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Epistaxis, (1) commonly known as a nosebleed, is a medical condition wherein blood flows out of one or both of the nostrils due to some kind of irritation or injury to the blood vessels lining the inside of the nose.
These blood vessels are fairly superficial, which means that they can be easily damaged with the slightest irritation.
It can take a few seconds to over 10 minutes for a nosebleed to cease completely. The volume of blood flow can range from light to heavy in different cases of epistaxis.
Global Incidence of Nosebleeds
Nosebleeds are common with as many as 60% of the global population experiencing this ordeal at least once in their life. (2) Merely 10% of all nosebleed episodes are serious enough to warrant medical help, while most of them resolve on their own.
Although people from all age groups are susceptible to nosebleeds, it is more prevalent among young children (aged 2–10 years) and older adults (aged 50 – 80 years). (2)
The risk of such severe nosebleeds increases with age, which means the geriatric population is the most affected.
Types of Nosebleeds
Nosebleeds are basically of two types:
1. Anterior nosebleeds
Anterior nosebleeds are usually characterized by light bleeding that occurs in the front part of the nose and runs out through either of the two nostrils.
2. Posterior nosebleeds
Posterior nosebleeds, as the name suggests, start at the back of the nose and usually involve fairly heavy bleeding that may trickle out of both nostrils. A substantial amount of blood may even drain down the throat.
This condition is mostly a consequence of some underlying health problem and affects the elderly population more than the young ones.
Causes of Nosebleeds
Several causes can trigger a nosebleed.
1. Environmental causes
- Living in an arid environment can render your nasal membrane increasingly dry and cracked, resulting in a nosebleed.
- Traveling to higher altitudes can also cause your nose to bleed due to the gradual loss of oxygen and humidity from the air.
- During winters, indoor heating can suck the moisture from the air and dry out your nasal membranes.
- Nosebleeds are also a common occurrence in areas with high temperatures but low humidity.
- Exposure to chemical irritants and polluted air can also irritate the lining of your nose and make it prone to bleeding.
- Air pollution is another precipitating factor for nosebleeds.
2. Local causes
- Picking and scratching the nasal mucosa can lead to erosion of the blood vessels and can result in bleeding.
- Incessant and forceful nose blowing or sneezing can exert a great deal of trauma on the sensitive lining of the inner nose and trigger a nosebleed.
- Insertion of any foreign object inside the nasal cavity can damage the inner lining and trigger a nosebleed.
3. Systemic causes
- Excessive alcohol intake, smoking, and vaping can dry out your nose from within and make you more prone to nosebleeds.
- Certain health conditions such as hypertension, cancer, upper respiratory infections, vascular malformations, and bleeding disorders that keep your blood from clotting, including Von Willebrand disease and hemophilia, can cause nosebleeds.
- People who run low on certain vital nutrients such as vitamins C and K exhibit an increased tendency for nosebleeds.
- Women often suffer nosebleeds during pregnancy on account of certain hormonal fluctuations.
- Overuse of certain medications that have a blood-thinning effect can also induce a nosebleed. These include nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, anticoagulants such as warfarin, and platelet aggregation inhibitors such as clopidogrel, among others.
- The use of recreational drugs such as cocaine is another major contributor to nosebleeds.
- People with Osler-Weber-Rendu syndrome, also called hereditary hemorrhagic telangiectasia (HHT), are also frequent sufferers of nosebleeds because this genetic disorder leads to abnormalities in the formation of mucosal blood vessels. (3)
- People with a deviated septum are at an increased risk of nosebleeds.
- Nosebleeds are often a complication of facial or nasal surgery.
- A nosebleed can also be a manifestation of an allergic reaction.
Signs and Symptoms of Nosebleeds
Most cases of nosebleed are characterized by the dripping of blood from a single nostril; unless your bleeding is unusually heavy, in which case, there may be spillage into the other nostril as well.
The overflowing blood may even trickle down the throat and into the stomach and later be coughed up in the form of bloodied sputum or vomit.
In rare cases, people may even encounter various signs of weakness during a heavy nosebleed, such as:
- Confusion
- Faint-headedness
- Unusual sense of fatigue
- Fainting
First Line of Treatment for Nosebleeds
Here’s what you need to do to get relief from a nosebleed.
1. Pinch the nose
Perhaps the most common way to stop a regular nosebleed is to apply pressure to the source of bleeding on the nasal septum. The pinch-the-nose strategy works on the same principle and almost always yields quick results.
- Sit with your spine erect, and your head tipped slightly forward.
- Firmly pinch the soft cartilage portion of the nose located just below the bony bridge with your thumb and index finger.
- Hold this position continuously for at least 10–12 minutes.
- Breathe through your mouth, and try to stay calm.
- Slowly release the pressure from your nose.
- Sit quietly and rest for 5 minutes; do not pick or blow your nose as this could cause the bleeding to recur.
- If the bleeding continues, squeeze your nose for an additional 10 minutes.
- Repeat the process until the bleeding stops.
2. Apply a cold compress
A cold compress or an ice pack may help stop the blood flow by shrinking the blood vessels inside the nose.
- Wrap a few ice cubes in a towel or cloth.
- Tilt your head back while sitting up straight.
- Apply the ice pack to the bony nasal bridge of your nose for 5–10 minutes.
- Repeat the process until the bleeding stops.
Note: To reiterate, always wrap the ice in a cloth or towel before applying it to your skin, as direct application can further irritate the skin and even cause frostnip.
Medical Treatment for Nosebleeds
Prolonged or excessive bleeding from the nose may warrant medical assistance. Some of the most commonly used or recommended medical interventions, (4) for nosebleeds include:
- Saline nasal drops or sprays
- Nasal cauterization with silver nitrate
- Thrombogenic foams and gels
- Pressure application with anterior nasal packing using gauze or inflatable latex balloons
- Nasal tampons such as Rapid Rhino and Rhino Rocket
Diagnosing the Cause of Nosebleeds
A nosebleed is typically a result of some underlying health problem that can be diagnosed through the following tests:
- Nasal endoscopy
- Complete blood count
- CT scan
- Partial thromboplastin time
- X-ray, in some cases
Self-Care Tips
Here are some simple measures to keep your nasal membranes well hydrated and less prone to bleeding:
- Avoid exerting your body or doing any kind of heavy lifting after a recent nosebleed, as the undue physical strain can trigger another episode.
- If you feel like you are about to break into a sneeze, open your mouth fully to let it out. This helps minimize the pressure on the nasal cavity.
- The need to maintain optimum fluid intake cannot be stressed enough, as this is one of the foundational steps for keeping the nasal membranes along with the rest of your body hydrated.
- Breathing in steam while taking a warm shower may help soothe your irritated nasal membranes.
- Application of petroleum jelly to the inner lining of the nose may be protective to some degree, as it helps protect the dried-up inner cavity of your nose.
- Use a humidifier in your room during winter or arid conditions.
Preventive Tips
You can minimize the risk of nosebleeds by keeping your nasal membrane moist and safe from injury and by improving the structural integrity of your blood vessels. Here are a few ways to achieve that:
- Refrain from picking or scratching your nose.
- Avoid blowing your nose too much or too hard as it can rupture your nasal blood vessels.
- A humidifier can add moisture to the air and may come in handy if your home environment is particularly dry. Given that this equipment can easily become a breeding ground for germs and mold, it must be cleaned regularly.
- Make sure that you trim your nails every other week and do the same for your child.
- Strictly instruct your child not to dig or scratch his/her nose. Also, you have to keep an eye out to ensure that your little one does not insert a foreign object into his/her nose until the child outgrows this habit.
- Consume a healthy, well-balanced diet to keep your blood vessels in the best of shape. This entails eating foods rich in vitamins C and K and bioflavonoids.
- Increase your iron intake via foods such as spinach, meats, and legumes to increase your hemoglobin levels.
- Foods that are rich in zinc may help build and strengthen your blood vessels and keep them from rupturing under pressure. To that end, it may help to eat more brown rice, whole-wheat bread, and other such zinc-heavy foods.
- If you are prone to nosebleeds, avoid the use of blood thinners. If you cannot exclude such drugs from your ongoing treatment, do let your doctor know if you encounter nosebleeds after using them so that he/she can prescribe a more suitable alternative.
- Limit your consumption of fried, greasy, and spicy foods.
- If you are a smoker and have a tendency for nosebleeds, it is best to quit the habit at the earliest. Smoking irritates the nasal mucosa and makes it more vulnerable to damage. Protect yourself from secondhand smoke as well.
Saline Water to Keep the Nasal Cavity Moist
Nosebleeds are often a result of an overly dry and crusty nasal cavity, which is prone to irritation and injury. Thus, it is essential to restore moisture to the dried-out nasal membranes, particularly during the arid winter months.
Saline water is a safe, easy, and nontoxic solution in this regard, as it can help hydrate and soothe the sensitive mucous membranes without triggering any severe side effects. (5) To make your saline solution, add a pinch of salt to ½ cup of water, and mix it well.
There are also multiple varieties of commercially available saline nasal mists, drops, and sprays that can get the job done.
Saline water can be tried for the management of recurrent anterior epistaxis, especially because saline water is not associated with any harmful side effects.
Nosebleeds in Children
Children are generally more prone to nosebleeds than adults because they are not careful about handling their nose, especially during winter or when they come down with a cold and develop a dry, flaky nose.
The following habits can contribute to this problem:
- Vigorously scratching or picking the nose can damage the nasal membranes.
- Shoving objects inside the nose can result in injury and is especially observed in toddlers.
- A long-term struggle with allergic rhinitis can also hamper the delicate inner lining of a child’s nose.
- Other trauma (like bumping their nose with a fall)
- The first line of treatment for nosebleeds in children is the same as that for adults.
Nosebleeds: What Not to Do?
The following points will debunk some of the common myths associated with nosebleeds and how to stop it:
- A lot of people make the mistake of stuffing their bloodied nose with cotton or gauze to stop the blood flow, which only aggravates the damage without providing any real relief.
- Another common misconception is that you can stop your nose from bleeding by leaning your head backward, which causes the blood to drain into the back of the throat and then to the stomach, rather than out of the nose.
- It is also strictly ill-advised to blow, rub, or scratch your nose in an attempt to expel the blood faster.
- When tilting your head forward to drain out the blood through the nose, make sure that the head remains above the heart level to slow down the bleeding. Therefore, sticking your head between your legs is not advised as the downward pressure can amplify the blood flow. Lying flat on your back is also ill-advised for the same reason and will only cause the blood to pool inside the nasal cavity and run down the throat.
Complications Related to Nosebleeds
Persistent or heavy nosebleeds can also result in an anemic (6) condition and cardiac dysfunctions.
When to See a Doctor
You must seek medical care from a physician, preferably an ENT specialist or surgeon, if:
- You experience labored breathing.
- The nosebleed doesn’t respond to first aid within 15–30 minutes.
- The nosebleed is severe enough to cause a heavy amount of blood loss.
- You start vomiting blood after swallowing a lot of it.
- The nosebleed occurs in the wake of a serious injury to the nose.
- You experience frequent nosebleeds.
Expert Answers (Q&A)
Answered by Dr. Jordan Glicksman, MD (Otolaryngologist)
Yes, alcohol can affect the production and quality of platelets and clotting factors, which can predispose to nosebleeds.
It is generally not normal to have nosebleeds, but if someone is prone to nosebleeds, stress can certainly make a nose bleed, especially if it leads to an increase in blood pressure.
About Dr. Jordan Glicksman, MD, MPH, FRCSC: Dr. Glicksman is an otolaryngologist and a head and neck surgeon, with fellowship training in rhinology and skull base surgery. He is also a lecturer (part-time) at Harvard Medical School.
Final Word
The sight of blood gushing out of your nose can be quite alarming, but the fact remains that most cases of nosebleeds are fairly mild, nonthreatening, and can easily be treated through simple self-care measures at home.
But medical attention is required if they occur frequently or cause copious blood loss that may stem from an underlying medical problem such as hypertension or blood clotting disorder.
Nosebleeds that result from an injury or trauma to the nose can pave the way for potentially serious complications if not tended properly and in time.
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