Persistent Nosebleeds (Epistaxis)

Clinically speaking, nosebleeds are referred to as epistaxis, defined as bleeding from the nostril, nasal cavity, or nasopharynx.

Nosebleeds are considered commonplace. The location of the nose in the middle of the face and the large number of blood vessels close to the surface in the lining of your nose make it an easy target for injury. In fact, in the United States, approximately 60% of the population will experience epistaxis at some point in their lives.

In most cases, nosebleeds are rarely life threatening and usually stop on their own. While most nosebleeds can be handled at home, certain symptoms / scenarios do necessitate professional medical attention.

TYPES

There are two categories of nosebleeds:

• Anterior nosebleeds (common) occur when the bleeding is coming from the front of the nose, typically the septum. The septum contains many tiny blood vessels that can be easily broken by a blow to the nose or the edge of a sharp fingernail. Anterior nosebleeds often begin with a flow of blood out one or both nostrils when the patient is sitting or standing.
• Posterior nosebleeds (less common) originate from further back in the nose often where the source of bleeding cannot be seen without examination, and may flow down the throat, even if the patient is sitting or standing. Posterior nosebleeds involve large blood vessels and are often more severe and almost always require a physician’s care. Medical attention for this type of bleed is urged, especially if the bleeding occurs after an injury and the bleeding hasn’t stopped after 20 minutes of applying direct pressure.

NOSEBLEED CANDIDATES

Anyone can get a nosebleed. However, there are categories of people for whom nosebleeds are more likely / common:

• Children between ages two and 10. Dry air, colds, allergies and sticking fingers and objects into their nose make children more prone to nosebleeds.
• People who have blood clotting disorders, such as hemophilia or von Willebrand disease.
• Adults between ages 45 and 65. Blood may take longer to clot in mid-life and older adults.
• Pregnant women. Blood vessels in the nose expand while pregnant, which puts more pressure on the delicate blood vessels in the lining of the nose.
• People who take blood-thinning drugs such daily aspirin or warfarin) and /or have high blood pressure, or atherosclerosis (hardening of the walls of arteries).

CAUSES

There are innumerable causes for recurring or frequent nosebleeds, including, but not limited to:

• Alcohol use
• Allergic and non-allergic rhinitis (inflammation of the nasal lining)
• Blood-thinning drugs (aspirin, non-steroidal anti-inflammatory drugs, warfarin, and others)
• Blowing your nose with force
• Chemical irritants / fumes
• Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing and nose blowing.
• Deviated septum
• Dry air
• Foreign object in the nose
• Frequent use of nasal sprays and medications to treat itchy, runny or stuffy nose.
• Hemophilia or other bleeding disorders
• High altitudes. The air is thinner (lack of oxygen) and drier as the altitude increases.
• High blood pressure
• Illicit drug use through the nose
• Injury to the nose and/or face
• Nasal polyps
• Nasal tumors
• Nose picking
• Pregnancy
• Sinusitis
• Tumors

TREATING NOSEBLEEDS

There is no single definitive treatment for the management of chronic nosebleeds and many factors including severity of the bleeding, use of anticoagulants, and other medical conditions can play a role in which treatment is utilized.

Treatment options for epistaxis may include:

• Localized pressure (i.e., pinching the nose – see below)
• Decongestant nasal sprays
• Chemical or electric cautery (burning the vessel shut)
• Hemostatic agents (topical therapies to stop bleeding)
• Nasal packing
• Embolization (a procedure to place material within the vessel to block it off)
• Surgical arterial ligation (tying off the vessel).

A posterior nosebleed that does not stop bleeding on its own requires admission to the hospital.

HOW TO STOP ANTERIOR NOSEBLEEDS

Most nosebleeds resolve within a few minutes and are easily treated at home. Some tips to help a nosebleed stop:

• Stay calm, or help a young child stay calm.
• Lean slightly forward, chin tucked to chest to avoid swallowing any blood.
• Gently blow any clotted blood out of the nose.
• Pinch the soft parts of the nose between your thumb and two fingers. Breathe through your mouth.
• Hold it for 20 minutes without releasing (timed by a clock).
• If it’s still bleeding, hold it again for an additional 10 minutes.
• Do not pack the inside of the nose with gauze or cotton.

To prevent rebleeding after initial bleeding has stopped:

• Do not pick, rub, or blow nose.
• Sneeze with mouth open.
• Do not strain or bend down to lift anything heavy.
• Dab a pea-sized amount of lubricant (normal saline gel, Vaseline®, antibiotic ointment) on the end of your fingertip and gently apply it inside the nose on the middle portion (the septum) to keep the surface lubricated.