Nosebleeds (Epistaxis)

What is epistaxis?
Epistaxis is bleeding from the nostril. At least 11% of all Americans have at least one nosebleed in their lifetime. Nosebleeds are very common in athletes who are involved in contact or collision activities, such as boxing, wrestling, hockey, and football.

There are two types of nosebleeds: anterior (front) (Fig. 1) and posterior (back) (Fig. 2). The anterior type is usually less severe, but can be more frightening because blood is seen oozing from the nostril. Unlike anterior nosebleeds, posterior nosebleeds are not easily visible because blood oozes down the back of the throat.

Anterior nosebleeds usually occur in younger patients as a result of injury to the nose or dry nasal membranes. Posterior nosebleeds usually occur in elderly patients in whom the vessels and arteries of the posterior nose become hardened and break.

Causes and risks
The most common cause of nosebleeds is trauma (sudden, forceful injury) to the nose. Trauma can cause broken nasal bones, which in turn can cause lacerations (cuts) to nasal membranes. Upper respiratory tract infection, allergies, drug inhalation, and sinusitis can cause swelling of the membranes, which leads to tissue that can bleed easily. Some drugs, such as aspirin, nosedrops, and blood thinners, and certain diseases, such as aplastic anemia, leukemia, hemophilia, Hodgkin's disease, rheumatic fever, arteriosclerosis, high blood pressure, thrombocytopenia (low platelet count), and liver disease, can also cause nosebleeds. Dry climates and high altitudes can cause vessels in the nose to bleed easily, especially when you blow your nose.

Signs and symptoms
In an anterior nosebleed, blood is usually seen running out of the nose. If the area of bleeding is close to the nostril, bright red blood can be seen. If the area of bleeding is deeper in the nose, the blood is usually dark red. Dizziness, rapid heartbeat, and shortness of breath can be experienced if a large amount of blood is lost.

Prevention
Since most nosebleeds come from direct trauma, using protective equipment for the head and face during athletic activities can reduce the chance of injury. Treatment for any underlying medical condition can also prevent nosebleeds. During winter months and in dry climates, humidifying the air can help moisturize nasal passages and prevent overly dry nasal tissue.

Treatment
Most nosebleeds can be controlled with simple treatment. Sit up with your head bent forward. Using your thumb and index finger, pinch the nostril for at least 5 minutes. If bleeding continues, keep pinching the nostril for another 10 minutes. Pinching the nose allows the blood to clot and seal off the bleeding vessel. Ice wrapped in a towel or plastic bag can be applied to the nose, while it is being pinched, to help stop the bleeding. Ice causes constriction of the bleeding vessels. Don't blow your nose for at least 12-24 hours because that can dislodge the blood clot. It is also important to remain quiet and not talk excessively, which could cause you to inhale blood. Normal activity can be resumed if the bleeding has stopped for at least 24 hours. If the bleeding does not stop, or if there has been an injury such as a broken nose, a doctor's treatment should be sought. A doctor can insert gauze into the nostril to place direct pressure on the bleeding vessel. If bleeding still continues, your doctor can prescribe certain medications or perform certain procedures to help stop the bleeding.

Raymond C. Hui, M.D.
Columbus, Georgia