Doctor, Please Explain

Nosebleeds

Insight into care and prevention of nosebleeds 

• Why is the nose prone to bleeding? 

• How can nosebleeds be prevented? 

• How to stop a nosebleed?  and more...

The nose is an area of the body that contains many tiny blood vessels or arterioles that can break easily. In the United States, one of every seven people will develop a nosebleed some time in their lifetime. Nosebleeds can occur at any age but are most common in children aged 2-10 years and adults aged 50-80 years. Nosebleeds are divided into two types, depending on whether the bleeding is coming from the front or back of the nose.

What is an anterior nosebleed?

Most nosebleeds or epistaxes begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. Nosebleed coming from the front of the nose or anterior nosebleeds often begin with a flow of blood out one nostril when the patient is sitting or standing.

Anterior nosebleeds are common in dry climates or during the winter months when dry, heated indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of petroleum jelly or an antibiotic ointment on the end of a fingertip and then rub it inside the nose, especially on the middle portion of the nose (the septum).

How to stop an anterior nosebleed? 

• Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who’s been reassured and supported. 

• Keep head higher than the level of the heart. Sit up. 

• Lean slightly forward so the blood won’t drain in the back of the throat. 

• Using the thumb and index finger, pinch all the soft parts of the nose or place a cotton ball soaked with Afrin, Neo-Synephrine, or Dura-Vent spray into the nostril and apply pressure. The area where pressure should be applied is located between the end of the nose and the hard, bony ridge that forms the bridge of the nose. Do not pack the inside of the nose with gauze or cotton. 

• Apply ice—crushed in a plastic bag or washcloth—to nose and cheeks. 

• Hold the position for five minutes. If it’s still bleeding, hold it again for an additional 10 minutes.

What is a posterior nosebleed?

More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat even if the patient is sitting or standing.

Obviously, when lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow toward the back of the throat especially if coughing or blowing the nose. It is important to try to make the distinction between the anterior and posterior nosebleed, since posterior nosebleeds are often more severe and almost always require a physician’s care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face.

What are the causes of recurring nosebleeds? 

• Allergies, infections, or dryness that cause itching and lead to picking of the nose. 

• Vigorous nose blowing that ruptures superficial blood vessels. 

• Clotting disorders that run in families or are due to medications. 

• Drugs (such as anticoagulants or anti-inflammatories). 

• Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously. 

• Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose. 

• Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.

When should an otolaryngologist be consulted?

If frequent nosebleeds are a problem, it is important to consult an otolaryngologist. An ear, nose, and throat specialist will carefully examine the nose using an endoscope, a tube with a light for seeing inside the nose, prior to making a treatment recommendation. Two of the most common treatments are cautery and packing the nose. Cautery is a technique in which the blood vessel is burned with an electric current, silver nitrate, or a laser. Sometimes, a doctor may just pack the nose with a special gauze or an inflatable latex balloon to put pressure on the blood vessel.

Tips to prevent a nosebleed 

• Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Commonly used products include Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline. 

• Keep children’s fingernails short to discourage nose picking. 

• Counteract the effects of dry air by using a humidifier. 

• Use a saline nasal spray to moisten dry nasal membranes. 

• Quit smoking. Smoking dries out the nose and irritates it.

Tips to prevent rebleeding after initial bleeding has stopped

• Do not pick or blow nose. 

• Do not strain or bend down to lift anything heavy. 

• Keep head higher than the heart.

If rebleeding occurs: 

• Attempt to clear nose of all blood clots. 

• Spray nose four times in the bleeding nostril(s) with a decongestant spray such as Afrin or Neo-Synephrine. 

• Repeat the steps to stop an anterior nosebleed. 

• Call a doctor if bleeding persists after 30 minutes or if nosebleed occurs after an injury to the head.