ENT - Nosebleed (Epistaxis)

Article by Dr Gan Eng Cern

ENT - Nosebleed (Epistaxis)

Dr Gan Eng Cern

ENT Surgeon / Otorhinolaryngologist
University of New South Wales
National University of Singapore
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What is epistaxis?
Epistaxis is the medical term for bleeding from the nose, which may be from the nostril,  nasal septum (the wall or partition that separates the nose into right and left sides), nasal cavity or nasopharynx (back of nose).

What causes nosebleed?
Nosebleed is usually caused by a burst blood vessel in the nose. This is usually the case in children and in most adults. In many people, the front part of the nasal septum has many prominent blood vessels (telangiectasia) (Fig 1). These are benign and are not tumours or dangerous growths. We do not know why some people have more prominent vessels on the nasal septum but sometimes it can be hereditary (genetic). Often, when the child grows older, the vessels become less prominent and the frequency of nosebleed lessens.

Figure 1
A front view of the left nasal cavity showing prominent dilated vessels on the Little’s area

A dry environment, frequent nose picking or violent nose blowing/sneezing may trigger or worsen nose bleeding in patients with prominent blood vessels in the nose. Causes of nosebleed can be broadly divided into local and systemic causes. Some of the more common causes are as follows:

Local causes:

  • Telangiectasia (prominent vessels) in the nose
  • Trauma from nose picking or external force
  • Deviated nasal septum (crooked septum)
  • Rhinitis (Sensitive nose)
  • Sinusitis (Infection of the sinuses)
  • Foreign body in the nose
  • Tumours (rare)

Systemic causes:

  • High blood pressure
  • Blood thinning medications (e.g. aspirin and warfarin)
  • Poor blood clotting function (coagulation disorders)

Are nosebleeds serious?
Most of the time, nosebleeds are not serious and stop on their own. However, if one has frequent episodes (e.g. many times in a week) or the duration of each episode of nose bleed is long (e.g doesn’t stop within minutes of pinching the nose), it can cause significant blood loss, resulting in anaemia (low blood level). In addition, heavy nosebleeds may be a sign of  more serious health problems such as uncontrolled high blood pressure, blood clotting problems or in rare situations, tumours.

What should I do if I have a nosebleed?
The first thing that you should do is to pinch the nostrils of your nose together (soft part of your nose), tilt your head forward and breathe through your mouth (Fig 2). Do this in a sitting or standing position. This will help the blood clot in the front part of your nose. You should not tilt your head backwards or lie down as the blood will continue to flow to the back of your nose and down your throat. If you do this, you may end up swallowing the blood and feel nauseas or even vomit the blood out.

Figure 2
Pinch the nostrils (soft part of your nose) of your nose together, tilt your head forward (chin to the chest) and breathe through your mouth when you have a nosebleed

To make yourself more comfortable, you can place an icepack on your forehead while you continue to pinch your nose. You can also rinse your mouth off the blood with ice gargle (water or mouthwash through a straw and cup) to remove the blood that has gone down your throat and mouth.

If the bleeding does not stop, you should consult a doctor. Continue pinching your nose till you are seen by the doctor. For heavy bleed (e.g. does not stop after 20 minutes of pinching your nose), it is best to go to the Emergency Department in a hospital.

What should I expect when I see a doctor for nosebleed?
If you are not actively bleeding from the nose, your doctor will take a clinical history to find out more about the frequency, amount and possible causes of your nose bleed. A thorough ENT examination will be performed, which may include a nasoendoscopy (passage of a small lighted tube with a camera into the nose and back of throat done under local anaesthesia) (Fig 3a&b).


Figure 3a & 3b

(3a) Flexible nasoendoscope is inserted in the nasal cavity and is guided to the posterior nasal space (back of nose) and to the level of the larynx (voice box) 

(3b) The procedure is done in the clinic setting after application of topical anaesthesia (numbing agent)  and decongestant

If the cause of your nosebleed is due to prominent blood vessels in the nose, it is likely that your doctor will apply a stick with some chemical (silver nitrate cautery) in your nose to seal the blood vessels (Fig 4). This is done after spraying a numbing agent  (topical anaesthesia) to the front part of the nose. Silver nitrate application is a quick and relatively painless procedure (some patients may feel some mild discomfort or stinging sensation in the nose but most do not complain of pain). Over the next few weeks, there may be mild crust (dried mucous) and mild nosebleed or bloodstain in the mucous as the wound in the nose is healing. Your doctor may give you some medications to hydrate and moisturize your nose during this period.

Occasionally other investigations such as blood tests, monitoring of blood pressure or radiologic imaging may be performed as part of the assessment of frequent nosebleed.

What is the treatment for nosebleed?
The treatment for nosebleed depends on the underlying cause (e.g silver nitrate cautery for prominent blood vessels, nasal steroid sprays for sensitive nose, antibiotics for sinus infection, high blood pressure medication for uncontrolled high blood pressure etc). You need to discuss with your doctor on the possible cause of your nose bleed and the treatment options.

What precautions can I take after my nosebleed stops?
To reduce the chance of another nose bleed, you should:

  • Avoid blowing your nose
  • Avoid picking your nose
  • Avoid hot drinks, alcohol or spicy food
  • Avoid any heavy lifting or strenuous exercise
  • Do not pick the scabs in the nose that helps with healing 

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