NOSE BLEEDING

Epistaxis (from Greek επιστάζω (epistazo) to bleed from the nose: a nosebleed is the relatively common occurrence of hemorrhage from the nose, usually noticed when the blood drains out through the nostrils. Nosebleeds can be dramatic and frightening. Luckily, most nosebleeds are not serious and can be handled fairly easily. They are divided into two types, depending on whether the bleeding is coming from the anterior (front of the nose) or posterior (back of the nose).

A.   Anterior nosebleeds make up more than 90% of all nosebleeds. The bleeding usually comes from a blood vessel at the very front part of the nose. Anterior nosebleeds are usually easy to control, either by measures that can be performed at home or by a doctor.

B.   Posterior nosebleeds are much less common than anterior nosebleeds. They tend to occur more often in elderly people. The bleeding usually comes from an artery in the back part of the nose. These nosebleeds are more complicated and usually require admission to the hospital and management by an otolaryngologist (an ear, nose, and throat specialist).

In the United States, one of every seven people will develop a nosebleed at some time. Nosebleeds tend to occur during winter months and in dry, cold climates. Nosebleed also usually happens in Nigeria during harmattan. They can occur at any age but are most common in children aged 2 to 10 years and adults aged 50 to 80 years.

Nosebleed Causes

Most commonly, trauma to the nose triggers a nosebleed. Trauma to the outside of the nose, such as a blow to the face, or trauma inside the nose, such as nose picking or repeated irritation from a cold, can cause a nosebleed.

Less commonly, an underlying disease process, such as an inability of the blood to clot, may contribute to the bleeding. Inability of the blood to clot is most often due to blood-thinning drugs such as warfarin (Coumadin) or aspirin. Liver disease can also interfere with blood clotting. Abnormal blood vessels or cancers in the nose are rare causes of nosebleeds. High blood pressure may contribute to bleeding but is almost never the only reason for a nosebleed.

Nosebleed Symptoms

Bleeding usually occurs from only one nostril. If the bleeding is heavy enough, the blood can fill up the nostril on the affected side and overflow within the nasopharynx (the area inside the nose where the two nostrils merge), spilling into the other nostril to cause bleeding from both sides. Blood can also drip back into the throat or down into the stomach, causing a person to spit or even vomit blood.

1. Signs of excessive blood loss include dizziness, light-headedness, confusion, and fainting. Excessive blood loss from nosebleeds does not often occur.
2. Additional bleeding from other parts of the body, such as in the urine or bowels, or easy bruising may indicate an inability of the blood to clot.
3. Additional bleeding or easy bruising is a sign of a more significant medical problem.

When to call the doctor about nosebleeds:

1. If you have repeated episodes of nosebleeds
2. If you have additional bleeding from places other than the nose, such as in the urine or stool
3. If you bruise easily
4. If you are on any blood-thinning drugs, including aspirin or warfarin (Coumadin)
5. 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)
6. If you recently had chemotherapy

Go to the hospital for nosebleeds if:

1. You are still bleeding after pinching the nose for 10 minutes.
2. You are having repeated episodes of nosebleeds over a short time.
3. You feel dizzy or light-headed or like you are going to pass out.
4. You have a rapid heartbeat or trouble breathing.
5. You are coughing up or vomiting blood.
6. You have a rash or temperature greater than than 101.4°F (38.5°C).
7. Your doctor instructs you to go to a hospital's emergency department.

Nosebleed Exams and Tests

1. To examine the nose, the doctor places medications into the nostrils, usually with a cotton ball, that numb the inside of the nose as well as constrict the blood vessels in that area. This will also reduce swelling and allow the doctor to see inside the nose better
2. The diagnosis of a posterior nosebleed is usually made when attempts to control the bleeding when the measures used for an anterior nosebleed have failed. Seeing the source of a posterior nosebleed is nearly impossible.
3. Lab tests may be done to evaluate blood loss or the effects of blood thinning drugs.

Home Treatment for Nosebleeds

A small amount of bleeding from a nosebleed requires little intervention. A common scenario is when a person with a cold or a sinus infection blows his or her nose vigorously and notices some blood in the tissue. Avoiding any more vigorous nose blowing, sneezing, or nose picking is usually enough to keep the bleeding from getting worse.

o    To stop a nosebleed:

a)       Remain calm.

b)       Sit up straight.

c)       Lean your head forward. Tilting your head back will only cause you to swallow the blood.

d)       Pinch the nostrils together with your thumb and index finger for 10 minutes. Have someone time you to make sure you do not release the nostrils any earlier.

e)       Spit out any blood in your mouth. Swallowing it may make you vomit.

o    After the bleeding has stopped:

a)       Try to prevent any irritation to the nose, such as sneezing or nose blowing, for 24 hours.

b)       Ice packs do not help.

c)       Exposure to dry air, such as in a heated home in the winter, can contribute to the problem. Adding moisture to the air with a humidifier or vaporizer will help keep the nose from drying out and triggering more bleeding. Another option is to place a pan filled with water near a heat source, such as a radiator, which allows the water to evaporate and adds moisture to the air.

Anterior nosebleed

1. A minor nosebleed that has stopped may require no treatment at all. Frequently, the body will form a clot at the site of the bleeding that stops any further bleeding.
2. If the source of the bleeding is a blood vessel that is easily seen, a doctor may cauterize it (seal the blood vessel) with a chemical called silver nitrate. Cauterization is most effective when the bleeding is coming from the very front part of the nose.
3. In more complicated cases, a nasal packing may be required to stop the bleeding. The idea behind this is to put pressure from inside the nostril to halt the bleeding. Many different types of packings are available, ranging from petroleum (Vaseline) gauze to balloon packs to synthetic sponge packs that expand when moistened. The decision as to which one to use is usually made by the doctor.
4. Most people who receive an anterior nasal packing go home with it in place. Because these packings block the drainage pathways of the sinuses, antibiotics may be started to prevent a sinus infection. The packing is usually left in for 24-72 hours.

Posterior nosebleed

1. A posterior nosebleed that does not stop bleeding on its own requires admission to the hospital. A posterior nasal packing is required. Different types of packings are available, though a balloon pack is most commonly used.
2. Unlike the anterior nasal packings, posterior nasal packings are very uncomfortable and frequently require sedatives and pain medications. Complications can be associated with these packs, including infection and blockage of the breathing passages. Admission to the hospital and close monitoring are required.
3. Posterior packings are usually left in place for 48 to 72 hours. If this does not stop the bleeding, surgical or radiologic procedures can be performed.

Next Steps for Nosebleeds

1. Most people can be seen and discharged from a doctor’s office or the hospital's emergency department after treatment for a nosebleed. If nasal packing has been placed, do not try to remove the packing yourself. You need to be seen again, usually within one to three days, at which time the packing will be removed.
2. Try to avoid any further irritation of the nose. Do not blow your nose. Try not to sneeze or cough, if possible. Avoid any strenuous activities, such as heavy lifting or exercise.
3. If possible, try not to take any drugs that may interfere with normal blood clotting. These medications include aspirin or anti-inflammatory drugs such as ibuprofen (Motrin or Advil) or naproxen (Aleve or Naprosyn). If you take these drugs for a chronic medical condition, consult with your doctor about to what to do. Acetaminophen (Tylenol) can be taken for fever or pain.

Nosebleed Prevention

1. Most nosebleeds occur during the winter in cold, dry climates. If you are prone to nosebleeds, use a humidifier in your home. Use petroleum jelly (Vaseline), an over-the-counter nasal lubricant spray, or a saline nasal spray to keep your nasal passages moist.
2. Avoid picking your nose or blowing your nose too vigorously.
3. If the nosebleed is related to another medical condition, such as liver disease or a chronic sinus condition, follow your doctor’s instructions to keep that problem under control.
4. Stop smoking. Smoking contributes to nasal dryness and irritation.

REFERENCES

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5.       The Journal of Laryngology & Otology (2008), 122: 1074-1077

6.         Guarisco JL, Graham HD (1989). "Epistaxis in children: causes, diagnosis, and treatment". Ear Nose Throat J 68 (7): 522, 528–30, 532 passim. PMID 2676467.

7.         MedlinePlus Medical Encyclopedia: Nosebleed U.S. National Library of Medicine Medline Plus service. Retrieved 2010-03-15.

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