My son has chronic nosebleeds in the left side of his nose only. He has had it cauterized several times. The doctor says he cannot cauterize it again without burning a hole through his nose. What do you think could be done about this situation?

C.E.G.

One common cause of one-sided nosebleeds is a deviated septum. The septum is the bony/cartilaginous partition that divides your nose into two nasal cavities. If it is crooked, the flow of air through the nose can be turbulent, and some areas of the septum may dry, chap and bleed. If this is the cause of your son's nosebleeds, then an operation to straighten the septum (known as a "septoplasty") could cure his problem.

Let's get back to his doctor's contention that he might burn a hole through your son's nose. What he's afraid of is a condition known as "septal perforation," a hole in the septum. This fear may or may not be justified; without seeing your son's septum, it is hard for me to offer an opinion. Nevertheless, I would like to comment on how unlikely this complication would be.

The frontmost portion of the septum is made up of cartilage. Cartilage is the "white gristle" that one encounters, for example, while carving a turkey. Cartilage does not contain blood vessels, yet it is living tissue, and like all living tissue it requires a steady supply of oxygenated blood. It receives its blood supply via the tissue that coats it, known as "mucoperichondrium." The septum is a sandwich: cartilage in the middle, and a coating of mucoperichondrium in the left and right nasal cavities. If portions of mucoperichondrium in BOTH nasal cavities are injured, and if these portions are directly opposite each other, then the area of cartilage between the two injured areas can die, and a septal perforation results. Usually, injury to one mucoperichondrial surface, even if severe, is not enough to cause a septal perforation.

What should be done now? If I were your son's doctor, I would first take a thorough history before examining him, and only then would I suggest a plan of action. For the time being, several questions come to mind:

• Have more conservative measures been tried? Ear, nose and throat doctors (ENTs) are familiar with several options for treating recurrent nosebleeds. For example, frequent use of a nasal saline spray, in conjunction with topical application of a TINY amount of antibiotic ointment to the raw area, can be very helpful. There are also gentle packing techniques that can simultaneously discourage recurrent nosebleeds while providing an environment that promotes healing.
  
• Is your son a child or an adult? Cancer is not very high on my list of possible explanations for recurrent, one-sided nosebleeds, but it's a little higher when this problem occurs in a previously asymptomatic adult. If there is any suspicion for this, a biopsy would be prudent.
  

• Did your son's nosebleeds begin following an injury to his nose? Septal deviation is still the most common explanation in this case, but there is a rarer, much more serious, possibility: arteriovenous malformation. These blood-vessel malformations can be present from birth but can also occur as a result of trauma. Bleeding from such malformations is usually very dramatic and typically will not respond to simple cautery.
  
• Last but not least: Is your son's doctor an ENT? If not, he may be feeling unnecessarily nervous about repeated cautery. (A better reason to avoid repeated cautery, in your son's case: It just isn't working.) If your son's doctor is not an ENT, then the first step is straightforward: Take him to an ENT!