Nosebleeds

The most common causes of nosebleeds are

• Trauma (such as nose blowing and picking)

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

Less common causes of nosebleeds include

• Nasal infections

• Foreign objects

• Hereditary hemorrhagic telangiectasia

• Tumors of the nose or sinuses

• Bleeding disorders (coagulopathies)

• Bodywide (systemic) disorders

High blood pressure (hypertension) is unlikely to cause a nosebleed, but in people with high blood pressure, the nosebleed may last longer than expected.

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 medications that interfere with blood clotting

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

• Bleeding that is not easily stopped—for example by direct pressure

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

Signs of a bleeding disorder include

• Numerous small, red or purplish spots on the skin (petechiae)

• Many large bruises

• Easily bleeding gums

• Bloody or tarry stools

• Coughing up blood

• Blood in the urine

• Excess bleeding while brushing the teeth, having blood tests, or getting minor cuts

• Heavy menstrual periods in women

People who cannot get the nosebleed to stop by pinching the nose should go to the hospital right away. Even if the bleeding has stopped, people who have warning signs should also 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.

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 medications 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 first look for signs of extensive blood loss (such as a fast heart rate and low blood pressure) and for markedly high blood pressure.

Doctors then 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 and an instrument used to hold the nostrils open. Sometimes the doctor uses a headlamp or head mirror to reflect light into the nose, To see a posterior bleeding site, doctors need to use a flexible viewing scope (nasal endoscope). However, an actively bleeding posterior site produces too much blood for the doctor to see anything, even with a viewing scope.

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

Bleeding from blood vessels in the front part of the nose 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.

Bleeding from blood vessels in the back part of the nose is very difficult to stop and can be life threatening. For this type of 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. This procedure causes discomfort, but the discomfort can be relieved with treatments.

If the balloon or packing does not work, doctors need to directly close the bleeding vessel. Doctors typically do a surgical procedure in which an endoscope is used to examine the interior of the sinus. The endoscope enables 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).