A 40-year-old man comes to the office for evaluation of recurrent epistaxis. Every morning, the patient wakes up with significant nasal congestion; when he blows his nose, he often sees crusting and blood clots in the tissue. Afterward, his nose frequently (several times a week) starts bleeding. It stops with

Question

A 40-year-old man comes to the office for evaluation of recurrent epistaxis.  Every morning, the patient wakes up with significant nasal congestion; when he blows his nose, he often sees crusting and blood clots in the tissue.  Afterward, his nose frequently (several times a week) starts bleeding.  It stops with <5 minutes of pinching his nasal alae.  Medical history includes obesity, hypertension, and obstructive sleep apnea treated with continuous positive airway pressure (CPAP).  Vital signs are within normal limits.  On examination, the nose has bilateral crusting with excoriations on both sides of the nasal septum, but there is no bleeding.  Which of the following is the most appropriate step in management of this patient's condition?

Quizplus · Accepted Answer

This patient's nasal crusting and recurrent epistaxis are likely related to his use of continuous positive airway pressure (CPAP). After beginning CPAP, many patients develop new nasal symptoms, including dryness, obstruction, and epistaxis due to mucosal damage caused by the cold, dry, pressurized air. On examination, the nasal mucosa appears dry and erythematous with significant crusting. Nasal symptoms often improve significantly with warming and humidification of the air through the CPAP machine. Nasal saline irrigation is recommended to moisturize the nasal mucosa and assist with clearing of dry secretions. Patients may also apply a lubricating jelly (eg, saline gel, petroleum) to the anterior septum. However, improvement in nasal symptoms does not appear to increase compliance with CPAP therapy. (Choice A) Excoriations and crusting sometimes represent malignancy, which can present with recurrent epistaxis and may require biopsy for diagnosis. This patient has no focal lesion, and exposure to dry air from the use of CPAP is a much more likely reason for his symptoms. (Choice B) A complete blood count is ordered in cases of severe epistaxis that may require transfusion, but that is not needed in this patient. Coagulation studies are required in patients who are receiving anticoagulation medication or who have recurrent, spontaneous epistaxis. This patient has an obvious cause of epistaxis (CPAP). (Choice D) Although corticosteroid nasal sprays are effective in the treatment of allergic rhinitis, they have no effect on nasal symptoms induced by CPAP use. In addition, corticosteroids may cause thinning, dryness, and/or damage of the nasal septum, further contributing to epistaxis. (Choice E) For the treatment of acute epistaxis, nostril pinching is the first step in management. Oxymetazoline (a topical vasoconstrictor) can be applied if direct compression alone is not effective. However, oxymetazoline is not useful for prevention and should not be used for more than 3 days due to the risk of rebound congestion (ie, rhinitis medicamentosa). nostril pinching Educational objective: Continuous positive airway pressure (CPAP) predisposes users to recurrent epistaxis because of its drying effect on the nasal mucosa. Humidification is often effective in preventing CPAP-associated epistaxis. References: Topical nasal steroid treatment does not improve CPAP compliance in unselected patients with OSAS. (http://www.ncbi.nlm.nih.gov/pubmed/21129944) Impact of heated humidification with automatic positive airway pressure in obstructive sleep apnea therapy. (http://www.ncbi.nlm.nih.gov/pubmed/18982206)

A 40-Year-Old Man Comes to the Office for Evaluation of Recurrent