Nosebleeds

The most frequent location for a nosebleed is the nasal septum, which is the wall that separates the two sides of the nose. In particular, the majority of nosebleeds occur in a region of the nasal septum where four arteries connect to form Kiesselbach's plexus.

Nosebleeds are most commonly caused by dry air. They are more common during winter months, when heating is used indoors. As dry air passes through the nose, it can irritate the membranes that line the inside of the nose. The irritation can cause crusts to form around the fragile blood vessels. The crusts then cause irritation or itchiness, and when scratched or picked, can cause a nosebleed.

Nosebleeds are normally not serious, but frequent or heavy nosebleeds may indicate a more serious underlying medical condition. Nosebleeds can occur at any age, but younger children (under the age of 10) have more nosebleeds than older children, and adults most susceptible to nosebleeds are those aged 70-79.

Nosebleeds in children can be frightening for both the child and parent, but they normally stop on their own, and can usually be safely managed with home care. However, for older people, nosebleeds may present a more serious threat and may be associated with another underlying condition.

Most episodes of nosebleeds can be well managed with first aid at home, or treatment from a healthcare professional. Surgical intervention is rarely needed.

The majority of nosebleeds occur in a region of the nasal septum called Kiesselbach's plexus. 

Causes

• Trauma to the outside of the face;
• Trauma inside the nose, such as nose-picking;
• Taking antihistamines, which can dry out the nasal membranes;
• Frequent nose-blowing;
• Constipation - excessive straining;
• Excessive alcohol consumption;
• Cocaine use;
• Very cold or dry air;
• Irritation caused by allergies or colds;
• Sneezing;
• Deviated septum;
• Chemical irritants;
• Overuse of decongestant nasal sprays, and;
• A foreign object in the nose (most common in children).

Less commonly, nosebleeds are caused by an underlying condition, such as blood clotting problems caused by taking anticoagulant drugs such as warfarin or aspirin. Liver disease may also cause nosebleeds. Although high blood pressure (hypertension) can contribute to nosebleeds, it does not commonly cause them.

Types

Nosebleeds can be classified as anterior or posterior, based on the location of the vessel that bleeds.

Anterior nosebleeds

Bleeding is from a blood vessel at the front part of the nose. Anterior nosebleeds comprise around 90% of all nosebleeds, but are generally easy to control.

Posterior nosebleeds

Bleeding is from an artery in the back part of the nose. These nosebleeds are much less common. They tend to occur in elderly people, are generally more complicated and may require hospital admission.

Signs and symptoms

Nosebleeds typically only occur in one nostril, except in cases where there is heavy bleeding that fills up the nostril on the affected side, which then overflows in the back of the nose and flows out of the other nostril.

Some of the symptoms that may accompany a nosebleed include:

• Blood that drips down the back of the throat and into the stomach, making the person spit up or vomit the blood, and;
• Rarely, excessive blood loss that causes dizziness, light-headedness, confusion and fainting.

Methods for diagnosis

Most mild anterior nosebleeds in healthy people can be self-diagnosed and treated at home. Recurrent or heavy nosebleeds and those that are accompanied by other symptoms may need further treatment from a healthcare professional.

Your doctor may take a detailed medical history to assess:

• If there has been recent trauma or surgery;
• How frequent and severe the nosebleeds are;
• What other symptoms accompany the nosebleeds;
• If you are taking non-steroidal anti-inflammatory drugs (NSAIDs) or anticoagulants, and;
• What other medical conditions are present.

Your doctor may examine the nose, and nasendoscopy can be used to examine the surfaces of the inside of the nose to identify the origin of the nosebleed. A posterior nosebleed is usually diagnosed when the bleeding is heavy and cannot be controlled using routine measures.

In some cases, diagnostic tests may be used to measure the rate at which the blood clots to assess if there is an underlying bleeding disorder. Some patients may have a computerised tomography (CT) scan carried out to closely examine their nose and sinuses to identify the source of the nosebleed. When the bleeding has been heavy, a full blood count test may be ordered to assess the degree of blood loss.

Types of treatment

For healthy people, nosebleeds involving a small amount of blood that are not caused by head trauma can generally be treated at home using first aid.

First aid and home care for nosebleeds

To stop a nosebleed at home:

• Sit down and gently squeeze the soft portion of the nose for 10 minutes;
• Lean forward to avoid swallowing the blood and breathe normally through the mouth;
• For a child, sit them upright in a comfortable position and lean them slightly forward;
• Do not keep checking to see if the bleeding has stopped;
• Encourage the child to spit out any blood that has dripped into the back of the throat, and;
• Using a cold compress or ice across the bridge of the nose and around the neck can help stop the bleeding.

Once the nosebleed has stopped:

• Avoid inserting gauze inside the nose;
• Avoid lying down during the nosebleed;
• Encourage your child to rest for the next 12-24 hours;
• Avoid giving your child hot drinks, a hot bath or shower for at least 24 hours;
• Avoid sniffing or blowing the nose for several hours, and;
• Encourage your child to avoid picking their nose for the next 24 hours.

Seek medical attention if the nosebleed fails to respond to basic first aid measures, or for a nosebleed associated with:

• Head trauma;
• Heavy bleeding;
• Frequent recurrence, or;
• Underlying medical conditions.

Medical management

Nasal spray

The blood-clotting process may be sped up by spraying the inside of the nose with co-phenylcaine, a medication containing an anaesthetic and vasoconstrictor, to help stop bleeding.

Chemical cauterisation

Silver nitrate may be used to create a superficial burn to the nasal membrane at the site of the bleeding vessel. Topical anaesthetic is first applied around the bleeding site inside the nose, and an application wand tipped in silver nitrate is rolled across the affected area. Although only minimally invasive, this procedure is not as effective as electrocauterisation (see below).

Electrocauterisation

An electric current is used to create a burn to the nasal membrane at the site of the bleeding vessel. Unlike chemical cauterisation, this procedure produces a deeper burn with greater scarring. This procedure has a high success rate, but may be more painful than chemical cauterisation and may need to be carried out under general anaesthetic.

Nasal packing

This involves inserting a tampon-like device into the nose to apply constant pressure across the source of bleeding. This packing stays in place for up to several days, and works by effectively collapsing the vessels and preventing further nosebleeds.

Embolisation

This involves insertion of a catheter in the groin and up through to the nasal area. The catheter is used to inject material into the blood vessel to cause it to clot and stop bleeding.

Nosebleeds caused by medication

Further nosebleed episodes attributed to anticoagulants or NSAIDs can be prevented or reduced by changing the dosage of the medication, or stopping it altogether.

Prognosis

The prognosis for children with nosebleeds is generally excellent. However, nosebleeds associated with another underlying medical condition may have a more variable prognosis.

Prevention

Measures you can take to avoid nosebleeds include:

• Wearing protective equipment for the head and face during contact sports to reduce the chance of injury;
• For people who are prone to nosebleeds during the winter months, using a humidifier to reduce the recurrence, as well as using petroleum gel or saline nasal spray to keep the nasal passages moist;
• Avoiding nose-picking and vigorous nose-blowing;
• Where applicable, treating the underlying medical condition;
• Quitting smoking, and;
• Avoiding excessive alcohol consumption.