Nosebleeds (Epistaxis)

How epistaxis happens

The nasal lining has a rich blood supply to warm and humidify air. Several arteries meet at the front of the septum in a network called Kiesselbach's plexus (Little's area). The lining here is thin and exposed to drying airflow, so small vessels crack and bleed. Deeper branches of the sphenopalatine artery supply the back of the nose and cause posterior bleeds.

Types of nosebleed

Causes and risk factors

Local causes in the nose

• Dryness: low humidity, heating, air conditioning, oxygen therapy and CPAP without humidification.
• Digital trauma: nose picking, especially in children.
• Inflammation: colds, acute sinusitis and allergic rhinitis.
• Injury: a blow to the face or nasal fracture.
• Nasal sprays: steroid sprays and antihistamine sprays, particularly when aimed at the septum.
• Septal deviation or perforation: turbulent airflow dries one area.
• Drugs: cocaine and other intranasal drugs.
• Tumors: rare; juvenile nasopharyngeal angiofibroma in adolescent boys, and nasal or sinus cancers in older adults.

Systemic causes

• Medicines: antiplatelets (aspirin, clopidogrel) and anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran). See anticoagulant use.
• Bleeding disorders: von Willebrand disease (the most common inherited bleeding disorder), hemophilia, and low platelets from thrombocytopenia, leukemia or liver disease.
• Hereditary hemorrhagic telangiectasia (HHT): an inherited condition causing fragile vessels in the nose, skin, lungs, liver and brain. Recurrent, spontaneous nosebleeds are usually the first sign.
• High blood pressure: linked to more severe and prolonged bleeding, especially in posterior epistaxis.
• Alcohol, which affects platelets and blood vessels.

Diagnosis

A doctor will ask how often bleeds occur, which side, how long they last, medicines and supplements, other bleeding symptoms, and family history. They will check blood pressure and look inside the nose with a light and speculum, often after a decongestant and numbing spray. A nasal endoscopy (thin camera) examines the back of the nose and identifies posterior bleeding points or growths.

Tests when needed:

• Complete blood count: for anemia and platelet count after heavy or repeated bleeds.
• Clotting tests: INR for people on warfarin; tests for von Willebrand disease and other disorders when there is a personal or family bleeding history.
• CT or MRI: for suspected tumors or one-sided persistent symptoms.

Treatment

The AAO-HNS guideline recommends firm sustained compression of the lower third of the nose for at least 5 minutes, and usually longer, as the first step. Then, as needed:

1. Topical vasoconstrictors: oxymetazoline spray or soaked cotton pledgets to shrink vessels.
2. Cautery: once a bleeding point is visible, a clinician seals it with a silver nitrate stick under local anesthetic. Electrocautery is used for stubborn vessels. Only one side of the septum is cauterized at a time to avoid a perforation.
3. Nasal packing: absorbable materials or non-absorbable sponges or balloons placed in the nose. Non-absorbable packing is usually left 1 to 3 days. Posterior bleeding may need a posterior balloon and hospital monitoring.
4. Tranexamic acid: applied topically or given by mouth in some cases to help clotting.
5. Surgery or embolization: for bleeding that continues despite packing, endoscopic sphenopalatine artery ligation, or embolization by interventional radiology.

Managing blood thinners

Do not stop a blood thinner on your own. For most nosebleeds, the bleed can be controlled without stopping it. For life-threatening bleeding, doctors may reverse the anticoagulant. Your prescriber will weigh bleeding risk against stroke or clot risk.

Treating recurrent nosebleeds

• Keep the lining moist with saline sprays and petroleum jelly or antiseptic nasal cream (some creams contain peanut oil; check allergies).
• Cautery of a prominent vessel, especially in children with repeated bleeds.
• Treat allergies and sinusitis.
• Review medicines and supplements.
• For HHT: laser treatment, septal dermoplasty, and medicines such as tranexamic acid or bevacizumab, at a specialist center.

Complications

Most nosebleeds have no lasting effects. Possible complications include anemia from repeated bleeds, aspiration of blood, septal perforation from repeated cautery, and with nasal packing, sinusitis, pressure sores or, very rarely, toxic shock syndrome.

Prevention

• Humidify bedroom air in dry seasons.
• Use saline spray or gel daily if you are prone to nosebleeds.
• Aim nasal steroid sprays away from the septum.
• Treat allergies and avoid forceful nose blowing.
• Keep children's fingernails short.
• Keep blood pressure controlled, and take blood thinners exactly as prescribed with regular monitoring.

For step-by-step first aid, see how to stop a nosebleed.

Frequently asked questions

What is the difference between anterior and posterior epistaxis?

Anterior nosebleeds come from small vessels at the front of the septum. They account for about 90% of nosebleeds and usually stop with pressure. Posterior nosebleeds come from larger arteries at the back of the nose, bleed heavily down the throat, and often need packing or hospital care.

Why do I keep getting nosebleeds?

Recurrent nosebleeds are most often caused by dry nasal lining, a prominent vessel on the septum, nose picking, allergies or nasal sprays. Blood thinners, bleeding disorders such as von Willebrand disease, and hereditary hemorrhagic telangiectasia are other causes. An ENT exam can usually identify and treat the source.

Are frequent nosebleeds in adults a sign of something serious?

Usually not, but they deserve a check. Frequent bleeds can reveal a bleeding disorder, medicine effect, uncontrolled high blood pressure or HHT. One-sided bleeding with blockage, facial pain or numbness can rarely signal a tumor and needs an endoscopy.

What is nasal cautery?

Nasal cautery seals a bleeding vessel in the nose. After numbing spray, a clinician touches the vessel with a silver nitrate stick or uses a small electrical device. It takes a few minutes, stings briefly, and is very effective for recurrent anterior nosebleeds.

How long is nasal packing left in?

Absorbable packing dissolves on its own. Non-absorbable sponges or balloons are usually removed after 1 to 3 days. Some people with packing are given antibiotics and should avoid blowing their nose, straining and heavy lifting until it is removed.