Nosebleeds, also called epistaxis, is a common problem that involves bleeding from the nostril, nasal cavity, or nasopharynx. Nosebleeds can be classified depending on their location into anterior and posterior nosebleeds. Erosion of mucosa and exposing or breaking of blood vessels in the nose is usually the result of the bleeding.

The two most common causes of nosebleeds are dryness and nose picking. Other causes of nosebleeds may include, frequent use of decongestant nasal sprays, infection, allergy, bleeding disorders, bumps or falls, and the common cold. Less common causes of nosebleeds may include, hereditary hemorrhagic telangiectasia, nasal polyps, and alcohol use.

Several risk factors can increase the chance of having nosebleeds, such as having hypertension or diabetes mellitus, taking aspirin or anticoagulants, and having blood clotting disorders.

Signs and symptoms associated with nosebleeds can include, bleeding from one or both nostrils, the urge to swallow frequently, palpitations, and shortness of breath.

An occasional nosebleed is usually not a cause for concern, but frequent episodes may indicate an underlying condition that needs checking.

To diagnose the cause of nosebleeds, doctors usually perform a physical exam and may suggest particular diagnostic tests like complete blood count and nasal endoscopy.

Many treatment options are available to treat nosebleeds. Most nosebleeds can be controlled by simple first aid interventions, but recurrent episodes may require arterial embolization to prevent further bleeding.

There are several preventive measures that can lower the possibility of having nosebleed, such as not picking the nose, keeping the home humidified, applying petroleum jelly regularly, wearing protective clothing and head guard to provide more protection when engaging in certain activities, such as contact sports.

A severe nosebleed can sometimes lead to hypovolemia, or decreased blood volume, especially for people who suffer from other diseases but are rarely life-threatening.

According to a study published in the journal Otolaryngologic Clinics of North America, the estimated lifetime incidence of nosebleeds is approximately 60% with severity ranging from mild to severe or life-threatening.

Nosebleeds are common and involve bleeding from the nostril, nasal cavity, or nasopharynx. Bleeding most often occurs in one nostril. Nosebleeds are generally minor and not critical, despite that they may seem critical.

Nosebleeds can be classified into:

• Anterior nosebleeds: These are the most common type of nosebleeds which originate from the wall between the two nose channels (the lower septum), just inside the nose. Anterior nosebleeds are the least dangerous and mostly seen among children.

• Posterior nosebleeds: These nosebleeds are uncommon and are mostly seen among the elderly. The bleeding comes from branches of arteries that supply the nasal cavity between the roof of the mouth and the brain. Posterior nosebleeds are mainly severe and are difficult to locate and control.

Nosebleeds can be attributed to many causes, which has been classified into:

• Local causes: The result of mucosal irritation, trauma, anatomic deformities, and intranasal tumors.
• Systemic causes: The result of blood disorders, vascular/cardiovascular diseases, and immunodeficiency.
• Environmental causes: Related to changes in temperature and humidity, which causes nose dryness.
• Pharmacological causes: Related to many medications that alter coagulation such as nonsteroidal anti-inflammatory drugs (NSAIDS) and warfarin.
• Unknown causes: Some nosebleeds are idiopathic.

The two most common causes of nosebleeds are nose picking and dryness. Other common and less common causes of nosebleeds include:

Common Causes

• Frequent use of decongestant nasal sprays, such as those used to treat allergies.
• Using of anticoagulants, such as warfarin and heparin.
• An infection of the nose lining, sinuses or adenoids.
• Allergic or non-allergic rhinitis.
• Coughing.
• A foreign object in the nostril.
• Bleeding disorders, such as hemophilia.
• Ammonia and other chemical irritants.
• Deviated septum.
• Trauma to the nose.
• Atherosclerosis.
• Common cold.
• High Altitude.
• Cocaine use.

Less common causes:

• Granulomatosis with polyangiitis, which is a condition characterized by inflammation of blood vessels that can affect many organs and parts including the nose and sinuses, a condition called.
• A skin growth that looks like a shiny red mass (pyogenic granuloma).
• Idiopathic thrombocytopenic purpura, a condition that causes excessive bleeding or bruising.
• Hereditary hemorrhagic telangiectasia, a blood vessel disorder that leads to bleeding.
• Second-trimester pregnancy.
• Surgeries affecting the nose.
• Nasal polyps.
• Nasal tumors.
• Leukemia.

Anyone can get a nosebleed, but the risk increases among certain groups of people:

• People with hypertension and diabetes mellitus as these conditions can trigger atherosclerotic changes in the nasal vessels, making them more at risk for bleeding.
• Children between 2 and 10 years of age.
• People with congestive heart failure.
• Pregnant women.
• Elderly people.

Many capillaries can be found within the nose, which makes nosebleeds a common problem among people. Most nosebleeds occur in the front lower part of the nasal septum in an area known as Kiesselbach’s plexus. Erosion of mucosa and exposing or breaking of blood vessels can cause bleeding to occur.

Exposing or breaking the of blood vessels occurs directly as a result of trauma. Dryness due to low humidity can cause the collapse of the delicate membrane lining the nasal passages, leading to the rupture of tiny blood vessels due to a cough, sneeze, sharp fingernail, or blowing the nose.

The relationship between nosebleeds and hypertension is often misunderstood and it is relatively rare for hypertension to be a direct cause of a nosebleed.

Signs and symptoms associated with nosebleeds include:

• Blood coming out of one or both nostrils.
• The urge to swallow frequently.
• Vomiting, sometimes, when a large volume of blood is swallowed.
• Palpitations (an irregular heartbeat).
• A feeling of flowing liquid in the throat.
• Shortness of breath.
• Pale skin.

Diagnostic steps for nosebleeds look for the cause and possible complications and may involve:

• Physical examination: Usually, the physician performs a physical exam to determine the severity and cause of the nosebleed. This may involve looking inside the nose and measuring pulse and blood pressure. Patients may be closely monitored for signs and symptoms of hypovolemic shock that appears as low blood pressure due to blood loss.
• Diagnostic tests: Test in the case of nosebleed may include:

• Complete blood count to look for causes, such as bleeding disorders like hemophilia, or for complications of bleeding like anemia.
• Examination of the nose with a camera in a procedure known as nasal endoscopy.
• Partial thromboplastin time and prothrombin time tests, which measure the time it takes for blood to clot to detect issues affecting blood clotting that may be the cause of nosebleeds.
• CT scan of the nose and sinuses, which may help detect causes of nosebleeds like tumors and polyps.

Treatment options for nosebleeds can include the following:

First aid

The aim of first aid measures is to stop the bleeding as quickly as possible.

• Sit up straight and tilt your head slightly forward to prevent blood going down into the stomach.
• Close your nostrils by pinching them together for 10 minutes. Breathe through your mouth and do not remove pressure from your nostrils.
• Remove any tight clothing around the neck.
• Monitor pulse and blood pressure, if possible.
• Apply ice or a cold water compress to the bridge of the nose, if possible.
• After 10 minutes, release the pressure on the nostrils and check if bleeding has stopped.
• If the bleeding has stopped, avoid actions that may cause the bleeding to start again, such as sniffing or blowing your nose, for at least 15 minutes.
• If bleeding has not stopped, repeat the above steps one more time.
• If the bleeding continues after that, seek medical aid.

Medical Therapy

This step involves therapeutic and prophylactic actions to treat the underlying cause of nosebleeds and prevent or lessen the frequency of further episodes of bleeding. Treatments include:

• Conservative Therapy

• Nasal cautery: This is a common treatment for nosebleeds and it is performed by using chemical cautery, such as silver nitrate, or by electrocautery in which electrically charged wire, such as platinum, is heated and then placed on the nasal mucous membrane to seal blood vessels.
• Nasal packing: The goal of this procedure is to stop bleeding by applying enough pressure on the vessel using special gauze or an inflatable latex balloon that is inserted into the nose to stop bleeding.
• Surgical Therapy
• Direct surgical ligation: This surgery is performed by using small instruments to tie off blood vessels that bleed in the back of the nose. The ligation is usually applied to the anterior and posterior ethmoid arteries via an external facial incision.
• Endoscopic sphenopalatine artery (SPA) ligation: This surgery is considered as the most specific and currently the most widely used technique because it minimizes the risk of persistent bleeding from other sources and spares the patient from a transoral incision.

• Arterial embolization

This is a relatively new technique which is used to block the distal branches of the internal maxillary artery by purposely embolizing or blocking them. The success rate of this procedure is high, although not without risk as it may lead to stroke of facial palsy.

• Additional treatments

Other treatments that may be used to treat nosebleeds include:

• Blood transfusions to replace the lost blood of the patient.
• Tranexamic acid, which is a drug that can reduce bleeding by enhancing blood clotting.
• Packing the nose with gauze under anesthesia to apply pressure and stop the bleeding.

The most common complication of nosebleeds is anemia, which is a decrease in the number of healthy red blood cells leading to an inadequate oxygen supply to body tissues.

Some of the measures that can prevent nosebleeds include:

• Not picking the nose and keeping the fingernails of children short to discourage nose picking.
• Blowing the nose only when necessary and gently.
• Keeping the home humidified when the air is dry by using a cool mist humidifier.
• Applying petroleum jelly regularly to the inside of the nostrils to keep the inside of the nose moist, especially at bedtime.
• Wearing protective clothing and head guard to provide more protection when playing sports or engaging in activities in which the nose or the head could be injured.
• Using nasal decongestants or anticoagulants with caution for those with a history of nosebleeds.
• Quitting smoking because it dries out the nose and irritates it.
• Opening the mouth when sneezing.

Death due to a nosebleed is rare. Nosebleeds can lead to hypovolemia if severe bleeding occurs or in patients who suffer from other diseases. Most episodes of nosebleed resolve spontaneously, normally without treatment.

A study published in Otolaryngologic Clinics of North America reports the estimated lifetime incidence of nosebleeds at approximately 60% and its severity ranges from mild to severe or life-threatening.

Results of a study published in the International Journal of Advances in Medicine confirm that nosebleeds are more prevalent in those older than 60 years of age. Moreover, the most common cause of epistaxis was trauma followed by hypertension and infection of sinuses.

According to a study published in Annals of Emergency Medicine, a journal issued by the American College of Emergency Physicians, nosebleeds are more common in the winter and accounts for about 1 in 200 emergency visits in the United States with the highest rates present in the elderly.