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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.
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.
Less common causes of nosebleeds include
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.
The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
In people with a nosebleed, certain symptoms and characteristics are cause for concern. They include
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.
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.
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
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.
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.
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).
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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