Nosebleeds (Epistaxis) | Nasal Hygeine

NOSEBLEED (EPISTAXIS)

The nose is the entry point for air into the body. It channels the air towards the lungs and at the same time warms and humidifies the air. The nose is lined with moist mucous membranes to do this effectively. These membranes have a very rich blood supply.

Bleeding from the nose is quite common, especially in children. It may occur from one or both sides, and will usually come out the front when the patient is upright. Typically the quantity is relatively small, but it can make quite a mess, and may be somewhat scary.

The inside of the nostril is normal dry skin for not quite one half inch. This is the part that has hairs. Behind that, the nose is lined with a moist mucous membrane. Commonly, just behind the junction of the skin with the membrane, there will be one or several small veins lying on the surface. These are in a perfect position to become dried out depending on the weather, or traumatized with nose blowing, picking, Q-tips, etc. When the vessel bursts, blood leaks out and then the hole usually scabs over. The scab is not very sturdy, and may break again causing additional bleeding. This is why nose bleeds often come several in a row. Wintertime is typical nosebleed season, between the drying effects of indoor heat, and more frequent common colds and upper respiratory infections.

Other kinds of nosebleeds can happen higher up or farther back in the nose. These can be related to more severe injuries, rarely tumors, or from rupture of vessels farther back in the nose. These may be related to high blood pressure. Any kind of blood thinner, including aspirin and especially Coumadin can make this kind, and any kind, of bleeding harder to control. Occasionally, bleeding will come from irritation of the nasal membranes from smoking, from nasal steroid sprays, or from a hole in the internal wall of the nose called a “septal perforation”.  These may come from surgery, from trauma, and occasionally from cocaine abuse. Bleeding following an injury may be a sign of a broken nose, or even sinus fractures, but will almost always stop by itself.

In the doctor's office, listening to your story carefully, and examining the nose directly or sometimes with telescopes will allow identification of the bleeding site. Depending on the severity and frequency of bleeding, sometimes nasal hygiene measures will be sufficient (see "Nasal Hygiene Instructions"), and sometimes cautery is required.  This usually entails a silver nitrate chemical “burn”under mild local anesthesia, or sometimes electrical cautery which requires more thorough numbing. This can be done in the office in many cases, but occasionally requires a trip to the operating room. Packing can be used, especially in the emergency room, but is usually a temporary measure until a specialist can get involved.  In the case of severe nose bleeding, checking on the level of blood thinners, and the blood pressure are important. It is quite unusual that nosebleed is sufficiently severe or frequent to cause anemia or require transfusions. Nasal hygiene measures after cautery to the nose are always valuable.  Most patients can resume normal activities within one or two days.

Again, depending on the severity of bleeding, the First step with nosebleed is to lean forward, so you do not swallow the blood, and so you can determine just how much blood is coming out. Second, blow all the clots out of the nose, and then pinch the entire tip of the nose all the way down to the face. Pinching the bridge of the nose, the lip, ice packs on the back of the neck, don't do any real good. Third, hold the nose for 5 minutes and then gently release. If you have some Afrin spray or similar in the house, it is okay to spray this into the nose after blowing out the clots but before pinching it. If the bleeding is farther back, this may divert the blood into the throat in which case you will be spitting out more blood and it probably will not do any good to pinch it further.  If you begin to feel faint, or pass out, lie down on your side or your stomach so that the blood can drain out and you don’t choke on it. Many nosebleeds will stop with these simple measures, and a trip to the doctor may be avoided, or at least not in the middle of the night. Usually, your family doctor can help you decide when it is time to see an ENT specialist for difficult or recurrent nosebleeds.