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Epistaxis

 

Nosebleeds are fairly common, particularly in children, and can usually be easily treated at home. The medical name for a nosebleed is epistaxis.

How do nosebleeds occur?

The inside of the nose is full of tiny blood vessels which can bleed if they are disturbed. This is usually the result of a minor injury that is caused by picking or blowing your nose.

Nosebleeds can also occur if the mucous membrane (the moist lining) inside the nose dries out and becomes crusty. This can be the result of an infection, cold weather or the drying effect of central heating. The mucous membrane becomes inflamed or cracked, making it more likely to bleed, particularly if picked or disturbed by a minor bump.

Nosebleeds are not usually serious

Nosebleeds are not usually serious. However, in very rare cases, nosebleeds can be life threatening, particularly in older people whose blood may take longer to clot, resulting in high blood loss. Nosebleeds are more common in people taking aspirin, anticoagulants (blood-thinning medicines), or people with blood disorders.

If nosebleeds become frequent (more than once a week), it could be due to an underlying problem, such as high blood pressure (hypertension). Your GP will be able to take a blood pressure reading and advise you about suitable treatment. They can also check to see whether any medicines you are taking are causing your nosebleeds.

If your GP suspects there is a more serious problem, they may refer you to an ENT (ear, nose and throat) specialist for further tests.

Anticoagulants
Anticoagulant is a substance that stops blood from clotting (prevents coagulation), for example warfarin.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
High blood pressure
High blood pressure, known as hypertension, is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.

During a nosebleed, blood comes out of your nose. The flow of blood may be heavy or light, and the nosebleed may last a few seconds or more than 10 minutes. During most nosebleeds, blood only comes from one nostril, but it can come from both.

Nosebleeds can also happen when you are asleep. You may feel liquid in the back of your throat before blood runs from your nose. This symptom usually occurs if you are lying down.

When to seek medical assistance

Visit your GP if you have the following symptoms:

  • very heavy bleeding from your nose
  • palpitations (an irregular heartbeat)
  • shortness of breath
  • you turn pale
  • you swallow large amounts of blood that makes you vomit

The bleeding may be more prolonged and harder to stop if you have high blood pressure (hypertension), heart failure, a blood clotting disorder, or you are taking anticoagulants (blood-thinning medicines), such as warfarin or aspirin.

If you are taking warfarin and you have heavy or re-occurring nosebleeds, seek medical advice immediately.

Anticoagulant
Anticoagulant is a substance that stops blood from clotting (prevents coagulation). For example warfarin.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
High blood pressure
Hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.

There are two types of nosebleeds:

  • anterior, and
  • posterior.

The type of nosebleed that you have will depend on where the bleeding originates.

Anterior nosebleeds

If you have an anterior nosebleed, the bleeding comes from the lower septum (the wall between the two nose channels), just inside your nose. This part of the nose, which is sometimes known as Littles' area, has a lot of delicate blood vessels inside it.

The blood vessels are supplied with blood from your carotid arteries (the two main arteries in your neck which supply the blood flow to your brain). These delicate blood vessels are easily damaged and if they are knocked they will begin bleeding.

Sometimes, the cause of anterior nosebleeds is unknown (idiopathic). However, the main causes include:

  • picking your nose, particularly if you scratch the inside of your nose with a sharp fingernail,
  • blowing your nose very hard,
  • a minor injury to your nose,
  • a deviated septum (a crooked nose, either present from birth or due to an injury),
  • a cold or flu (influenza),
  • sinusitis (an infectionan of the small, air-filled cavities inside your cheekbones and forehead),
  • a blocked or stuffy nose that is often caused by an infection,
  • a dry nose that is caused by dry air in a hot climate or heated indoor air,
  • hayfever or other allergies,
  • high altitude,
  • excessive use of nasal decongestants,
  • use of the illegal drug, cocaine.

Children almost always have anterior nosebleeds and these are easily treated at home.

Posterior nosebleeds

A posterior nosebleed is where the bleeding is heavy and comes from further back, and higher up your nose. Posterior nosebleeds are more common in adults than in children and they may need medical attention.

During posterior nosebleeds, the bleeding originates from branches of the arteries which supply blood to your nasal cavity (the space inside your nose between the roof of your mouth and your brain).

This type of nosebleed can be more serious. If your nosebleed has resulted from a large blow to your head, or a fall, you should seek medical attention because you may have broken your nose. 

Other possible causes of posterior nosebleeds include:

  • recent nasal surgery,
  • high blood pressure,
  • hardened arteries (from fat, cholesterol, or other substances that build up in your arteries), 
  • a calcium deficiency, 
  • exposure to irritating chemicals,
  • a tumour in the nasal cavity, and
  • certain medicines, such as aspirin, medicines for arthritis, and anticoagulants (blood-thinning medicines), such as warfarin and heparin.

In some cases, nosebleeds can be a symptom of another condition such as: 

  • a blood clotting abnormality - for example haemophilia (an inherited condition that affects the blood's ability to clot) or von Willebrand's disease (an inherited disorder that causes bleeding and bruising) , or l
  • Leukaemia (although this is rare and you are likely to have other symptoms as well).

The initial treatment for a nosebleed is always the same, regardless of what has caused it. The first step is always to stop the bleeding. The next step will be to consider what has caused it and what, if any, further action needs to be taken.

Stopping the bleeding

If you are having a nosebleed you should:

  • sit down and firmly pinch the soft part of your nasal cavity, just above your nostrils, for 10 minutes, 
  • lean forward and breathe through your mouth. Leaning forward drains the blood down your nose instead of down the back of your throat,
  • stay upright, rather than lying down, as this reduces the blood pressure in the veins of your nose and will discourage further bleeding,
  • maintain the pressure on your nose for up to 20 minutes (time this on the clock) so that the blood clots,
  • place a covered ice pack on your cheek to help soothe the area,
  • avoid blowing your nose, bending down and strenuous activity for at least 12 hours after a nosebleed. Try to keep your head above the level of your heart for this time.

Recurrent bleeding in children that arises from persistent crusting of the inside of the nostrils is best treated using a softening ointment such as petroleum jelly (Vaseline) to soften the inside of the nose.

See your GP if the bleeding is very heavy or if it does not stop after maintaining pressure for 20 minutes.

Also seek help if:

  • you often have more than one nosebleed a week (it may be due to an undiagnosed underlying condition),
  • you have had an injury to your head, such as a blow, or a fall (you may have broken your nose), or
  • you are taking an anticoagulant (a blood-thinning medicine), such as warfarin, and the bleeding does not stop, or re-occurs.

Nasal packing

If you seek medical help because your nosebleed has not stopped bleeding, your nose may be packed with ribbon gauze, or a special nasal sponge. The aim is to apply pressure to the source of the bleeding in order to cut off the flow of blood. This is done by packing the ribbon gauze inside your nose as far back as possible.

Your GP, or the healthcare professional who is treating you, will explain the process to you and tell you how long you will need to keep the pack in place. You should also be given an appointment to return to have it removed. After the bleeding has stopped, and your nose is unpacked, it will be thoroughly examined.

You should avoid any over-exertion while your nose is packed, and for 1-2 weeks afterwards. 

Further tests

Your GP may check your blood pressure and pulse rate to identify any underlying causes of your nosebleed. Frequent or heavy nosebleeds can be a symptom of some types of blood disorder, such as haemophilia, so your GP may order a blood test to see if your blood is clotting properly.

If your nosebleeds are found to be caused by medication that you are taking, such as blood-thinning medicines (anticoagulants) like aspirin, warfarin, or heparin, or an anti-inflammatory medicine, your GP may need to change, or adjust, these.

In severe cases, you may require surgery to your nose to prevent the nosebleeds happening again (see below).  If necessary, your GP will refer you to an ENT (ear, nose and throat) specialist.

Nasal fractures

Nasal fractures (cracks or breaks in the bones of the nose) account for nearly 50% of all facial fractures. Most fractures are simple and will not require an X-ray. However, if it is a more serious injury, an X-ray may be taken of your entire face and skull.

Fractures can cause a lot of swelling around the nose. It may take between 5-7 days for this to go down enough to allow a full examination. Once the swelling has settled, there is often little change to the shape of your nose and it can be left to heal alone.

If there is a change in the appearance of your nose it can be manipulated under anaesthetic by an ENT specialist (they will move your nose back into place using their hands). Manipulation is most effective within two weeks of injuring your nose.

Surgery for recurring nosebleeds

Your ENT specialist may recommend surgery if you have frequent nosebleeds and the cause can be identified. 

Septal surgery

Your septum (the wall between the two nose channels) can be crooked from birth, or it can become crooked following an injury. If it causes nosebleeds, you can have septal surgery to straighten it. This will be carried out under local or general anaesthetic and should take less than an hour.

As septal surgery  is surgery inside your nose, it should not leave any external scars. During the surgery, some of the bone and cartilage inside your nose is removed and the septum is moved back into the middle of your nose. Afterwards, you will have a dressing placed on your nose for a day or two to keep it in place and prevent bleeding. You will need to rest for a week, or for two weeks, if your job involves heavy lifting, or carrying.

After the operation, you may experience the following side effects:

  • bleeding up to 10 days after the surgery,
  • a blocked nose for two weeks after the surgery, though it can take up to three months for your breathing to clear completely, or
  • an infection in your nose (although this is rare).

Your ENT specialist will explain the procedure to you in more detail.

Cautery

A minor procedure to cauterise (burn) the place where the bleeding is coming from can be successful in stopping recurring nosebleeds. If a particular blood vessel is rupturing and causing your nosebleeds, it can be cauterised to prevent it happening again. This will be done with either:

  • an electric current running through a wire, (electrocautery), or
  • a chemical agent, on the end of a wool swab (chemical cautery). 

The bleeding area will be touched for around 10 seconds with one of the above in order to burn and seal it.

Cautery does have some associated problems - for example:

  • chemical cautery can be a painful experience, particularly for children, even with the use of a local anaesthetic,
  • it is also not always effective as bleeding can occur from around the cauterised area , and
  • it can only be used if a specific bleeding point can be identified.

Ligation

If other treatments do not work, ligation may be recommended. This involves tying off the end of the relevant blood vessel that is bleeding. Endoscopic surgery (using very fine instruments) can be used to tie off the end of the blood vessel so that blood can no longer escape from it. In some, rare cases, the main artery, which the bleeding blood vessel branches off from, may need to be tied off.

If the bleeding blood vessel is very far back in the nose, or if it is difficult to compress, more major surgery may be required. Some possible side effects of ligation include:

  • re-bleeding (the blood vessel still cause nosebleeds),
  • swelling, numbing, or bruising of the face, or
  • a dry, or runny, nose.

 

Glossary of Terms

Anti-inflammatory

Anti-inflammatory medicines reduce swelling and inflammation.

Artery

Arteries are blood vessels that carry blood from the heart to the rest of the body.

Blood

Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.

Blood vessel

Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.

High blood pressure

Hypertension is when the pressure of the blood in your bloodstream is regularly above 140/90 mmHG.

Local anaesthetic

A local anaesthetic is a drug that is injected by needle or applied as a cream, which causes a loss of feeling in a specific area of the body.

Swab

A swab is a small piece of absorbent material, such as gauze or cotton, attached to the end of a stick or wire. Swabs are used to clean wounds, apply medicine, or to absorb samples of body fluids so that they can be tested. 

 

Nosebleeds can sometimes be distressing due to the amount of visible blood loss, but they are very common.

If you have heavy or recurring nosebleeds, your GP may refer you to an ear, nose and throat (ENT) specialist for further investigation.

Anaemia

Excessive bleeding over a period of time can lead to anaemia (a group of disorders affecting red blood cells). Frequent (more than once a week), or heavy, nosebleeds can contribute to this condition if you are losing a lot of blood. Other symptoms, such as tiredness, will also be present. You should mention your nosebleeds to your GP if you suspect that you have anaemia.

Nasal deformity

A broken nose can result in a permanent change to the shape of your nose. If you break your nose, an ENT (ear, nose and throat) specialist will attempt to manipulate your nose (move it back into place with their hands) while you are under anaesthetic. However, this is not always effective and surgery may be required to correct the shape of your nose.

Nosebleeds are common, particularly in children, but some simple measures can help to prevent them:

  • do not pick your nose and discourage your children from doing so,
  • only blow your nose when necessary and do not blow it too hard,
  • wear appropriate protective clothing if you are playing a sport where your nose could get hit,
  • always follow the instructions of nasal decongestants, and
  • if you are prescribed anticoagulants (blood-thinning medicines) and have a history of nosebleeds, discuss your concerns with your GP.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.