From the Guidelines
Management of postoperative nasal bleeds following orthognathic surgery should prioritize a systematic approach, starting with proper patient positioning and application of pressure, as this has been shown to be effective in controlling bleeding and promoting healing 1. The patient should be placed in an upright position with the head tilted slightly forward to prevent blood from draining down the throat.
- Apply direct pressure to the soft part of the nose for 10-15 minutes.
- Topical vasoconstrictors such as oxymetazoline nasal spray (0.05%) can be administered, with 2-3 sprays in each nostril, which works by constricting blood vessels in the nasal mucosa, as recommended by recent clinical practice guidelines 1. For persistent bleeding, nasal packing with materials such as Merocel or ribbon gauze soaked in 1:1000 epinephrine solution may be necessary for 24-48 hours.
- In cases of severe bleeding, surgical intervention might be required to identify and ligate the bleeding vessel, particularly if the sphenopalatine artery is involved, as identified in the clinical practice guideline 1. Postoperatively, patients should avoid activities that increase blood pressure, such as heavy lifting or strenuous exercise, for at least 2 weeks.
- Additionally, patients should avoid NSAIDs, which can inhibit platelet aggregation and worsen bleeding, as highlighted in the executive summary of the clinical practice guideline 1. Maintaining adequate hydration and using a humidifier can prevent nasal mucosa dryness, which may contribute to bleeding. These measures are effective because orthognathic surgery can disrupt the rich vascular network of the maxillofacial region, and targeted interventions help control bleeding while allowing for proper healing, as supported by the evidence from the clinical practice guidelines 1.
From the Research
Algorithm for Postoperative Nasal Bleeds Following Orthognathic Surgery
- The management of postoperative epistaxis after orthognathic surgery involves a step-by-step approach, as outlined in a literature review and three case studies 2.
- Initial management includes nasal packing and tamponade, which may be sufficient for cases of isolated epistaxis that occur within the first week after surgery.
- For more severe cases, local electrocautery or vascular imaging, such as angiography, may be necessary to identify and treat the source of bleeding.
- Angiography with embolization is the preferred approach for diagnosis and management of pseudoaneurysm rupture, which is a common cause of postoperative epistaxis 2.
- Surgical intervention, including repeat maxillary down-fracture with surgical exploration, may be reserved for cases where embolization is not possible or has failed.
Role of Tranexamic Acid in Reducing Blood Loss
- Several studies have investigated the use of tranexamic acid to reduce blood loss in orthognathic surgery, with mixed results 3, 4, 5, 6.
- A meta-analysis of randomized controlled trials found that tranexamic acid can effectively reduce intraoperative blood loss in orthognathic surgery, especially when administered intravenously 3, 5.
- However, the clinical relevance of this blood-sparing effect is debated, and some studies have found no significant difference in postoperative hemoglobin and hematocrit levels between patients who received tranexamic acid and those who did not 3, 4, 5.
- A more recent meta-analysis found that tranexamic acid promotes bleeding control in orthognathic surgery, with significantly decreased blood loss and higher postoperative hemoglobin levels compared to placebo 6.