18 October 2013

Nosebleeds seldom need invasive treatment

Fewer than one in 10 people hospitalised for an unexplained nosebleed requires invasive treatment to stop the bleeding.


Fewer than one in 10 people hospitalised for an unexplained nosebleed requires invasive treatment to stop the bleeding, a review of nationwide data has found.

About 38% of people with nosebleeds so bad they are admitted to the hospital wind up having their nosebleed resolved with little or no treatment, according to the study published online in the journal JAMA Otolaryngology – Head & Neck Surgery.

Clinicians successfully treated another 53% of nosebleed patients either by stuffing the nose with cotton or by cauterising a broken blood vessel using heat, electricity or chemicals.

Only about 8% of hospitalised nosebleed patients needed treatment through surgery or by embolisation, a process in which doctors seal off the bleeding vessel from within, the researchers found.

Increased risk and expense

The small minority of patients who needed invasive treatment faced increased risk and expense, the data showed. For example, the odds of patients suffering a stroke following embolisation were significantly higher than in patients who were treated by packing their nose with cotton.

Study co-author Dr Jennifer Villwock said the results show why doctors like to proceed slowly when treating a bad nosebleed, giving the more conservative options a chance before opting for more invasive treatments.

"Sometimes it seems like we are putting patients through a lot, but we are doing it with their best interests in mind because the more invasive treatments are not without risk," said Villwock, an otolaryngologist with the State University of New York-Upstate Medical University, in Syracuse. "If we can get it stopped at the bedside, that's going to be best for all involved, but that can seem frustrating when your nose has been bleeding for hours."

Three of every five people will suffer a nosebleed – also known by the medical term epistaxis – in their lifetime, Villwock said.

The nose contains many small blood vessels, and these can be ruptured easily, she said. Just the act of breathing can dry out and irritate the lining of the nose, particularly in low humidity or if a person is suffering from a cold or allergies.

Seasonal changes

Seasonal changes can also have an impact, an expert explained.

"This is the beginning of nosebleed season, as the weather gets cold and the heated air is on in most people's houses," said Dr. Lisa Liberatore, an ear, nose and throat specialist at the New York Head & Neck Institute at Lenox Hill Hospital in New York City. "We're going to see several patients a day, and I'm sure the emergency room is going to get their fair share of nosebleeds."

People also can suffer nosebleeds if they have taken a blow to the nose, are on a blood-thinning medication or have a cancerous lesion in their nose.

Almost everyone is able to treat their nosebleed themselves, or receive successful outpatient treatment at their doctor's office, an urgent-care clinic or an emergency room, the researchers said. Only 0.2% of nosebleeds require hospitalisation, they said.

Risk of stroke

This study used nationwide data provided by hospitals to review the care provided to those hospitalised for a nosebleed. Researchers looked at more than 57 000 patients who were hospitalised for nosebleeds between 2008 and 2010. In all cases reviewed, the nosebleed had occurred spontaneously and for no apparent reason, Villwock said.

About 4.7% of patients underwent arterial ligation, a surgical procedure that ties off a blood vessel. Another 3.4% underwent embolisation, in which a catheter delivers a sealant that closes off the bad blood vessel.

These treatments are both riskier and pricier, the researchers said. Embolisation carries a five times greater risk of stroke than nasal packing, with 1.5% of people who underwent that procedure suffering a stroke. About 1.3% of people died while undergoing arterial ligation, a mortality rate nearly twice as high as that of nasal packing.

At the same time, people receiving embolisation paid an average nearly $66 000 for their hospital stay, more than three times the amount charged to people treated with nasal packing. Despite this, embolisation patients had average hospital stays about as long as people receiving other types of treatment for nosebleeds.

Although the study found an association between embolisation treatment for nosebleed and an increased risk of stroke compared to other treatments, it did not establish a cause-and-effect relationship.

Treatment decisions

Dr Richard Rosenfeld, chairman of otolaryngology with the SUNY Downstate Medical Centre in New York City, praised the study. "This is the best sort of rocket fuel for evidence-based decisions and shared decision-making for treating [nosebleeds]. If I were a patient going into the hospital, I'd want to know these numbers. It could tip a little bit the way people make treatment decisions."

Of the hospitalised patients in the study, "these people are sick, sick pups. They have a lot of [other existing health conditions]," Rosenfeld said, including high blood pressure, alcoholism, kidney failure and lymphoma. "These data might not apply to the average healthy patient who comes in with a really bad nosebleed."

Rosenfeld said invasive treatments, although more risky, still were incredibly safe.

"Even for the most invasive treatments, most people did very well," he said. "Very few of them had poor outcomes."

Most people can handle their own nosebleeds by keeping their head parallel to the ground and applying a little ice and pressure, Villwock said.

"The rule is, if it hasn't stopped within 20 minutes, it's time to come in," she said.

More information

To learn more about nosebleeds, visit the US National Library of Medicine.

Picture: Nosebleed from Shutterstock




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