NOSEBLEEDS (EPISTAXIS)

Nosebleeds (also known as epistaxis) are very common and are usually noticed when blood pours from the nostrils.

There are two categories of nosebleed: anterior and posterior. Anterior nosebleeds are the most common type of nosebleed whilst posterior nosebleeds are less common but generally more serious.

Nosebleeds are caused by a tear in the mucosal lining of the nose where there are tiny blood vessels. In most cases, nosebleeds are caused by injury to the nose but they can also result from fragility, which may be associated with other health disorders or previous injury. Inflammation, underlying health disorders and coagulation problems can make it harder to treat nosebleeds.

Causes of nosebleeds

Local factors:

• Trauma and injury
• Inhaling certain chemicals
• Using nasal sprays
• Foreign bodies entering the nose
• Anatomic abnormalities or irregularities
• Surgical procedures, such as endoscopic and septoplasty nasal surgery
• Tumours inside the nasal cavity (this includes nasopharyngeal carcinoma in adults and juvenile angiofibroma in children)
• Inflammatory conditions, such as allergic rhinitis, chronic sinusitis and acute respiratory tract infections)

Systemic factors:

• Drinking alcohol
• Taking certain medications, including aspirin and warfarin, desmopressin and clopidogrel
• Allergies
• Taking narcotics
• Hypertension (high blood pressure)
• Heart failure, which is caused by an increase in pressure in the veins
• Malnutrition and anaemia
• Haematological malignancy
• Blood dyscrasias
• Infectious conditions
• Muscle tightness brought on by scoliosis; the tightness of the muscles contributes to the blood vessels becoming constricted, which in turn causes nosebleeds on the same area as the muscle tightness.

Treatment

Treatment aims to stem the surge of blood from the nose and is usually achieved by causing the blood to clot. People who have nosebleeds are encouraged to tilt their head slightly forwards and apply pressure to the nose to encourage the blood to clot and slow the run of blood. It is not advisable to tilt the head backwards as this can cause blood to flow into the respiratory system, which can be very serious and potentially fatal. Petroleum jelly can be applied to the nose to stop blood from flowing out of the nose; it also helps to keep the nasal cavity moist. The use of petroleum jelly is not always recommended as it can drain into the lungs, causing a collection that can contribute to lipoid pneumonia.

If this treatment is ineffective it may be necessary to pack the nose to stop bleeding. An anterior pack applies pressure internally to stop bleeding. If you are at home you can use tissue or gauze to pack the nose and you can also buy nasal sponges from pharmacies.

If bleeding continues it is advisable to seek urgent medical attention, as prolonged bleeding is often indicative of an underlying health condition. Emergency first aid treatment for severe nosebleeds includes using a dry hydrophilic nasal tampon or a balloon inflated nasal tampon.

Chronic epistaxis can be associated with dry nasal mucosa. If this is the case nasal saline spray is usually recommended and should be used three times each day.

If nosebleeds recur on a frequent basis this should be investigated urgently. Treatment options for severe, persistent nosebleeds include cryosurgery, nasal packing, the use of trichloroacetic acid and electrocautery.

Death is a rare complication of nosebleeds and the nosebleeds are most often minor and can be treated simply and effectively. However, if the maxillary artery is damaged this can bring about rapid blood loss, which can make treatment very difficult. The only treatment option may be embolisation or ligation of the artery, but this does carry a risk of harm to the facial nerves. Severe nosebleeds can result in iron deficiency anaemia.

If a nosebleed continues for longer than fifteen minutes it is advisable to seek urgent medical attention, especially if you have suffered a severe injury or lost a lot of blood.