What is nose bleeds

A nose bleed also called epistaxis, is loss of blood from the tissue lining your nose. Bleeding most often occurs in one nostril only. Nosebleeds are very common. Most nosebleeds occur because of minor irritations, after an injury or colds. Most nosebleeds are mild and do not last long. Nose bleeds are common in children and older people with medical conditions.

Although nose bleeds can be scary, they’re generally only a minor annoyance and aren’t dangerous. Frequent nosebleeds are those that occur more than once a week.

In the United States, one of every seven people will develop a nosebleed some time in their lifetime. Nosebleeds can occur at any age but are most common in children aged 2-10 years and adults aged 50-80 years.

Older people and people with medical conditions, such as blood disorders or those taking blood-thinning medicines, can also be more likely to experience nosebleeds. In these cases the bleeding can be severe and medical assistance may be needed to stop the bleeding.

Nose bleeds can often occur if you:

• Have allergies, infections, or dryness that cause itching and lead to picking of the nose.
• Pick your nose
• Blow your nose too hard that ruptures superficial blood vessels
• Strain too hard on the toilet
• Have an infection in the nose, throat or sinuses
• Low humidity or irritating fumes: If your house is very dry, or if you live in a dry climate, the lining of your child’s nose may dry out, making it more likely to bleed. If he is frequently exposed to toxic fumes (fortunately, an unusual occurrence), they may cause nosebleeds, too.
• Receive a bump, knock or blow to the head or face
• Have a cold
• Have a bunged-up or stuffy nose from an allergy.
• Anatomical problems: Any abnormal structure inside the nose can lead to crusting and bleeding (e.g., deviated septum)
• Are taking some types of medicines, such as anticoagulants (e.g., warfarin) or anti-inflammatories (e.g., aspirin) or nose sprays
• Clotting disorders that run in families or are due to medications.
• •Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously.
• •Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.
• Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.

In general, nose bleeds are not a symptom or result of high blood pressure. It is possible, but rare, that severe high blood pressure may worsen or prolong bleeding if you have a nosebleed.

How do I stop a nosebleed?

• •Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who’s been reassured and supported.
• Keep head higher than the level of the heart. Sit up.
• Sit down and lean slightly forward so the blood won’t drain in the back of the throat.
• Gently blow any clotted blood out of the nose.
• Using the thumb and index finger, pinch all the soft parts of the nose. Do not pack the inside of the nose with gauze or cotton.•
• Hold the position for five to ten minutes. If it’s still bleeding, hold it again for an additional 10 to 15 minutes.

Once the bleeding has stopped, encourage your child not to blow or pick his nose for about 24 hours. This will help the blood clot in his nose to strengthen.

Your child might vomit during or after a nosebleed if she has swallowed some blood. This is pretty normal, and your child should spit out the blood.

When the bleeding won’t stop

If you can’t stop the bleeding with the treatment steps above, you should take your child to the doctor or hospital emergency department.

The doctor might put some cream or ointment up your child’s nose to help stop the bleeding.

Another treatment can involve nose-packing. This is where the doctor puts a special cloth dressing into your child’s nose. Your child will need a follow-up appointment 24-48 hours later to have the dressing taken out.

Cautery is another common treatment. This is where a special chemical is used to seal off the bleeding and ‘freeze’ the blood vessel. Doctors usually use anaesthetic for cautery.

Very rarely your child might need to see an ear, nose and throat specialist and go into hospital for treatment.

After a bleeding nose

Here’s what to do after your child has had a bleeding nose:

• Ensure your child rests over the next 24 hours.
• Keep your child out of hot baths.
• Encourage your child not to pick or blow her nose.

Sometimes a doctor will recommend that your child uses a saline nasal spray or lubricating ointment to help with dryness. The doctor might also recommend using an antibiotic ointment, which you’ll need to put up your child’s nose.

Why do people get nose bleeds

The nose is an area of the body that contains many tiny blood vessels (or arterioles) that can break and bleed easily (see Figure 1). Air moving through the nose can dry and irritate the membranes lining the inside of the nose. Crusts can form that bleed when irritated. Nosebleeds occur more often in the winter, when cold viruses are common and indoor air tends to be drier.

Nosebleeds are divided into two types, depending on whether the bleeding is coming from the front or back of the nose.

Most nosebleeds occur on the front of the nasal septum (anterior nosebleed). This is the piece of the tissue that separates the two sides of the nose. This type of nosebleed can be easy for a trained professional to stop. Less commonly, nosebleeds may occur higher on the septum or deeper in the nose such as in the sinuses or the base of the skull. Such nosebleeds may be harder to control. However, nosebleeds are rarely life threatening.

Figure 1. Arteries involve in nose bleeds (nasal septum)

Figure 2. Nose cartilage (nasal septum)

Figure 3. Nose external anatomy

What is an anterior nosebleed?

Most nosebleeds (or epistaxes) begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. Nosebleeds coming from the front of the nose, (anterior nosebleeds) often begin with a flow of blood out one nostril when the patient is sitting or standing.

Anterior nosebleeds are common in dry climates or during the winter months when dry, heated indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of petroleum jelly or an antibiotic ointment on the end of a fingertip and then rubbing it inside the nose, especially on the middle portion of the nose (the septum).

What is a posterior nosebleed?

More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat, even if the patient is sitting or standing.

Obviously, when lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow toward the back of the throat, especially if coughing or blowing the nose. It is important to try to make the distinction between the anterior and posterior nosebleed, since posterior nosebleeds are often more severe and almost always require a physician’s care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face.

Recurring nosebleeds

Recurring nosebleeds can be a nuisance, but are usually nothing to worry about. However, you should discuss it with your doctor as they may want to investigate that there is no underlying medical condition which is causing the bleeds.

If your nosebleeds persist and become a problem, you may need treatment, such as surgery to cauterize (burn) the blood vessels in the nose. Talk to your doctor about your options.

What to expect at your doctor

Your doctor will perform a physical exam. In some cases, you may be watched for signs and symptoms of low blood pressure from losing blood, also called hypovolemic shock.

You may have the following tests:

• Complete blood count (CBC)
• Nasal endoscopy (examination of the nose using a camera)
• Partial thromboplastin time measurements
• Prothrombin time (PT)
• CT scan of the nose and sinuses

The type of treatment used will be based on the cause of the nosebleed. Treatment may include:

• Controlling blood pressure
• Closing the blood vessel using heat, electric current, or silver nitrate sticks
• Nasal packing
• Reducing a broken nose or removing a foreign body
• Reducing the amount of blood thinner medicine or stopping aspirin
• Treating problems that keeps your blood from clotting normally

You may need to see an ear, nose, and throat (ENT) specialist for further tests and treatment.

How to stop nose bleeds

To stop a nosebleed:

• Sit upright and lean forward. By remaining upright, you reduce blood pressure in the veins of your nose. This discourages further bleeding. Sitting forward will help you avoid swallowing blood, which can irritate your stomach.
• Gently blow your nose to clear out any clotted blood.
• Pinch your nose. Use your thumb and index finger to pinch both nostrils shut, even if only one side is bleeding. Breathe through your mouth. Continue to pinch for 10 to 15 minutes by the clock. This maneuver puts pressure on the bleeding point on the nasal septum and often stops the flow of blood. If the bleeding is coming from higher up, the doctor may need to apply packing up into your nose if it doesn’t stop on its own.
• Wait at least 10 to 15 minutes before checking if the bleeding has stopped. Be sure to allow enough time for the bleeding to stop.
• Repeat. If the bleeding doesn’t stop, repeat these steps for up to a total of 15 minutes.

After the bleeding has stopped, to keep it from starting again, don’t pick or blow your nose and don’t bend down for several hours. Keep your head higher than the level of your heart.

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. If bleeding persists, a nasal spray decongestant (Afrin, Neo-Synephrine) can sometimes be used to close off small vessels and control bleeding.

Things you can do to prevent frequent nosebleeds include:

• Keep the home cool and use a vaporizer/humidifier to add moisture to the inside air. A humidifier will counteract the effects of dry air by adding moisture to the air.
• Use nasal saline spray and water-soluble jelly (such as Ayr gel) to prevent nasal linings from drying out in the winter.
• Keeping the lining of the nose moist. Especially during colder months when air is dry, apply a thin, light coating of petroleum jelly (Vaseline) or antibiotic ointment (bacitracin, Neosporin) with a cotton swab three times a day. Saline nasal spray also can help moisten dry nasal membranes.
• Trimming your child’s fingernails. Keeping fingernails short helps discourage nose picking.

Tips to prevent a nosebleed

• •Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Commonly used products include Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline.
• Keep children’s fingernails short to discourage nose-picking.
• Counteract the effects of dry air by using a humidifier.
• Use a saline nasal spray to moisten dry nasal membranes.•
• Quit smoking. Smoking dries out the nose and irritates it.

Tips to prevent rebleeding after initial bleeding has stopped

• Do not pick or blow nose.•
• Do not strain or bend down to lift anything heavy.•
• Keep head higher than the heart.

If rebleeding occurs

• Attempt to clear nose of all blood clots.•
• Spray nose four times in the bleeding nostril(s) with a decongestant spray.•
• Repeat the steps to stop an anterior nosebleed.•
• See a doctor if bleeding persists after 30 minutes or if nosebleed occurs after an injury to the head.

Nosebleeds in children

A child with a nosebleed may be very frightened or distressed about it. Try to comfort and reassure your children that nosebleeds are very common and lots of other kids get them. It doesn’t mean they are ill, and they will get better very soon.

Some toddlers and young children like to put small foreign objects into their ears or noses, or swallow things that aren’t food, out of curiosity. They’re experimenting with the world around them and learning what happens when they try different things.

If an item becomes stuck in your child’s nose, you should not try to remove the object yourself. You should take the child to your nearest doctor or emergency department for further treatment.

Pushing an object, especially a sharp one, up the nose, can cause damage that leads to bleeding from the nose.

If the object falls back into the throat and your child can start to choke, call your local emergency services number for an ambulance. If the object contains chemicals (like a battery) or is a bean (which can swell) you should go to the Emergency Department.

Signs your child has a foreign object stuck in his/her nose

Your child might:

• complain of pain or itchiness
• have a smelly discharge from one nostril
• bleed from the nose
• have bad breath.

Foreign objects to look out for

Children under four years are most at risk of inserting or swallowing small foreign objects, so keep the following out of reach of your child:

• foods such as popcorn, dried peas, watermelon seeds, nuts and chocolate with nuts
• marbles, buttons, beads and pen lids
• polystyrene balls found in bean bags and stuffed toys − these can be inhaled and don’t show up on x-rays
• coins
• small batteries, which can leak acid and cause injury if swallowed
• toys with removable eyes, noses or other small parts
• needles, pins and safety pins.

It’s best to use pins with a safety catch, and keep them closed when you’re not using them. Also avoid putting safety pins in your mouth, because your child might copy you.

Preventing foreign objects from being swallowed, inhaled or inserted

It’s important to try to identify potentially risky situations ahead of time. These tips can help:

• Supervise toddlers and small children while they eat − they like to experiment and play with food, which can lead to injuries. Encourage your child to sit quietly when eating and drinking.
• Don’t give your child popcorn or nuts (especially peanuts) until he’s at least three years old. A thin layer of peanut butter or hazelnut spread on bread is a good alternative.
• Cut all food into small pieces, and remove sharp or small bones from fish, chicken and meat before giving them to your child. Preboned fillets can be a good option.
• Try to wait until your child is four years old before letting her eat small lollies. Lollies are sometimes food and best saved for special occasions anyway.
• Avoid glitter, glue and small beadwork.
• Teach older siblings that a baby’s ears and nose are delicate, and that they’re not for poking things into.
• It’s best to sand or polish any rough, splintery timber your child might come into contact with – for example, on old furniture or veranda rails.
• Check the floor and low tables for pieces of jewellery, dried peas and other small objects.

What can cause nose bleeds

The two most common causes of nosebleeds are:

• Dry air — when your nasal membranes dry out, they’re more susceptible to bleeding and infections
• Nose picking

Other causes of nose bleeds include:

• Acute sinusitis (sinus infection)
• Allergies
• Aspirin use
• Bleeding disorders, such as hemophilia
• Blood thinners (anticoagulants), such as warfarin and heparin
• Blowing the nose very hard, or picking the nose
• Chemical irritants, such as ammonia, including medicines or drugs that are sprayed or snorted
• Chronic sinusitis
• Cocaine use
• Common cold
• Deviated septum
• Foreign body in the nose
• Irritation due to allergies, colds, sneezing or sinus problems
• Nasal sprays, such as those used to treat allergies, if used frequently
• Nonallergic rhinitis (chronic congestion or sneezing not related to allergies)
• Overuse of decongestant nasal sprays
• Oxygen treatment through nasal cannulas
• Trauma to the nose, including a broken nose, or an object stuck in the nose
• Very cold or dry air

Less common causes of nosebleeds include:

• Alcohol use
• Hereditary hemorrhagic telangiectasia
• Idiopathic thrombocytopenic purpura (ITP)
• Leukemia
• Nasal and paranasal tumors
• Nasal polyps
• Nasal surgery
• Pregnancy
• Sinus or pituitary surgery (transsphenoidal)

Repeated nosebleeds may be a symptom of another disease such as high blood pressure, a bleeding disorder, or a tumor of the nose or sinuses. Blood thinners, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, may cause or worsen nosebleeds.