Wednesday, November 5, 2008

Nose Bleeds

I am one of those people who have periodic nose bleeds from dry mucosa (and the trauma of blowing my nose – allergies and/or colds).  I have had them since childhood.  There have never been any polyps or other issues noted on the couple of exams I have had.  So I learned long ago how to deal with mine.  I thought I would review some basic information with you.

The technically correct medical term for nose bleeds is epistaxis.  It is classified on the basis of the primary bleeding site

Anterior (90% of nose bleeds) 

  • The most common source  if bleeding is from the Kiesselbach plexus which is an anastomotic (think multiple roads coming together) network of vessels on the anterior portion of the nasal septum. (photo credit)
  • May also be due to bleeding anterior to the inferior turbinate.

Posterior

  • Bleeding will originate from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
  • This is much more serious and usually require admission to the hospital and management by an otolaryngologist.

 

CAUSES of NASAL BLEEDING (epistaxis)

Most cases have no easily identifiable cause.

Local trauma (ie, nose picking, blowing too vigorously, foreign bodies) is the most common cause.  Other local causes include:

  • facial trauma or surgery
  • nasal or sinus infections
  • allergies
  • nasal polyps
  • prolonged inhalation of dry air (climate or too warm house)
  • tumors

Systemic causes include

  • Blood disorders (hemophilia, leukemia, polycythemia vera, thrombocytopenia, von Willebrand’s disease, etc)
  • Acquired platelet dysfunctions (related to use of aspirin, NSAIDs, dipyridamole, etc
  • Anticoagulation therapy (ie warfarin, enoxaparin, etc)
  • Hypertension is rarely (if ever) a direct cause of epistaxis.  Therapy should be focused on controlling bleeding before blood pressure reduction.
  • Vascular abnormalities that contribute to epistaxis may include the following:
  1. Arteriovenous Malformations
  2. Hereditary Hemorrhagic Telangiectasis
  3. Sclerotic Vessels
  4. Neoplasm (tumor)
  5. Septal abnormality (ie perforation or deviation)
  6. Endometriosis

WHAT TO DO at HOME

As with all bleeding the first thing to do is remain calm, then apply pressure.   How do you apply pressure correctly?

    • Sit up straight.
    • Lean your head forward rather than back.  This way you won’t swallow the blood which can irritate your stomach and make you nauseated.
    • Pinch the nostrils together with your thumb and index finger for 5-10 minutes. Pinch them tightly and don’t let go early.  Yes, it will be uncomfortable if you have enough pressure.  (photo credit)
    • Repeat for another 5-10 minutes, if the bleeding hasn’t stopped.  You may not have held consistent pressure the first time.

 

Things that can help prevent a nose bleed or re-bleed:

  • Avoid local trauma.  No nose picking.  Try not to blow your or sneeze for 24-48 hrs after the nose bleed.
  • Minimize exposure to dry air.  This can be a problem if you live in Arizona or in a heated home in the winter.  Adding moisture to the air with a humidifier or vaporizer will help.
  • Using salt water nasal spray can help.   This can be used with abandon, no limits.
  • Using vaseline occasionally to help keep the lining of your nose moisturized.  Don’t overdo this.

WHEN it’s appropriate to go to the hospital

  • You are still bleeding after REALLY pinching the nose for 10 minutes.
  • You are having repeated episodes of nosebleeds over a 12-36 hour period.
  • You feel dizzy or light-headed or like you are going to pass out.
  • Your doctor instructs you to go to a hospital's emergency department.

WHEN it’s appropriate to call your doctor

  • Repeated episodes of nosebleeds.  You may need to see a specialist to make sure there are no polyps, etc in your nose.
  • Additional bleeding from places other than the nose, such as in the urine or stool.  You may have a blood abnormality or other health issue.
  • Bruising easily and are not on a blood-thinner.  This may be a sign of another health issue.
  • If you are on any blood-thinning medications, including aspirin or warfarin (Coumadin).  Your doctor should know about your bleeding, as they may wish to change your dosage if you bleed too often or it is difficult to stop.
  • If you have any underlying disease that may affect your blood clotting, such as liver disease, kidney disease, or hemophilia (inability of blood to clot)
  • If you recently had chemotherapy.  Again your doctor should now, so they can check and make sure you aren’t having other issues.

 

For anyone interested in more information, may I recommend the following articles.

REFERENCES

Epistaxis by Jeffrey A Evans, MD and Todd Rothenhaus, MD; eMedicine Article; Nov 28, 2007

Epistaxis by Quoc A Nguyen, MD; eMedicine Article; Nov 29, 2007

Nasal Pack, Anterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 10, 2008

Nasal Pack, Posterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 3, 2008

Current Approaches to the Management of Epistaxis;  JAAPA May 2003;16:52-64; Richard M Bishow, MPAS, PA-C

Nosebleeds; eMedicineHealth Article

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6 comments:

P. Driscoll said...

Thanks for this review. Having had chronic nosebleeds since I was young (nose was cauterized twice, when I was 10 and 12), I have suffered with this. Pinching as you described, for 10 minutes, usually took care of it. However, the best solution was to deal wit it prophylactically by anticipating the conditions, especially dry weather (winter and southwest) and travelling by plane (re-circulated air is very dry) and applying vaseline and/or neosporin to the septum and hydrating almost to a fault would preempt the problem. At age 43, I needed to have angioplasty and stenting in coronary artery, subsequently requiring use of Plavix, which heightened the need for prophylactic measures, since every nose bleed became a major ordeal (three times requiring ER visit to pack the nose, once a tampon for three days!). I am convinced of hydrating, avoiding trauma, using vaseline/neosporin. Small bleeds have also been taken care of with Afrin or other vasoconstricting nasal sprays. Hope this helps even one person, because I know how miserable you feel physically and socially with a nosebleed.

enrico said...

Excellent post, I suffer from these too. I have come full circle to having Afrin-like sprays help to having irritated mucosa to the point where it's so hyperemic that the bleed risk is increased again, but that was my fault w/overuse.

So be careful with the nose candy (spray kind :P) people! ;)

Laika said...

Great Review, thanks.
1. I suffer from nosebleeds as well from time to time, although they're easy to stop. Mostly related to dry air, I guess. And they may coincide with the once-in-2-weeks-pain-in-the-nose-&-head (sinuses?) I have, often when the weather changes. Do you know by any chance what might be causing this? (no, I know this is not a consult, I'm just curious).
2. In my presentation on evidence based searching, I use the example of "treatment of recurrent anterior nosebleeds in children" (I'm a medical librarian). By searching the free TRIP-database (http://www.tripdatabase.com/) for epistaxis you find Clinical Evidence as well as a Cochrane Review (plus a lot of Emedicine stuff). According to Clinical Evidence antiseptic cream is likely to be beneficial, whereas cautery and petroleum jelly may not be. Do you agree with this conclusion?
(p.s. aggregate evidence can also be found by using the "systematic reviews" filter in PubMed's clinical queries. You find 22 results

Jacqueline (https://twitter.com/laikas)

p.s. did my best to link directly to results, but now find that your blog justs accepts [b] etc.

rlbates said...

Laika, I think that if you are trying to prevent the bleeds then vaseline or Aquaphor or even antibiotic ointment to moisturize the nasal lining are beneficial. If you are trying to stop bleeding that didn't respond to pressure, then I think cauterization is a helpful tool.

sober white women said...

I just happened to stumble here. I love your blog. I was looking for pictures of lady Jane quilts.
My daughter had a bad nose bleed last month. I told her to use a tampon. I was kidding but here come my sixteen year old daughter and what is that hanging out her nose? A tampon! LOL
Kelli

Elizabeth Bryant Alexander said...

I also found pinching until it is rather uncomfortable normally did the trick. Whew, those blood clots get nasty. Allergies/over-heating were my main triggers. A clean vaporizer and avoiding allergens were essential. I wonder if you have any explanations to a couple of things I noticed... Mine always seemed worse if the nosebleed just started randomly/without a sneeze or nose rubbing. Why do they get better with age? They decreased significantly at puberty and when I was 18 had a major both nostril gusher and haven't had another major one since. (6 years) Just curious.

I agree with driscoll, having a nosebleed in public is socially miserible.