Pearls of Wisdom: Allergic Rhinitis With Recurrent Nosebleeds
Adam is a high school student who uses a fluticasone nasal spray 3 months of each year for seasonal allergic rhinitis. Loratadine and fexofenadine didn’t work. Although montelukast was helpful, it wasn’t as effective as his nasal steroid. Although his symptoms are well controlled, he gets nosebleeds 2-3 times each allergy season. He has never had a nosebleed that was sufficiently problematic to visit the emergency department or seek urgent care assistance, but nonetheless it is disconcerting.
Adam has considered allergy testing with the potential for desensitization and environmental manipulation, but he is currently sufficiently satisfied with the efficacy of nasal steroids.
For an adolescent patient who is achieving satisfactory symptom control of allergic rhinitis with fluticasone nasal spray, but has recurrent epistaxis, what could you advise to reduce risk of further bleeding?
A. Run a complete blood count, looking for low platelets. This is probably the cause.
B. Check factor VIII levels; his epistaxis is probably a manifestation of von Willebrand disease.
C. Switch to budesonide nasal spray, since it has less frequent epistaxis.
D. Check the method with which he administers the nasal spray.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
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Answer: Check the method with which he administers the nasal spray.
Clinical experience has taught us that epistaxis is the most common adverse effect in patients who chronically use nasal steroids. As far as likelihood of experiencing epistaxis, there does not appear to be any meaningful difference amongst nasal steroids. For many years, epistaxis was explained by the observed phenomenon that nasal steroids can regress hypertrophic nasal turbinates and polyps. The thought was that induction of thinned nasal mucosa led to a relative level of mucosal atrophy that increased susceptibility to bleeding.
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Allergic Rhinitis and Asthma: Role of Environmental Determinants
Allergic Rhinitis: Nothing to Sneeze at
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Observations
Although this physiology might play a role in some patients, a much simpler explanation was determined by investigators at the University of Florida; they hypothesized that simple mechanical trauma from abrading the mucosa with the nozzle of the nasal inhaler was the actual culprit.
Preventing Nosebleeds from Nasal Steroids1
Researchers noted that most folks use their right hand to insert the nozzle into their right nostril—at an angle that would easily scrape up against the nasal septum (ie the most vascular area of the anterior nose and the site from which most epistaxis emanates).
Theory: If patients were instructed to instead use the right hand to insert the nozzle into the left nostril, and use the left hand to insert the nozzle into the right nostril, thereby coming into contact (if any) with the alar mucosa of the nose rather than the septal mucosa, might epistaxis be reduced?
Conclusion: Simple mechanical trauma from abrasion of the septum can be minimized by altering the angle at which the nasal spray device enters the naris.
In the event that checking the method of nasal steroid utilization determined that the patient was already using optimum technique, it would certainly be reasonable to seek underlying bleeding diatheses (eg, von Willebrand disease and thrombocytopenia), but typically these disorders manifest earlier and in more diverse ways than simple minor nosebleed.
What’s the “Take Home”?
Although prior physiologic explanations for epistaxis in users of nasal steroids may still be pertinent, it appears that simple mechanical trauma is the primary cause of epistaxis. Restructuring the administration technique to assure angling the device towards the nasal ala instead of the septum can be quickly obtained by suggesting that the patient use the right hand to spray the left nostril (and vice versa), with attention to try and avoid septal contact when possible.
Reference:
Hatton R. Preventing nosebleeds from nasal steroids. Drugs and Therapy Bulletin. 2004;18(3):3.