Definition

Epistaxis, commonly known as nosebleeds, refers to the loss of blood from one or both nostrils. It is a common issue, with about 60% of people experiencing it at least once in their lives. This often occurs due to the numerous blood vessels in the nasal septum, the wall that divides the nostrils, which can easily rupture, especially when the nose is exposed to dry air and other irritants.

As worrying as they seem, most nosebleeds can be managed at home with self-care measures. However, certain signs may indicate the need for medical attention:

There are two types of nosebleeds based on the location of the ruptured blood vessels:

• Anterior epistaxis. This type results from blood vessel rupture on the front part of the nose. It is the most common type of epistaxis and is typically not dangerous. Children often experience anterior epistaxis due to the fragility of these vessels.
• Posterior epistaxis. Posterior epistaxis involves blood vessels at the back of the nose. These vessels are larger, and bleeding can be more severe and persistent. Blood clots may form, potentially obstructing the airway, and requiring medical intervention.

Causes

Nosebleeds can be caused by various factors, many of which do not typically require serious treatment. These include:

• Dry air, which can occur in warm climates, low-humidity environments, or heated rooms, dry air can dry out the blood vessels in the nose, making them more prone to bleeding when irritated
• Habits of picking the nose
• Upper respiratory tract infections like flu and sinusitis, which lead to frequent nose blowing, coughing, or sneezing
• Nose or facial injury
• Insertion of foreign objects into the nostrils
• Use of inhaled medications or drugs such as cocaine or nasal sprays
• Exposure to irritating substances like strong odors or chemicals in cleaning products
• Living in high-altitude areas
• Deviated septum, where the nasal septum (the wall between the nostrils) is not centered
• Use of allergy medications containing antihistamines or decongestants, which can dry out nasal membranes

Less common causes of nosebleeds include:

• Excessive alcohol consumption
• Blood clotting disorders like hemophilia
• High blood pressure
• Facial or nasal surgery
• Nasal tumors
• Nasal polyps (small, stalk-like growths inside the nose)
• Pregnancy

Risk factor

Several factors can increase the risk of nosebleeds:

• In children aged 2–10 years, risk factors include dry air, allergies, and curiosity leading to putting their fingers or foreign objects to their noses, causing nasal irritation
• Adults aged 45–60 years or older may experience bleeding more often because of lack of clot formation due to decreased clotting ability
• Pregnant women experience hormonal changes that dilate blood vessels, including those in the nose, making them more susceptible to nosebleeds
• Use of blood-thinning medications like warfarin 
• Clotting disorders such as hemophilia or von Willebrand disease 

Symptoms

When experiencing a nosebleed, typically the only symptom is bleeding from one or both nostrils. However, certain warning signs indicate the need for immediate medical attention:

• Signs of significant blood loss, such as weakness, fainting, or dizziness upon standing. 
• Use medications that affect blood clotting, like aspirin, clopidogrel, or warfarin.
• Presence of a blood clotting disorder, such as hemophilia, is characterized by symptoms like bleeding gums, extensive bruising, coughing up blood, bloody urine, heavy menstrual bleeding (menorrhagia), or difficulty stopping bleeding from injuries. 
• Recurrent nosebleeds without an obvious cause.

You must inform your doctor for further evaluation if any of these symptoms occur.

Diagnosis

During your medical assessment, the doctor will inquire about your symptoms, any risk factors, and your medical history, including family history. Questions may cover: 

• Recent activities like nose blowing, nose picking or recent upper respiratory infections
• History of previous nosebleeds
• Duration and severity of the bleeding (the amount of blood loss), and any attempts made to stop the bleeding
• Family history of clotting disorders
• History of treatments with blood thinning medications

A physical examination follows to identify the source of bleeding. The doctor will assess overall health for signs of significant blood loss or bleeding elsewhere, such as gum or skin bruising. Using a light source, the doctor examines the inside of the nose.

Additional diagnostic tests are seldom necessary unless there's suspicion of an underlying blood clotting disorder or other conditions causing frequent nosebleeds. In persistent cases, imaging tests like CT scans may be used to investigate the root cause of the bleeding.

Management

Home Remedies

If you experience a nosebleed, here are steps you can take at home:

• Stay calm
• Keep the body upright and lean your head slightly forward, this helps prevent blood from flowing into your airways
• Gently clean your nose and remove the remaining blood
• Pinch your nasal cartilage (the soft part of the nose) and apply gentle pressure for 10–15 minutes, you can also apply ice wrapped in cloth to the nose
• Breathe through your mouth
• Reapply pressure for 5 minutes if the nose is still bleeding, and if bleeding persists, seek immediate medical attention to ER
• Decongestant spray could be used albeit cautiously, these should not be used long-term without doctor supervision

After the bleeding stops, avoid the following for the next 24 hours:

• Blowing your nose
• Picking your nose
• Consuming warm drinks or alcohol
• Engaging in heavy physical activity
• Inserting foreign objects into the nose

Medical Treatment

• Nasal Tampon. If bleeding is significant and the source of nosebleed has been identified, a nasal tampon (made of cotton or sponge) can be used by a doctor to apply pressure at the source until the bleeding stops.
• Cauterization. Chemicals or heat may be applied to cauterize ruptured blood vessels. Local anesthesia at the nose may be used before the procedure.

Other treatments are tailored to address the underlying cause of the nosebleed. For instance, if the nosebleed is caused by foreign objects in the nose, the doctor will try to remove the objects. However, if a deviated nasal septum causes the nosebleed, surgical correction to reposition the septum could be recommended.

Complications

Nosebleeds generally do not cause serious complications. However, if the bleeding continues and you experience large blood loss, you may experience shock. Blood clots from nosebleeds can also block the airways. Recurrent nosebleeds can cause anemia or a deficiency of red blood cells.

Prevention

• Rinse your nose to keep the nasal mucosa moist
• Humidifier can be used
• Avoid blowing your nose too hard
• Refrain from inserting foreign objects into your nose, including fingers
• Quit smoking
• Trim your nails to keep them short
• Consult your doctor about the use of blood thinners or allergy medication

When to see a doctor?

Visit the emergency room immediately if you experience:

• Nosebleeds lasting more than 20 minutes
• Heavy bleeding that cannot be stopped with home remedies
• Swallowing a lot of blood until vomiting
• Nosebleeds occur after a blow to the head, being hit in the face, a fall, or a traffic accident
• Feeling dizzy and weak
• Difficulty breathing

Consult your doctor if:

• Nosebleeds occur in children under 2 years of age
• You have recurrent nosebleeds
• There are symptoms of anemia, such as rapid pulse, shortness of breath, and pale skin
• You are taking blood-thinning drugs
• You have a medical history or family history of blood clotting disorders

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