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Nosebleeds !nOz-+blEd

by Marvin P. Fried, MD

Some people get nosebleeds (epistaxis) rather often, and others rarely get them. There may be just a trickle of blood or a strong stream. If people swallow the blood, they often vomit it because blood is irritating to the stomach.

Nosebleeds usually come from the front part of the nose (anterior nosebleed) from small blood vessels on the cartilage that separates the two nostrils. This cartilage is the nasal septum, which contains many blood vessels. Most anterior nosebleeds are more frightening than serious. However, bleeding from blood vessels in the back part of the nose (posterior nosebleed), although uncommon, is more dangerous and difficult to treat. Posterior nosebleeds usually involve larger blood vessels than anterior nosebleeds. Because these vessels are in the back of the nose, they are hard for doctors to reach for treatment. Posterior nosebleeds tend to occur in people who have atherosclerosis (which reduces or blocks blood flow in arteries), who have bleeding disorders, who are taking drugs that interfere with blood clottng, or who have had nasal or sinus surgery.

Causes

Nosebleeds occur when the moist inner lining of the nose is irritated or when blood vessels in the nose are broken. There are many causes (see Some Causes and Features of Nosebleeds). In all cases, people who take aspirin or other drugs that interfere with blood clotting (anticoagulants), people with clotting disorders (see Bleeding Due to Clotting Disorders), and people with hardening of the arteries (arteriosclerosis) are more likely to develop nosebleeds.

Common causes

The most common causes of nosebleeds are

  • Trauma (such as nose blowing and picking)

  • Drying of the moist inner lining of the nose (such as occurs in winter)

Less common causes

Less common causes of nosebleeds include

  • Nasal infections

  • Bodywide (systemic) disorders

  • Foreign objects (bodies)

  • Rendu-Osler-Weber syndrome (see Hereditary Hemorrhagic Telangiectasia)

  • Tumors of the nose or sinuses

  • Bleeding disorders (coagulopathies)

High blood pressure (hypertension) may help keep a nosebleed going that has already begun but is unlikely to be the actual cause.

Evaluation

The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with a nosebleed, certain symptoms and characteristics are cause for concern. They include

  • Signs of excessive blood loss (such as weakness, fainting, or dizziness when standing up)

  • Use of drugs that interfere with blood clotting

  • Signs of a bleeding disorder or a known bleeding disorder (such as hemophilia)

  • Several recent episodes of nosebleeds, particularly with no clear cause

The most common drugs that interfere with blood clotting include aspirin, clopidogrel, and warfarin.

Signs of a bleeding disorder include numerous small, purplish spots on the skin (petechiae), many large bruises, easily bleeding gums, bloody or tarry stools, coughing up blood, blood in the urine, and excess bleeding while brushing the teeth, having blood tests, or suffering minor cuts.

When to see a doctor

People who cannot get the nosebleed to stop by pinching the nose (see Anterior nosebleed) should go to the hospital right away. Even if the bleeding has stopped, people who have warning signs also should go to the hospital right away. People without warning signs who had a nosebleed that stopped (with or without treatment) and otherwise feel well should call their doctor. They may not need to be seen.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination often suggests a cause of the nosebleed and the tests that may need to be done (see Some Causes and Features of Nosebleeds).

During the medical history, doctors ask about the following:

  • Obvious triggers (such as sneezing, nose blowing or picking, and recent upper respiratory infections)

  • The time and number of previous nose-bleeding episodes and how they were stopped

  • Whether the person (or a family member) has a bleeding disorder or other disorders that sometimes cause problems with blood clotting

  • Whether the person takes any drugs that interfere with blood clotting

Disorders that can cause problems with clotting include severe liver disease (such as cirrhosis or hepatitis) and certain cancers.

During the physical examination, doctors focus on the nose, looking for the bleeding site. They also check the person's skin for signs of bleeding disorders, including petechiae, large bruises, and dilated small blood vessels in and around the mouth and on the tips of the fingers and toes.

An anterior bleeding site is usually easy for the doctor to see with a handheld light. To see a posterior bleeding site, doctors need to use a flexible viewing scope. However, an actively bleeding posterior site produces too much blood for the doctor to see anything, even with a viewing scope.

Some Causes and Features of Nosebleeds

Cause*

Common Features

Tests

Common

Blowing or picking the nose

A blow or other injury to the nose

In people who report such behavior or injuries

A doctor's examination

Drying of the moist membranes lining the nose, as may occur in cold weather

Usually dryness that is seen during the examination

A doctor's examination

Less common

Nasal infections (such as a cold or sinusitis)

Crusting in the nostrils

Often pain and drying of the moist membranes lining the nose

A doctor's examination

Systemic disorders, such as severe liver disease or AIDS

In people who are known to have such disorders

A doctor's examination

A foreign object (body )in the nose, mainly in children

Often recurring nosebleeds and/or a foul-smelling discharge from one side of the nose

A doctor's examination

Arteriosclerosis

Usually in older people

A doctor's examination

Rendu-Osler-Weber syndrome

Dilated small blood vessels (telangiectasias) on the face, lips, membranes lining the mouth and nose, and tips of the fingers and toes

Usually in people with family members who have the disorder

A doctor's examination

Tumors (noncancerous or cancerous) of the nose or sinuses

Sometimes a mass that can be seen inside the nose

Bulging of the side of the nose

CT

A hole (perforation) in the nasal septum (which divides the interior of the nose in two)

A hole that can be seen during the examination

Sometimes in people who snort cocaine frequently

A doctor's examination

Bleeding disorders (coagulopathies)

In people who have had nosebleeds or other bleeding in other areas, such as the gums

Blood tests, such as a complete blood cell count and tests to measure how quickly blood clots

*Conditions that can cause nosebleeds are more likely to cause nosebleeds in people who also have a bleeding disorder or who take drugs that interfere with blood clotting. In such people, bleeding is often more severe and difficult to treat.

Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography.

Testing

Routine laboratory testing is not required. People with symptoms of a bleeding disorder and/or signs of significant blood loss and people with severe or recurring nosebleeds should have blood tests. Computed tomography (CT) may be done if a foreign object, a tumor, or sinusitis is suspected.

Treatment

Doctors initially treat all nosebleeds as they would treat an anterior nosebleed. The few people who have lost a large amount of blood are given fluids by vein (intravenously) and rarely blood transfusions. Any known or identified bleeding disorders are treated.

Anterior nosebleed

Bleeding usually can be controlled at home by pinching the nostrils together for 10 minutes while the person sits upright. People should not pinch over the bony upper part of the nose. It is important to hold the nose with a firm pinch and not let go even once during the 10 minutes. Other at-home techniques, such as ice packs to the nose, wads of tissue paper in the nostrils, and placing the head in various positions, are not effective.

If the pinch technique does not stop the bleeding, it can be repeated once for another 10 minutes. If the bleeding does not stop after the 10 minutes, the person should see a doctor. The doctor typically places several pieces of cotton in the bleeding nostril. The cotton is saturated with a numbing drug (such as lidocaine) along with a drug that causes blood vessels in the nose to close (such as phenylephrine). Then the nose is pinched for 10 minutes or so and the cotton is removed. For minor bleeds, often nothing more is done. Alternatively, doctors sometimes place a special foam sponge (nasal tampon) in the bleeding side. The sponge swells to stop the bleeding. The sponge is removed after 2 to 4 days.

For more severe or recurring bleeding, sometimes the doctor seals (cauterizes) the bleeding source with a chemical, silver nitrate, or an electrical current (electrocautery). If these methods are ineffective, various commercial nasal balloons can be used to compress bleeding sites. Rarely, the doctor may need to pack the entire nasal cavity on one side with a long strip of gauze. Nasal packing is usually removed after 3 days.

Posterior nosebleed

Bleeding in this area is very difficult to stop and can be life threatening. For a posterior nosebleed, the pinch technique does not stop the bleeding. Pinching simply makes the blood run down the throat instead of out the nose. For a posterior nosebleed, doctors may place a specially shaped balloon in the nose and inflate it to compress the bleeding site. However, this and other types of posterior nasal packing are very uncomfortable and interfere with the person’s breathing. Doctors usually give people sedatives by vein before inserting this kind of balloon and packing. Also, people who have had this type of packing are admitted to the hospital and given oxygen and antibiotics to prevent an infection of the sinuses or the middle ear. The packing remains in place for 4 to 5 days.

If the balloon does not work, doctors need to directly close the bleeding vessel. Doctors typically do a surgical procedure in which a fiberoptic endoscope is placed through the wall of the sinus. The endoscope allows the doctor to reach and close off (typically with a clip) the larger artery that feeds the bleeding vessel. Occasionally, doctors use x-ray techniques to pass a small catheter through the person’s blood vessels to the bleeding site and inject material to block the bleeding vessel (embolization).

Key Points

  • Most nosebleeds occur from the front part of the nose and are easily stopped by pinching the nostrils together.

  • If pinching the nostrils does not stop the bleeding, people should seek medical attention.

  • During the history and physical examination, doctors ask people about bleeding disorders and their use of drugs that affect blood clotting, such as warfarin, clopidogrel, and aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

  • People should try the 10-minute pinch technique to stop a nosebleed.

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