What Causes Nosebleeds and How to “Fix” Them?

Probably everyone has experienced some bleeding from their nose at some point in their lives. It is also known as epistaxis. Most nosebleeds are brief and minor, a result of a recognizable underlying cause such as trauma or inflammation. Some nosebleeds can be life-threatening, necessitating some drastic measures such as packing or even surgery and hospitalization.

The head and neck region of our bodies are rich in blood vessels since they supply oxygen and nutrients to vital and sensitive areas. Our noses have an intricate anatomy with the purposes of breathing, humidification, and filtration. The nose is a gateway to our paranasal sinuses which control inflammation, infection, and the defense against foreign invaders. Besides the eyes, the nose is one of the most recognizable of our facial features, and also the most vulnerable because of its natural prominence.

What causes nosebleeds?

There is an extensive list of potential causes for nosebleeds, most of which involve an underlying cause. When the underlying cause is eliminated, usually the nosebleeds stop. Perhaps the two most common causes of nosebleeds are ones no one wants to acknowledge, particularly in children. They are nose picking and nasal dryness.

In defense of rubbing or picking the nose, there is usually some reason such as dryness or irritation. Nasal humidification with saline spray or aqueous ointment can fix the problem quickly.

Another widespread problem is allergy. That constant nasal itchiness causes rubbing and manipulation, if not picking. In children, there is a famous motion of using an open hand to push up the nose. This is termed the “nasal salute” and it can be associated with nosebleeds. Allergy treatment even with over-the-counter antihistamines and other supportive measures can be more effective than trying to fix the bleeding directly.

Other causes include:

  • Trauma (in addition to picking or rubbing)
  • Infection (acute and chronic)
  • Inflammation
  • Chemical irritants
  • High altitudes
  • Blood thinners (anticoagulants such as aspirin)
  • Use of illicit drugs such as cocaine
  • Overuse of over-the-counter nasal sprays like Afrin
  • Foreign bodies (more common in children)
  • Allergic and nonallergic rhinitis
  • Pregnancy
  • Less common reasons
    • Bleeding disorders like hemophilia or von Willebrand disease
    • Nasal masses, polyps, or structural abnormalities like a deviated septum
    • Low platelets (thrombocytopenia)
    • Immunologic diseases (sarcoidosis, and others)
    • Hereditary diseases (Hemorrhagic telangiectasis) present a specific, difficult problem
    • Prior nasal surgery or nasal manipulation during surgery for another reason

What should I do if I have a nosebleed?

Primarily, do not panic. A drop of blood can seem like an ocean to almost everyone. Placing pressure on the nose or pinching the nostrils together and sitting upright is paramount. Unlike the common reflexive movement of tilting our head back, really to prevent the blood from soiling our clothes, desks, or car dashboards, the best thing to do is to lean forward.

By leaning forward, the blood does not trickle down our throats which can make matters worse. We can become sick to our stomach quickly and it can induce nausea, vomiting, and diarrhea, causing our anxiety to peak, all of which makes us bleed more. It can be a vicious cycle.

Most nosebleeds stop spontaneously with minor measures such as described above. If it persists, try ice to the bridge of the nose, over-the-counter nasal decongestants spray (oxymetazoline) such as Afrin or Neo-Synephrine), or gently trying to hold a towel or gauze up to the side of the nose that is bleeding. Placing something like tissue up inside the nose may worsen the situation. Strenuous activity can also make matters worse. A special note about the nasal sprays is that they are to be used sparingly. Continual usage can actually cause more bleeding and irritation to the nasal lining.

When should I seek medical help for a nosebleed?

Many people think about having to have a nosebleed “fixed” if it persists or turns out to be recurrent. The fix that people want are either cauterization or packing, or a combination of both.

While it is true that cauterization of a specific blood vessel is particularly effective, it is still to be considered in addition to any other medical treatment that may be necessary. If the person has high blood pressure or takes blood thinners or has a serious sinus infection, without controlling those underlying problems, cauterization or even nasal packing is only a temporary solution.

Of course, if there has been a foreign body inserted as with a young child, removing the offending agent will stop the nosebleeds. Also, if that baseball player took a line drive to the nose, fixing the broken nose stops the bleeding in most cases.

What is the difference between a mild and a severe nosebleed?

There are two main types of nosebleeds: anterior (front) and posterior (back of the nose). The vast majority of nosebleeds are anterior, making them accessible to compression, cauterization, or even control with ice. There is a specialized area in the front part of the nasal septum on both sides of the nose called “Kiesselbach Plexus”. This is a vascular network of fine blood vessels that supply oxygen and nutrients to the front part of the nose. It is also an area that can be exposed to drying and trauma like picking.

If conservative measures fail in stopping a nosebleed, it may mean that the bleeding is further back and a posterior nosebleed. Posterior nosebleeds represent a completely different situation, and they can be serious, necessitating hospitalization, deeper, more uncomfortable nasal packing, and even procedures such as arterial embolization or surgery.

Fortunately, because of improved techniques by interventional radiologists, arterial embolization can be lifesaving, involving minimal risks. Surgery is typically reserved for only specialized or difficult cases. The surgery involves either an incision made through the mouth above the teeth to access the cheek sinus or a small incision between the eye and the nose in the middle of the face, or both.

A final word

Nosebleeds are almost always a symptom of something else. The blood is the most dramatic sign we see, so it is what we want to cure right away, which is understandable.

But simple measures like humidification, decreasing irritation, treating an infection, quitting smoking, stopping the use of nasal sprays, or treating allergies can stop the nosebleeds from persisting or beginning in the first place. Often if we can get a child with allergies to stop his or her “nasal salute,” not only do they feel better overall, but the nosebleeds stop for the last time.

References

Cleveland Clinic https://my.clevelandclinic.org/health/diseases/13464-nosebleed-epistaxis

Mayo Clinic https://www.mayoclinic.org/symptoms/nosebleeds/basics/causes/sym-20050914

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