it away from the target vessel(s). This way, the cotton serves to tamponade (apply pressure with the cotton) any bleeding that may occur during the procedure. Sometimes the vessel will bleed as cautery is applied or bleed just from a little friction from the movement of the cotton. If bleeding is brisk, it’s difficult to view the targe and the cotton can easily be advanced and pressed onto the bleeding site for a minute or so. Then cautery can commence by alternating removal of shifting aside the cotton, cauterizing, tamponade if needed, and so on until the bleeding is controlled. Most patients tolerate this well.
There are other, more elaborate means to treat more difficult-to-control, continuous nosebleeds, which are covered in The Bloody Nose Part 2.
The sources of bleeding within the nose are variable, where one may find a single vessel, multiple vessels extending in different patterns, large, raised, juicy red vessels, or a simple-looking small focal vessel that bleeds like a dickens when barely touched.
Most of the time the bleeding sites are found on the nasal septum, the partition that divides the nose into right and left sides. The septum naturally has a rich network of blood vessels called Killian’s plexus, after—you guessed it—a guy named Killian.
Cautery itself is typically not too painful afterwards. The nose may feel a little sore at the cautery site, but most folks leave the office with minimal to no discomfort. And the majority need no pain medication afterwards.
I also explain there might be a few episodes of bleeding as this heals, due to sloughing of eschar, but usually briefer, fewer and in most cases not further bleeding at all.
I give a handout for daily use of nasal saline spray, a natural solution found in most stores, to keep the nose moist and prevent future bleeding, spraying gently 2-3 times a day or more, especially in the drier seasons where you live. Saline comes in gel form and can be applied to the nostrils with a clean finger.
You can resume normal activity that day, even sports if there’s little risk of injuring or tweaking the nose. You must avoid vigorously rubbing, bumping, or picking the nose. If needing to sneeze do so with mouth open and do not squeeze the nose shut when sneezing. If feeling the urge to blow the nose, first spray some saline to moisturize and loosen any snot you wish to clear, and then blow lightly!
©Randall
S. Fong, M.D.
For more topics on medicine, health and the weirdness of life in general, check out the rest of the blog site at randallfong.blogspot.com
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