Nosebleed

Definition

A nosebleed is loss of blood from the mucous membranes that line the nose, most commonly from one nostril only.

Considerations

Nosebleeds are very common. Most nosebleeds occur because of minor irritations or colds.  They can be frightening for some patients but are rarely life threatening.

The nose has an abundant supply of tiny blood vessels, which makes it easy for the nose to bleed. Air moving through the nose can dry and irritate the membranes lining the inside of the nose. The lining develops crusts that bleed when irritated by rubbing, picking, or blowing the nose.

The lining of the nose is more likely to become dry and irritated from low humidity and dry environment, allergic rhinitis, colds, or sinusitis. A deviated septum, foreign objects in the nose, or other nasal obstruction may cause also cause nosebleeds. A direct impact to the nose can also cause a nosebleed.

Most nosebleeds occur on the tip of the nasal septum, which contains many fragile, easily damaged blood vessels. More rarely, nosebleeds may occur higher on the septum or deeper in the nose. These higher or deeper nosebleeds may be harder to control.

Occasionally, nosebleeds may indicate other disorders such as bleeding disorders, hypertension, or arteriosclerosis. Hereditary hemorrhagic telangiectasia (also called HHT or Osler-Weber-Rendu syndrome, a disorder involving a vascular growth similar to a birthmark in the back of the nose) may be evidenced by nosebleeds.

Sometimes blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds. Most nosebleeds begin on the septum -- the midline, vertical cartilage that separates the nasal chambers and is lined with fragile blood vessels. This form of nosebleed is not serious, and is usually easy to stop.

Causes

• Sudden trauma to the nose, very cold or very dry air, fragile blood vessels, nasal sprays, strenuous exercise, or picking the nose cause most nosebleeds.
• Recurrent nosebleeds may be a symptom of an underlying disorder such as high blood pressure, taking large doses of aspirin or blood-thinning medication, allergies, a bleeding disorder, or a tumor of the nose or sinuses.
• Most nosebleeds come from blood vessels in the front of the nose. Some are caused by bleeding from the back of the nose into the throat (posterior bleeding) -- these are more difficult to control and almost always require medical attention.

Symptoms

• Bleeding from one or both nostrils.
• Frequent swallowing.
• Sensation of fluid in the back of the nose and throat.

First Aid

Sit down and gently squeeze the soft portion of the nose between your thumb and finger (so that the nostrils are closed) for about 5-10 minutes. Lean forward to avoid swallowing the blood and breathe through your mouth. Wait at least 5 minutes before checking if the bleeding has stopped. Almost all nose bleeds can be controlled in this way if sufficient time is allowed for the bleeding to stop.

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.

Do Not

Lying down with a nose bleed is not recommended, and you should avoid sniffing or blowing your nose for several hours after a nosebleed.

Call immediately for emergency medical assistance if

Get emergency care if:

• The bleeding does not stop after 20 minutes.
• A nosebleed occurs after an injury to the head -- this may indicate a skull fracture. (X-rays should be taken no matter how trivial the blow seemed to be at the time.)
• Your nose may be broken (for example, it is misshapen after a blow or injury).

Call your doctor for an appointment if you or your child has repeated nosebleeds, particularly if they are becoming more frequent and if they are not associated with a cold or other minor irritation.

Persistent nosebleeds may require urgent medical care such as packing, embolization, or surgery.

Prevention

A cooler house and a vaporizer, to return humidity to the air, help many people with frequent nosebleeds. Nasal saline spray also can help prevent nosebleeds, especially during the winter months.

References

Marx J. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, MO: Mosby; 2002:933.

Cummings CW, Flint PW, Haughey BH, et al. Otolaryngology: Head & Neck Surgery. 4th ed. St Louis, Mo; Mosby; 2005:942-960.

Illustrations

Nosebleed

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