Nose Bleeds

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

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