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Nosebleed

Definition

A nosebleed is loss of blood from the tissue lining the nose. Bleeding most commonly occurs in one nostril only.

Alternative Names

Considerations

Nosebleeds are very common. Most nosebleeds occur because of minor irritations or colds. They can be frightening for some patients, but are rarely life threatening.

The nose contains many tiny blood vessels that bleed easily. Air moving through the nose can dry and irritate the membranes lining the inside of the nose, forming crusts. These crusts bleed when irritated by rubbing, picking, or blowing the nose.

The lining of the nose is more likely to become dry and irritated from low humidity, allergies, colds, or sinusitis. Thus, nosebleeds occur more frequently in the winter when viruses are common and heated indoor air dries out the nostrils. A deviated septum, foreign object in the nose, or other nasal blockage can also cause a nosebleed.

Most nosebleeds occur on the tip of the nasal septum, the tissue that separates the two sides of the nose. The septum contains many fragile, easily damaged blood vessels. This form of nosebleed is usually easy to stop. Less commonly, nosebleeds may occur higher on the septum or deeper in the nose. Such nosebleeds may be harder to control.

Occasionally, nosebleeds may indicate other disorders such as bleeding disorders or high blood pressure.

Hereditary hemorrhagic telangiectasia (also called HHT or Osler-Weber-Rendu syndrome) may be evidenced by nosebleeds. This is a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.

Blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds.

Causes

• Nose picking
• Direct injury to nose, including a broken nose
• Blowing the nose very hard
• Very cold or very dry air
• An object stuck in the nose
• Allergic rhinitis
• Repeated sneezing
• Upper respiratory infection
• Barotrauma
• Chemical irritants
• Taking large doses of aspirin or blood-thinning medicine
• Nasal sprays
• Surgery on the face or nose

Repeated nosebleeds may be a symptom of another disease, such as high blood pressure, allergies, a bleeding disorder, or a tumor in the nose or sinuses.

Home Care

Sit down and gently squeeze the soft portion of the nose between your thumb and finger (so that the nostrils are closed) for about 5-10 minutes. Lean forward to avoid swallowing the blood and breathe through your mouth. Wait at least 5 minutes before checking if the bleeding has stopped. Almost all nosebleeds can be controlled in this way if enough time is allowed for the bleeding to stop.

It may help to apply cold compresses or ice across the bridge of the nose. DO NOT pack the inside of the nose with gauze.

Lying down with a nosebleed is not recommended. You should avoid sniffing or blowing your nose for several hours after a nosebleed.

When to Contact a Medical Professional

Get emergency care if:

• Bleeding does not stop after 20 minutes
• Nose bleeding occurs after an injury to the head -- this may suggest a skull fracture and x-rays should be taken
• Your nose may be broken (for example, it is misshapen after a blow or injury)

Call your doctor if you or your child has repeated nosebleeds, particularly if they are becoming more frequent and are not associated with a cold or other minor irritation.

What to Expect at Your Office Visit

The doctor will perform a physical examination. In some cases, you may be watched for signs and symptoms of hypovolemic shock. The doctor will ask you questions about your nosebleeds, including:

• Is there a lot of bleeding?
• Do the nosebleeds stop quickly when you press on the nostrils?
• Did they begin recently?
• Do they occur frequently or repeatedly?
• Does the bleeding always occur on one or both sides?
• What other symptoms do you have?
• Is there blood in the stools?
• Are you vomiting blood?
• Do you bruise or bleed easily?
• Are there tiny red or purple spots on the skin ( petechiae)?
• Are you taking blood thinners (Coumadin) or aspirin?

• Complete blood count
• Nasal endoscopy (examination of the nose using a camera)
• Partial thromboplastin time measurements
• Prothrombin (PT)
• X-rays of the skull

Treatment is usually focused on the cause of the nose bleeds, and may include:

• Closing the blood vessel using heat or silver nitrate sticks
• Reducing the amount of blood thinners or stopping aspirin
• Controlling blood pressure
• Reducing a broken nose or removing a foreign body
• Nasal packing

You may be referred to an ear, nose, and throat (ENT) specialist to diagnose and treat the condition.

Prevention

A cooler house and a vaporizer, to return humidity to the air, help many people with frequent nosebleeds. Nasal saline spray and petroleum jelly ointment (such as Vasoline) can help prevent nosebleeds, especially during the winter months.

References

Pallin DJ. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005; 46(1): 77-81.

Kucik CJ. Management of epistaxis. Am Fam Physician. 2005; 71(2): 305-311.

Marx J. Rosens Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:933.

Cummings CW, Flint PW, Haughey BH, et al. Otolaryngology: Head & Neck Surgery. 4th ed. St Louis, Mo: Mosby; 2005:942-960.

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