Disorders of the Nasal Mucous Membrane

Nasal dryness: With age, the mucous membrane becomes thinner, the number and size of elastic fibers and the amount of submucosal tissue decrease, and mucus-secreting structures atrophy, resulting in decreased mucus production and nasal dryness. Buffered saline nasal sprays, used as needed, may help.

Rhinorrhea: There are many causes of rhinorrhea, including allergies. In elderly persons, exposure to cold air or intake of certain foods (especially hot or spicy foods) may cause excessive watery, dripping nasal secretions. This effect probably results from age-related changes in the function of parasympathetic vasomotor secretory fibers in the nose. Ipratropium bromide 0.03% nasal spray is effective, although it should be used with caution in patients who have narrow-angle glaucoma or benign prostatic hyperplasia. Anticholinergic antihistamines are dangerous in the elderly and should not be used; antihistamines without anticholinergic properties have no effect on rhinorrhea unless it is caused by allergy.

Epistaxis (nosebleed): With age, the nasal mucous membrane atrophies and blood vessel walls in the nose thin. As a result, epistaxis is relatively common among the elderly.

Anterior epistaxis may result from ulceration of the mucosa overlying old septal spurs, from deviations (particularly in patients taking anticoagulants, such as daily aspirin for general cardiovascular prophylaxis), or from use of oxygen through nasal cannulas. Posterior epistaxis, the more serious type, is most commonly caused by rupture of a branch of the sphenopalatine artery, located near the posterior tip of the inferior turbinate. Hypertension may play a role. Rarely, a tumor is the cause.

Coagulopathies, if present, should be corrected at least temporarily, so that a thrombus can form and the mucous membrane can heal. Acute anterior epistaxis may be managed with oxymetazoline 0.05% nasal spray, which has long-acting vasoconstrictive properties and no significant systemic effects. It is applied to the bleeding site with cotton; the site is then compressed externally for at least 20 minutes until the bleeding stops. Alternatively, bleeding sites can be cauterized and protected with a petroleum-based ointment until they heal.

For posterior epistaxis, nasal packing is usually needed to control the bleeding, particularly in hypertensive patients. After the nose is anesthetized with a lidocaine-based spray, a vasoconstrictive nasal spray (eg, oxymetazoline 0.05%) is used. Then, an epistaxis balloon is inserted into the nose and expanded with water until the bleeding is controlled. It is left in place for about 5 days. Prophylactic antibiotics are given to prevent sinusitis, and follow-up sinus x-rays should be obtained. Alternatively, a compressed sponge may be placed in the nose and kept moistened with oxymetazoline 0.05% spray. Elderly patients should be hospitalized so that their respiratory status and arterial blood gas levels can be monitored. Gauze packing, although tolerated well by most young patients, should not be used in the elderly. It causes nasal obstruction and often depresses the palate, partially obstructing the oral airway. In the elderly, hypoxia and carbon dioxide retention can result.

If epistaxis persists despite treatment, endoscopic nasal examination and cauterization of the bleeding vessel, transantral ligation of the sphenopalatine artery in the pterygomaxillary space, or angiography with embolization of the internal maxillary and sphenopalatine arteries may be performed. After treatment, a full set of sinus x-rays should be obtained to determine if sinusitis has developed or if the cause of the bleeding was a tumor.