Nosebleed

Doctors that specialise in the conditions of the nose (ENT doctors) frequently deal with emergency cases of nosebleeds. It is most common in children between 2 and 10 years of age with boys affected more than girls. A scientific study in India showed a significant number of cases of nosebleed in people above 40 years. Out of these, 70.2% of people had high blood pressure or heart disease and were taking antiplatelet medicines. Also, the number of cases with bleeding from the anterior part of the nose or near the nose tip was more than those of bleeding from the backside of the nose. The study also showed that 78.6% of nosebleed cases were harmless occurring from near the nose tip and resolved with conservative or traditional treatment.

The symptoms of nosebleed can range from a mild to a severe form requiring emergency hospitalisation. It is essential to have a detailed information about the cause of the condition and its treatment.

What is Nosebleed?

Bleeding from the nose (or epistaxis) occurs due to a rupture or break in the small blood vessels inside the nose. The blood vessels can rupture spontaneously or after an injury. Nosebleed is usually self-limiting and harmless. It occurs repeatedly in many people. Although it is not life-threatening, it causes anxiety especially in parents whose children have frequent nosebleeds. In 90% of the cases, bleeding occurs from the anterior region of the nose, which is easy to control. This is because the anterior region is richly supplied with blood through a mesh of small blood vessels in the area, medically termed as the Kiesselbach plexus (the Little’s area). This makes the region prone to bleeding even after the slightest injuries or traumas, such as nose picking, blowing nose very hard, or irritation in the nose due to allergy. The inner lining of the nose (mucous membrane) is warm and moist, which maintains the humidity inside the nose. Dryness due to heat or air damages the blood vessels and causes bleeding. Bleeding from the backside or posterior region of the nose needs medical attention, as it is associated with larger blood vessels, and there are high chances of aspiration (blood flowing in the airway) along with a difficulty in controlling the bleeding.

Depending on the site of bleeding, nosebleeds are divided into anterior and posterior bleeding. An anterior bleeding occurs from the front side of the nose near the nose tip and nasal septum (the partition wall inside the nose) while a posterior bleeding occurs from the backside of the nose near the throat (pharynx).

On the basis of the cause, nosebleeds are also divided into primary, wherein there is no specific cause for bleeding, and secondary bleeding, which occurs due to a specific cause, such as high blood pressure or injury.

The type of bleeding helps the doctor in deciding the line of treatment and the management of nosebleed.

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Bleeding from the nose usually occurs due to a damage to the tiny blood vessels inside the nose in the area near the nose tip. It also occurs from the backside of the nose near the pharynx. When bleeding occurs from the outer area of the nose near the nose tip, it is not associated with any symptoms, as there is no definite cause that can be identified in a majority of the people. However, people in whom nosebleed is due to an underlying cause can have additional symptoms. These include:

• The presence of pain when nosebleed occurs due to an injury, such as a fall or fracture of bone (nasal bridge).
• Rapid heartbeat and breathlessness are present when bleeding is associated with heart diseases, such as heart failure or ischemic heart disease with a history of taking blood-thinning medicines, including warfarin.
• In a few cases of nosebleed, there is a history of genetic diseases related to a disorder in blood clotting (haemophilia).
• A headache with or without vomiting is present in some cases of nosebleed due to high blood pressure.
• Bleeding from the backside of the nose commonly occurs in elderly people who are taking blood-thinning medicines or individuals with a genetic blood clotting disorder.
• A layer of hard, dry, clotted blood (scab formation) or clots of blood may be seen on examination if the bleeding had occurred sometime back or in case of recurrent bleeding.

It can be challenging to identify the cause of a nosebleed. A detailed history plays an important role in determining the cause of the nosebleed. The causes could be local or systemic.

Local Causes

Local causes arise due to an injury, abnormality in the inner structure of the nose (e.g., deviated nasal septum), inflammation in the nose (due to sinusitis, allergic cold, and other respiratory problems), a tumour inside the nose, or a nasal polyp. These include:

• Irritation of the inner lining of the nose from frequent nose picking which is seen commonly in children.
• Dry cold air in the winter season leading to dryness and damage of the tiny blood vessels in the Little’s area of the nose.
• A foreign body, such as a broken part of a toy, inside the nose in children while playing.
• Injury and fracture of the nasal bone.
• Respiratory conditions, such as sinusitis or inflammation (swelling) of the inner lining of the nose (rhinitis); hard blowing of the nose; and nasal polyps.
• Nasal septum deviation (or tilt in the nasal septum) and damaged nasal septum.
• Chronic cigarette smoking leading to irritation of the inner lining of the nose.
• The repeated use of medicated nasal sprays (containing steroids) for nose block damaging the delicate blood vessels inside the nose.

Systemic Causes

Systemic causes are the underlying medical conditions which may also lead to frequent nosebleeds. These include:

• High blood pressure
• Congestive heart failure
• Genetic bleeding disorders
• Haemophilia
• Decrease in platelets or thrombocytopenia
• Haemorrhagic telangiectasia in which the blood vessels become weak and delicate, leading to an easy rupture of blood vessels on the slightest injury.
• Certain medicines called blood thinners used in the treatment of heart diseases (for example warfarin, clopidogrel).
• Inflammation in the wall of the blood vessels due to a disorder of the immune system (for example collagen disorder, arteriosclerosis).

Risk factors

Young children between 2 to 10 years, elderly people above 50 years of age, and pregnant women are prone to nosebleeds. Recurrent episodes of nosebleed are also common in the general population.

In recurrent epistaxis, nosebleed occurs at least once in a month and may last for few minutes to few hours.

Risk factors for recurrent episodes of nosebleed include:

• Congestive heart failure.
• High blood pressure and diabetes can lead to the hardening of the blood vessels in the nose (atherosclerosis), which can increase the risk of bleeding.

If you are prone to nosebleeds, the following tips can be helpful in preventing further episodes:

• Avoid taking a shower under hot water as hot water distends or expands blood vessels and may lead to bleeding from the nose.
• Stop cigarette smoking as it damages the inner mucous lining of the nose.
• Avoid long-term alcohol consumption as it can cause thinning of the blood. Excessive alcohol damages the liver and affects the production of enzymes, which are important for blood clotting.
• Avoid excessive physical exercise that may put pressure on the blood vessels in the nose and may cause bleeding.
• Keep your room cool and humid (by using humidifiers) at night especially during winter when the weather is dry and cold.
• Motivate children to avoid picking the nose, removing dry scabs from the nose, or blowing their nose very hard.
• Use saline drops (or spray) or apply petroleum jelly frequently to keep the inner lining of the nose moist.
• Avoid sneezing through the nose; instead, keep your mouth open to prevent injury to the tiny blood vessels.
• Reduce the episodes of nosebleed by using an appropriate treatment for allergies.

A physical examination along with a history of the onset, duration, bleeding from one or both nostrils, injury, medicines and previous diseases plays a key role in the diagnosis of nosebleed.

Physical Examination

• Doctors diagnose anterior nosebleed or bleeding from the front side near the nose tip by an examination of the nose using a special instrument called a nasal speculum in the presence of a good amount of light.
• Posterior nose bleeding is generally diagnosed when the bleeding fails to stop after conservative measures, such as pinching the nose for a few minutes.
• Posterior nosebleeds are diagnosed generally after a head injury, in elderly people, or in those with genetic bleeding disorders.

Investigations

Doctors advise different tests if they suspect a bleeding disorder, or when the bleeding occurs for a long time or is recurrent. These include:

• Complete blood count and platelet count may be advised to diagnose a clotting disorder.
• Bleeding time test is used to detect bleeding disorders.
• Prothrombin time and activated partial thromboplastin time tests are done when a nosebleed is suspected to occur due to blood-thinning medicines and liver diseases (liver produces enzymes that help in the formation of a clot to control bleeding).
• Blood grouping, which includes blood typing and cross-matching, is done beforehand to find a well-suited blood group if a blood transfusion is required in case of severe blood loss.
• Computed tomography and magnetic resonance imaging scans are carried out to detect any abnormality in the nasal septum, evaluate the severity of sinusitis, and detect the presence of a foreign body or a tumour inside the nose.
• If a nasal tumour is suspected as the cause of nosebleed, nasopharyngoscopy is performed to visualise the tumour.

The treatment for nosebleeds includes controlling the bleeding followed by the treatment of the underlying cause.

Control of Bleeding

Bleeding from the nose usually stops with a few simple steps taken at home before taking medical help. These include applying pressure by pinching the nose tip for 5 to 10 minutes while sitting straight. Do not bend the head backwards while sitting as the blood may flow back into the air-pipe. Medical help is necessary if the bleeding does not stop after pinching the nose for 20 minutes. Additionally, application of ice pack on the nose also helps in controlling the bleeding.

The following steps may be taken by the doctor if previous measures fail to stop bleeding:

• A cotton gauze (a cloth made up of a fine mesh of cotton fibres used for medical dressing) with epinephrine solution (a vasoconstrictor which causes narrowing of the blood vessels) and anaesthetic agent (lidocaine) is placed under pressure on the bleeding point. Alternatively, an absorbable gelatine foam or oxidised cellulose is used for packing the nasal cavity to stop bleeding. This stops the bleeding in most cases of anterior nosebleed.
• A chemical called silver nitrate is applied to the bleeding spot to plug that area and stop the bleeding. This process is called chemical cauterisation.
• A nasal packing is performed when the above-mentioned measures fail to stop bleeding. In this, a ribbon gauze is soaked with petroleum jelly or an anti-bacterial ointment and placed inside the nose in the form of layers to fill the nasal cavity. The firmly pressed nasal pack is kept inside the nose for three to five days to ensure that a well-formed clot is established and bleeding has stopped completely.
• A similar nasal pack may be inserted in the pharynx using a catheter.
• Specialised balloon devices may be used to stop bleeding in the backside of the nose.
• The back of the nose (posterior region) may be irrigated with a continuous flow of hot water to decrease the pain and other discomforting symptoms of nosebleed.
• Surgery may be performed after diagnosing bleeding from the larger blood vessels (internal maxillary artery or ethmoidal artery). Surgical procedures include arterial ligation (tying the artery to stop the blood flow) and angiographic arterial embolisation (stopping the blood flow in the artery by inserting a clot or specialised small particles inside the artery).
• A laser therapy, oestrogen therapy, embolisation, and septodermatoplasty (grafting of mucous membrane on the nasal septum) may be performed to relieve the pain in genetic bleeding disorders which are incurable, such as haemorrhagic telangiectasia.
• Treatment for Systemic Causes
  • Appropriate medicines to treat high blood pressure, which causes a nosebleed.
  • Antihistamines and other anti-allergic medicines to treat allergies.
  • Suitable antibiotics can help in eradicating infection in sinuses.

Lifestyle management

Nosebleeds are easy to manage at home in a majority of people. Bleeding from the nose occurring for the first time or due to local injury usually does not require investigations and hospitalisation for treatment. These can be easily managed with self-care at home. However, it is necessary to meet the doctor if:

• Bleeding of the nose does not stop and continues after 20 minutes of applying pressure on the nose (nose pinching).
• Blood or dark coloured vomit is seen with a nosebleed.
• You experience nosebleed with dizziness, paleness, weakness, difficulty in breathing, and headache.
• Nosebleed stops and appears frequently.
• Nosebleed is seen in a child aged below 2 years.

A few techniques that can help in the management of recurrent nosebleed include the following:

• Prepare an action plan in case of a sudden episode of nosebleed especially when you are away from home. Carry clamps, clean cloth wipes which can be used to control bleeding.
• Keep an ice pack ready at home, which can be applied on the nose in case the nosebleed occurs when you are at home.
• Keep small objects that can be inserted into the nose away from children.
• Train children not to pick their nose or blow their nose hard as it may lead to a nosebleed.
• Opt for moderate exercises instead of vigorous ones.
• Those with recurrent nosebleed should maintain a cool and humid environment inside their homes.

Prognosis

Nosebleed is rare above the age of 14 years. A nosebleed that is experienced due to genetic bleeding disorders cannot be treated completely but can only be managed to relieve pain.

Doctors generally advise continuing blood thinners and antiplatelet medicines for preventing serious heart diseases and other cardiovascular conditions (such as stroke). Hence, the outcome of nosebleeds is compromised in severe cases of cardiovascular diseases.

Complications

Complications of nosebleeds include the following:

• Development of anaemia due to recurrent nosebleeds.
• Aspiration or breathing difficulty due to blood flow in the windpipe requiring immediate medical attention.
• Persistent bleeding from the nose due to a wrong technique of insertion of the nasal pack inside the nose.
• High risk of infection due to a non-sterile gauze used for nasal packing.
• Profuse or prolonged nosebleed due to lack of immediate medical attention requiring a blood transfusion.