What are nosebleeds?

The nose contains numerous blood vessels close to its inner surface. These blood vessels are fragile and can easily be made to bleed.

A nosebleed is the loss of blood from the tissue lining the inside of the nose. Nosebleeds are a common problem; it is estimated that around 60% of people will experience at least one nosebleed in their lifetime. [1] [ 2] Most of the time, the bleeding tends to only last a little while and is usually easy to control.

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. [3]

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 where four arteries connect to form Kiesselbach's plexus.The majority of nosebleeds occur in a region of the nasal septum called Kiesselbach's plexus. 

Septum

A partition in the body that divides cavities, such as the cartilage wall that separates the nostrils (nasal septum).

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

Antihistamines

A substance that counters the physiological effects of histamine, a type of compound released by the tissues as an inflammatory response to an allergic reaction.

Deviated septum

Movement of the septum (the central part of the nose between the nostrils) to one side. This can cause blockage of the nasal passage and symptoms such as sinusitis, infection and headache.

Liver

A large, internal organ of the body, located on the upper right-hand side of the abdomen. The liver has hundreds of distinct functions, including producing bile, regulating the body's metabolism and detoxifying the blood.

Septum

A partition in the body that divides cavities, such as the cartilage wall that separates the nostrils (nasal septum).

Trauma

1. Physical injury to the body caused by force or a toxic substance. 2. Psychological damage caused by a severely disturbing experience.

Clotting

The process by which blood changes from a liquid to a semi-solid state, usually to seal off any sites of bleeding. This is also known as coagulation.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

Risk factors

  • Living in a hot and dry climate, which dries out nasal membranes;
  • Having a deviated septum, as this alters the airflow and causes the skin on the narrower side of the septum to dry out and crack;
  • Having a cold or suffering from allergies;
  • Being exposed to chemical irritants such as cigarette smoke;
  • Having a medical condition such as kidney failure, thrombocytopenia or haemophilia;
  • Being a heavy user of alcohol, which interferes with normal blood clotting, or cocaine, which irritates the nasal membranes and can damage the nasal septum, and;
  • Taking anticoagulants or non-steroidal anti-inflammatory drugs (NSAIDs).

Deviated septum

Movement of the septum (the central part of the nose between the nostrils) to one side. This can cause blockage of the nasal passage and symptoms such as sinusitis, infection and headache.

NSAIDs

Non-steroidal anti-inflammatory drugs are commonly used to manage arthritis-related pain and inflammation and other musculoskeletal disorders. NSAIDs include aspirin and ibuprofen.

Septum

A partition in the body that divides cavities, such as the cartilage wall that separates the nostrils (nasal septum).

Clotting

The process by which blood changes from a liquid to a semi-solid state, usually to seal off any sites of bleeding. This is also known as coagulation.

Haemophilia

A rare, inherited blood disorder that leads to individuals being prone to severe (usually internal) bleeding.

Thrombocytopenia

A deficiency of platelets in the blood, which causes bleeding into the tissues, bruising, and slow blood-clotting after injury.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

Artery

A blood vessel carrying blood saturated with oxygen from the heart to the body's tissues.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

Computerised tomography

A scan that uses X-rays to create a 3D image of the body. This can detect abnormalities more effectively than a simple X-ray can.

Full blood count

A blood test that examines the blood, either by using a microscope or an automated machine, to determine the number of red blood cells, white blood cells and platelets.

Nasendoscopy

A technique used for investigating the nasal passages. A thin, flexible telescope is inserted into the nose so that the doctor can examine inside the nose and upper airways.

NSAIDs

Non-steroidal anti-inflammatory drugs are commonly used to manage arthritis-related pain and inflammation and other musculoskeletal disorders. NSAIDs include aspirin and ibuprofen.

Sinuses

A cavity within bone or other bodily tissue. Often refers to the hollow cavities within the facial bones on either side of the nose that filter the air that is breathed in through the nose.

Trauma

1. Physical injury to the body caused by force or a toxic substance. 2. Psychological damage caused by a severely disturbing experience.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

Catheter

A thin, flexible tube inserted through a narrow opening into a body cavity for removing fluid.

General anaesthetic

An anaesthetic given to a person to put them to sleep while having an operation or medical procedure. Afterwards, the person regains consciousness and usually has no memory of the procedure. A general anaesthetic is given in hospital by a specialist called an anaesthetist.

NSAIDs

Non-steroidal anti-inflammatory drugs are commonly used to manage arthritis-related pain and inflammation and other musculoskeletal disorders. NSAIDs include aspirin and ibuprofen.

Trauma

1. Physical injury to the body caused by force or a toxic substance. 2. Psychological damage caused by a severely disturbing experience.

Vasoconstrictor

Medications or internal processes that constrict a blood vessel.

Clotting

The process by which blood changes from a liquid to a semi-solid state, usually to seal off any sites of bleeding. This is also known as coagulation.

Membrane

A thin layer of tissue that lines the surfaces of organs or cells.

Groin

The area where the abdomen joins the thighs.

Silver nitrate

A chemical used in medicine to help stop bleeding.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

Prognosis

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

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.

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.

1. Petruson, B., and Rudin. R. (1975) The frequency of epistaxis in a male population sample. Rhinology 13:129–133.

2. Villwock, J. A., and Jones, K. (2013) Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngology-- Head & Neck Surgery 139:1279–1284. doi:10.1001/jamaoto.2013.5220.

3. Pallin, D. J., Chng, Y-M., McKay, M. P., et al. (2005) Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine 46:77–81. doi:10.1016/j.annemergmed.2004.12.014.