Nosebleed

Definition

A nosebleed, also called epistaxis, is a loss of blood from any blood vessel in the nose. It usually appears in only one nostril.

Description

Although unexpected or persistent bleeding from anywhere is a warning sign of cancer and should be investigated, nosebleeds are rarely a sign of serious illness. They are usually the result of minor injury or irritation.

Nosebleeds most often come from the front of the septum, the cartilage that separates the nose into two nostrils. These anterior nosebleeds comprise 80 percent of all nosebleeds. A mass of blood vessels, called Kiesselbach's plexus, lie on either side of the septum. These blood vessels are easy to injure and bleeding can occur.

Posterior nosebleeds, which come from the back of the nose, are less common and much harder to manage. Bleeding usually begins in the upper part of the nose and flows toward the throat and mouth where it is swallowed. It is difficult to determine how much blood is lost in these nosebleeds.

Demographics

Though it is a common misconception that children are more susceptible to nosebleeds than adults, research has found that nosebleeds are more prevalent in older adults and more often are a sign of other health problems. Nosebleeds do, however, occur frequently in childhood. About 30 percent of children up to five years of age have had spontaneous nosebleeds that appeared without apparent injury to the nose. Of children six to ten years of age, 56 percent have had them and 64 percent of preadolescents and adolescents from 11 to 15 have as well. Moreover, over half of adults with recurring nosebleeds had them as children. Only about 10 percent of children with frequent nosebleeds have been found to have a previously undiagnosed bleeding disorder.

Rarely, menstruating women, even adolescents, who have endometriosis, a condition in which tissues resembling the lining of the uterus occur abnormally in other parts of the pelvic cavity and sometimes in other parts of the body, can have cyclical nosebleeds with their menstrual periods.

Causes and symptoms

Causes

The most common cause of nosebleeds is injury from picking or blowing the nose. People with respiratory allergies , hay fever, and sinus infections have swollen nasal membranes that are fragile and more likely to bleed. Physical injury to the nose from falls, sports , or fighting can also cause nosebleeds. Chemical irritants such as cleaning products, aerosols, and paint can irritate the nose, sometimes resulting in nosebleeds. In addition, some drugs, such as cocaine, inflame the nose, causing it to bleed. Children with deviated septums or crooked noses are also prone to nosebleeds.

Nosebleeds occur more frequently in the winter when the air is cold outside and homes are filled with dry air from furnaces and other heating sources. Changes from cold to warm air or dry to humid air stress the delicate membranes of the nose and make it vulnerable to injury and bleeding. Also, flu, colds, and other respiratory illnesses seem to occur more often in the winter. These also stress the nasal passages and make injury more likely. Bleeding from the nose, therefore, usually follows these seasonal stresses.

A nosebleed can also be an indication of illness. Certain blood disorders, such as hemophilia , can cause the nose to bleed. In this case, medical help should be sought immediately. Some head injuries produce nosebleeds. Uncontrolled high blood pressure, liver disease, leukemia, and tumors of the nasal passages and the brain can also cause the nose to bleed.

Even some medications can cause nosebleeds. Anticoagulants, medications used to thin the blood, including aspirin, can cause spontaneous bleeding from the nose. Overuse of nasal sprays can also produce nosebleeds. In addition, nosebleeds can be a side effect of alcohol abuse.

Nosebleeds in children can sometimes be caused by children putting objects into their noses. The object can tear the delicate membranes of the nose. Objects inserted into the nose can also cause obstruction of airflow and may need to be removed by a doctor.

Symptoms

Bleeding from one or both nostrils may be a trickle or a flood. Sometimes, it accompanies direct injury to the nose as in a sports injury or in picking the nose or too vigorous nose blowing. Children may experience frequent swallowing or a sensation of fluid in the back of the nose and throat.

When to call the doctor

If the bleeding does not stop after 20 minutes, it is necessary to seek medical help. Also, if there is a known or suspected head injury accompanying the nosebleed, there may be a skull fracture or brain disorder. In this case, the child should be taken to the emergency room immediately. In addition, if the nose is misshapen, especially after an accident, fall, or injury, it may be broken and will need to be evaluated by a doctor. Frequent nosebleeds, especially if they are occurring more often and are not due to colds, allergies, or trauma, will need to be seen by a doctor as well.

It may be a medical emergency if the bleeding is rapid or if there is a lot of blood. If the child feels faint or weak during a nosebleed, it may be do to blood loss and the child should see the doctor immediately.

Diagnosis

Bleeding from the nose is the obvious determinant of a nosebleed. The severity of it, however, may require blood work to look for bleeding disorders, diseases of the blood, or infections. X rays may be taken to determine if there has been a head injury or abnormalities within the structure of the nose. To further examine the nose, the doctor may perform a nasal endoscopy, a procedure that involves inserting a tiny camera into the nose to look at blood vessels and nasal structures.

Treatment

The first line of treatment is to gently pinch the nostrils together with the thumb and forefinger, while sitting upright and breathing through the mouth, for five to ten minutes. Leaning forward will prevent the child from swallowing blood. After at least five minutes, the parent or child can check to see if the bleeding has stopped. If it has not, then the pinching of the nose should be resumed and the child or parent should wait another five minutes. Most nosebleeds will stop within this time period, especially if the child is encouraged to remain calm. Anxiety or panic will cause blood to flow more rapidly and can hinder this self-healing process. It is very important for the child not to lie down while having a nosebleed.

Sometimes, a cold compress or crushed ice in a washcloth or plastic bag can be placed across the bridge of the nose and cheeks to encourage clotting. It is important not to pack the inside of the nose with gauze since this might further injure the nose.

In 2004, a new over-the-counter product was introduced for a quick home treatment for simple nosebleed. Called Nosebleed QR (Quick Relief), the product is composed of a hydrophilic polymer, a synthetic powder that absorbs blood, and potassium salt that aids in scab formation. The parent or child sprinkles the product onto a swab and coats the nostril then pinches the nose for 15 to 20 seconds. The product stops bleeding within one minute. However, it does sting and may not be a comfortable product to use with children.

Alternative treatment

Estrogen cream, the same preparation used to revitalize vaginal tissue, can toughen fragile blood vessels in the anterior septum and forestall the need for cauterization. Botanical medicines known as stiptics, which slow down and can stop bleeding, may be taken internally or applied topically. Some of the plants used are achillea (yarrow), trillium, geranium, and shepherd's purse (Capsella bursa ).

Homeopathic remedies can be one of the quickest and most effective treatments for nosebleeds. One well known remedy is phosphorus.

Another natural treatment includes swabbing the nose with vitamin E oil for three days. If nosebleeds recur within that time, it is recommended to take 500 mg of bioflavonoids twice a day. Bioflavonoids are antioxidants found in citrus fruits that help strengthen blood vessels.

Prognosis

Most common nosebleeds are easily managed and can be prevented. Children usually recover quickly. Serious nosebleeds need further investigation but are usually controlled by treating the underlying cause.

Prevention

Keeping the home cooler in winter and using a humidifier help keep the nasal passages moist and reduce the risk of nosebleeds due to dry air. Some doctors also recommend using a nasal saline spray to enhance moisture in the nose.

Also, before sending children out to play on cold, dry days, parents can put a bit of petroleum jelly on a cotton swab and wipe it just inside their children's nostrils. This keeps the nose from drying out and producing surface cracks which can damage blood vessels in the lining of the nose and cause bleeding. Some parents routinely apply a thin layer of A & D ointment, petroleum jelly, or a mentholated salve around their children's noses at night as well as when they go outside.

KEY TERMS

Deviated septum —A shift in the position of the nasal septum, the partition that divides the two nasal cavities.

Endometriosis —A condition in which the tissue that normally lines the uterus (endometrium) grows in other areas of the body, causing pain, irregular bleeding, and frequently, infertility.

Hemophilia —Any of several hereditary blood coagulation disorders occurring almost exclusively in males. Because blood does not clot properly, even minor injuries can cause significant blood loss that may require a blood transfusion, with its associated minor risk of infection.

Kiesselbach's plexus —The mass of blood vessels on either side of the septum.

Nasal endoscopy —A procedure that involves inserting a tiny camera into the nose in order to look at blood vessels and nasal structures.

Otorhinolaryngologist —An ear, nose, and throat specialist.

Septum —A wall or partition. Often refers to the muscular wall dividing the left and right heart chambers or the partition in the nose that separates the two nostrils. Also refers to an abnormal fold of tissue down that center of the uterus that can cause infertility.

Gently blowing the nose and not picking it will also prevent nosebleeds. This is especially important for several hours after nasal bleeding has stopped. In some cases, strong sniffing is also discouraged to reduce further stress on the delicate tissues of the nose. Keeping the mouth open when sneezing can also reduce stress on the nose.

Treatment of hay fever and other respiratory allergies decreases sneezing and nasal inflammation. If a child is prone to sinus infections, some doctors may also use prophylactic or preventative treatment similar to allergy management.

Parental concerns

Nosebleeds can be frightening for children. Seeing any amount of blood may cause some children to panic or even faint. It is important to treat the nosebleed matter-of-factly as any parent would handle any other childhood scrape or wound. The parent's calm helps the child remain calm while waiting for the natural blood clotting mechanisms of the body to work. Parents should also be aware of any abnormal amount of blood during a nosebleed and make note of any recent falls or head injuries. These observations will inform parents about when to seek medical or emergency help.

Resources

PERIODICALS

"A Natural Solution for Nosebleeds: I Get Frequent Nosebleeds. Will Taking Bioflavonoids Help?" Natural Health 33 (April 2003).

"Dabbing That Bloody Nose." Pediatrics for Parents 19 (December 2001): 5.

"Nosebleeds Are Nothing to Sneeze At." Nutrition Health Review (Fall 2002): 6.

Pouliot, Janine S. "Nosing around for a Remedy." Better Homes and Gardens 82 (February 2004): 222.

"Quicker Relief for Nosebleeds." Consumer Reports 69 (February 2004): 45.

Janie Franz J. Ricker Polsdorfer

Nosebleed

Definition

A nosebleed is bleeding from the nose; the medical term for it is epistaxis.

Description

Unexpected bleeding from anywhere is cause for alarm. Persistent bleeding should always be investigated because it may be the earliest sign of cancer. Fortunately, nosebleeds are rarely a sign of cancer. A much more common cause of nosebleeds is injury from picking or blowing or fisticuffs. People with hay fever have swollen membranes that are fragile and more likely to bleed.

Most nosebleeds (about 90%) come from the front of the septum, that plane of cartilage that separates the nostrils. These are called anterior nosebleeds. The lower front part of the septum has a mass of blood vessels on either side called Kiesselbach's plexus that is easy to injure. Nosebleeds from the more remote reaches of the nose are called posterior nosebleeds. They are less common, are less likely to have a benign cause, and are much harder to manage.

Nosebleeds are most likely to occur in children between the ages of two and 10 years, in part because younger children frequently insert small objects in the nose or pick at the tissues lining the nose. Nosebleeds in adolescents may indicate cocaineabuse. Nosebleeds in older adults may result from arteriosclerosis or high blood pressure.

Causes and symptoms

Nosebleeds may result from a number of different causes:

• local infections (colds, sinus infections)
• systemic infections (scarlet fever, typhoid fever, malaria)
• drying of the membranes lining the nose, often during heating season in colder climates
• medications, most commonly, overuse of nasal decongestant sprays
• trauma (from foreign objects in the nose; scratching or picking with the fingers; or blunt trauma to the face)
• tumors in the nasopharynx or paranasal sinuses
• cocaine abuse
• bleeding disorders (leukemia, liver disease, hemophilia and other hereditary clotting disorders)

Treatment

The first treatment is to pinch the patient's nostrils together, have them sit forward, and ask them to stay that way for 5-10 minutes. This method usually stops nosebleeds originating in Kiesselbach's plexus. The patient should not tilt his or her head backward, as this position may cause blood to drip backward into the throat or windpipe. It is best to hold the head upright.

In the case of small children, the doctor may examine the inside of the nose to check for foreign bodies, evidence of scratching or picking, etc. Small foreign bodies (watch batteries, dried peas or beans, buttons, etc.) can be removed by suction if necessary. The doctor may also have to remove clotted blood by suction.

Bleeding that continues originates from the back of the nose in most cases and will flow down the throat. If that happens, emergency intervention is needed.

As an emergency procedure, the nose will be packed front and/or back with cotton gauze and a rubber balloon from a Foley catheter. This treatment is not comfortable. Having no place to flow, the blood should clot, giving the ear, nose and throat specialists (otorhinolaryngologists) a chance to find the source and permanently repair it. If the packing has to remain for any length of time, antibiotics and pain medication will be necessary—antibiotics because the sinuses will be plugged up and prone to infection. Nose packing may so interfere with breathing that the patient will need supplemental oxygen.

Newer options for controlling posterior nosebleeds include the use of Surgicel, Merocel, or other oxidized cellulose products that expand with moisture. These may control the bleeding without the need for bulky nasal packing.

Many bleeds are from small exposed blood vessels with no other disease. They can be destroyed by cautery, usually done by applying silver nitrate to the affected area. Larger vessels may not respond to cautery. The surgeon may have to tie them off, which is known as ligation. Another technique that is sometimes used with larger vessels is embolization, in which the doctor injects a chemical to block or close the blood vessel.

Alternative treatment

Estrogen cream, the same preparation used to revitalize vaginal tissue, can toughen fragile blood vessels in the anterior septum and forestall the need for cauterization. Botanical medicines known as styptics, which slow down and can stop bleeding, may be taken internally or applied topically. Some of the plants used are achillea (yarrow), trillium, geranium, and shepherd's purse (capsella-bursa ). Homeopathic remedies can be one of the quickest and most effective treatments for epistaxis.

Prevention

Both before and after a nosebleed, the patient should blow the nose gently and avoid picking or scratching the tissues that line it. Children with recurrent nosebleeds during heating season may benefit from the use of a cool-mist vaporizer to humidify the bedroom at night, or from the application of a small quantity of petroleum jelly to the inside of each nostril. Treatment of hay fever helps reduce the fragility of the tissues.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Epistaxis." Section 7, Chapter 86 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Bhatnagar, R. K., and S. Berry. "Selective Surgicel Packing for the Treatment of Posterior Epistaxis." Ear, Nose, and Throat Journal 83 (September 2004): 633-634.

Gluckman, William, DO, and Robert Baricella, DO. "Epistaxis." eMedicine October 11, 2004. 〈http://emedicine.com/ped/topic1618.htm〉.

Gurney, T. A., C. F. Dowd, and A. H. Murr. "Embolization for the Treatment of Idiopathic Posterior Epistaxis." American Journal of Rhinology 18 (September-October 2004): 335-339.

ORGANIZATIONS

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237 or (913) 906-6000. 〈http://www.aafp.org〉.

American Academy of Otolaryngology—Head and Neck Surgery. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. 〈http://www.entnet.org〉.

KEY TERMS

Cautery— The use of heat, electricity, or chemicals to destroy tissue.

Embolization— A technique for stopping bleeding by introducing a substance into larger blood vessels that blocks or closes them.

Epistaxis— The medical term for nosebleed.

Kiesselbach's plexus— An area on the anterior part of the nasal septum that has a rich supply of blood vessels and is a common site of nosebleeds. It is named for Wilhelm Kiesselbach, a nineteenth-century German otolaryngologist.

Septum— The partition that separates the two nostrils. It consists of membranes, cartilage, and bone.

Styptic— Any remedy with an astringent and hemo-static (stopping bleeding) quality.

Nosebleeds

Definition

A nosebleed is characterized by bleeding from the interior of the nasal cavity. It can be caused by heat, dry air, trauma to the nose, certain medications, or a medical condition.

Description

Anterior nosebleeds, or bleeding of the nose that comes from near the nose opening, are the most common nosebleeds in children. Children are twice as likely to experience nosebleeds as adults are. Bleeding that originates from deep within the nasal cavity is known as a posterior nosebleed, the type usually experienced by adults.

Causes & symptoms

The most common causes of nosebleeds are:

• Low humidity. Hot and dry climates can dry out the nasal cavities.
• Nasal trauma. Injuries to the nose can cause bleeding. Excessive nose picking can also injure the interior of the nose.
• Cold, allergies , and sinus infections . Excessive nose blowing and irritation to the mucous membrane can cause bleeding.
• Medications. Bleeding can be triggered by Certain medications, particularly those with anticoagulant (or blood thinning) properties.

Nosebleeds can also be symptomatic of less common, but more serious, medical conditions. These include:

• nasal polyps
• high blood pressure
• blood clotting disorders (i.e., thrombocytopenia, liver disease)
• leukemia
• malaria

Diagnosis

A nosebleed is easily diagnosed by sight. Further examination of the nasal cavity may be necessary to determine the source of the bleeding, and a medical history should be taken if the cause of the nosebleed is not readily apparent.

Treatment

The first step in treating a nosebleed is to stop the bleeding. An individual experiencing a nosebleed should lightly blow his or her nose, and then pinch both nostrils to encourage clotting of the blood flow. The nose should be pinched close for five to 10 minutes, or until bleeding has stopped. In most cases, this will resolve the nosebleed.

If pinching does not stop blood flow completely, an astringent can also be used to dry up the blood flow. A piece of cotton soaked in witch hazel (Hamamelis virginiana )

can be inserted into the bleeding nostril (s) to tighten and seal the blood vessels. Sniffing a small pinch of powdered yarrow (Achillea millefolium ) can also stop bleeding.

Allopathic treatment

Use of a spray decongestant is sometimes recommended to shrink blood vessels and stop bleeding. In severe cases where bleeding from the nose does not stop after 20 minutes, professional emergency care should be sought. Surgery to remove nasal polyps may be required in patients with this problem. In some cases of repeated, serious nosebleeds, cauterization of the blood vessels in the nasal passages is necessary.

Expected results

Most nosebleeds will resolve by themselves in 10–15 minutes. Nutritional and environmental measures can prevent further occurrences in many cases.

Prevention

The following precautions can prevent or lessen the frequency of nosebleeds:

• Vitamin C . An adequate supply of vitamin C is necessary to form collagen, the connective tissue that strengthens blood vessel walls.
• Humidify the air. Using a humidifier in the home and office can prevent nosebleeds caused by a dry environment.
• Vitamin E . Rubbing liquid vitamin E in the nose keeps the mucous membrane moist.

Resources

BOOKS

Hoffmann, David. The Complete Illustrated Herbal. New York: Barnes & Noble Books, 1999.

Paula Ford-Martin

Nosebleeds

What Are Nosebleeds?

What Causes Nosebleeds?

What Is the Treatment for Nosebleeds?

Can Nosebleeds Be Prevented?

Bleeding that begins inside the nostrils is referred to as nosebleed. Its medical name is “epistaxis.”

KEYWORDS

for searching the Internet and other reference sources

Bleeding

Epistaxis

What Are Nosebleeds?

Most nosebleeds occur in children and older people and last for a short time. In rare cases, nosebleeds can be associated with other illnesses.

What Causes Nosebleeds?

Nosebleeds usually start after a bump to the nose or when the lining of the nostrils becomes irritated, crusted, or dry. This often happens when someone has a cold, infection, or allergy that affects the amount of mucus secreted from the nose. A high fever can also dry out the lining of the nose and cause nosebleeds. When the crusts are removed, bleeding may occur.

What Is the Treatment for Nosebleeds?

Most nosebleeds can be stopped in a short time by holding the nostrils closed firmly for a few minutes between the thumb and forefinger. A person with a nosebleed should sit down and lean slightly forward and breath through the mouth while holding the nostrils shut. After 10 to 15 minutes, the bleeding should have stopped. The person should avoid blowing the nose for 12 hours after a nosebleed, because this could start the bleeding again. If the nosebleed does not stop after a few attempts at pinching the nostrils for 10 to 15 minutes each time, then a doctor should be contacted. The doctor might put cotton gauze with medication into the nostril to stop the bleeding. Nose drops may also be prescribed for a few days in some cases to help control further bleeding.

Prolonged nose bleeding may be a sign of serious injury to the head or an indication of an illness, like high blood pressure (hypertension) or sinus blockage.

Serious diseases that may rarely be the cause of nosebleeds include leukemia (cancer of the white blood cells), liver disease, atherosclerosis (also called hardening of the arteries), and some hereditary bleeding disorders such as hemophilia, where the blood fails to clot properly.

Can Nosebleeds Be Prevented?

The best way to prevent nosebleeds is to avoid bumping or picking the nose. People involved in contact sports, like football or boxing, are more likely to receive bumps to the head or nose that result in nosebleeds. Appropriate protective gear, such as face guards and masks, should be worn to help prevent these injuries. Humidifying the air indoors in the winter, when the air is very dry because of central heating, will also help.

See also

Hypertension

nosebleed Nosebleeds are common, particularly in children. They may be alarming but are very rarely ominous. The bleeding is usually from the septum of the nose — the central partition — and sometimes follows crusting and picking, or a minor injury. It usually stops quite quickly if the nostrils are compressed so that breathing is through the mouth; the clotting process can then proceed undisturbed. Various myths and old wives' tales are associated with nose-bleeding, such as the notion that a cold key placed on the back of the neck helps to stop it.

Rarely, nosebleeds may be a sign of a condition which causes a generalized tendency to bleed, such as a shortage of platelets in the blood, or treatment with anticoagulant drugs. In the elderly, the bleeding may be from further back in the nose, and less easy to stop without medical attention. Contrary to popular belief, people with high blood pressure probably do not have nosebleeds more often than others of similar age, but when they do, the high pressure does make bleeding more profuse.

Sheila Jennett