Ear, Nose and Throat Specialists of Middletown

Epistaxis

Nosebleeds

The quick summary:

To stop a nosebleed:

1. Squeeze all of the soft part of the nose for 15 minutes (by the clock) without letting go.
2. Repeat if bleeding recurs.
3. If the bleeding continues unchanged:
         a.  Use Afrintm spray
         b.  Control blood pressure
         c.  Seek medical attention if bleeding is substantial and ongoing (more than about a cup).

To heal and prevent a recurring bloody nose:

1. Apply Bacitracin Ointment (or Vaselinetm) to the inside of the nostrils frequently (about 5-10 times per day) with the soft surface of the little finger a far as you can reach to keep the inside of the nose continuously covered.
2. You may blow the nose, but do not pick the crust that forms over the cracked skin inside the nose.
3. Avoid aspirin and other drugs that impair clotting.
4. Keep blood pressure under control.

Factors Contributing to Bleeding From the Nose

In most cases, bleeding from the nose (also called “epistaxis”) comes from the front part of the nose on the “septum”, which is the wall of cartilage that divides the nose into two sides. There are several factors that contribute to this bleeding. 

1. Dryness.   The septum is covered with a special kind of skin called “mucosa”, which is     different from the skin on the outside of your body in several ways.    One important way that it is different is that it is designed to stay moist at all times.  If the mucosa on the septum dries out, it becomes very brittle and is easily cracked and split. This is usually the most important cause of bleeding from the nose and this will be discussed later.

2. Fragile blood vessels. The mucosa inside the nose is relatively thin and has many tiny,     fragile blood vessels running just under the surface. On some parts of the septum, these tiny blood vessels can be somewhat dilated or enlarged.  These dilated blood vessels are especially fragile and can bleed easily if they are scraped or injured in any way. The most common place this occurs is on the front part of the septum, just about where you can touch if you place your finger just inside the nostril.  Sometimes, especially in older individuals there are some of these dilated blood vessels in the back of the nose. 

3. Injury to the mucosa.  Most of the time the fragile blood vessels inside to not bleed unless they are scraped by something, usually a finger. This is more of a problem if a fragment of dried mucous, blood or scab is adherent to the mucosa. When the crust is pulled off, it tears  the mucosa causing it to bleed.

4. High blood pressure. Obviously, if someone’s blood pressure is higher than normal, it can make a blood vessel bleed more easily and it is harder to stop the bleeding than if the blood pressure is normal.  High blood pressure is more often a contributing factor in older individuals than it is in children or young adults.

5. Blood clotting problems. Anything that makes the blood slower to clot can make nosesbleed more easily and can make it harder to stop the bleeding. The body normally takes  about 13 minutes to form a blood clot, but this time can be prolonged if there is an illness that causes clotting problems or, more commonly, if a person is taking medications that interfere with clotting. Some of the medications that prolong clotting, such as “Non-Steroidal Anti-inflammatory Drugs” (NSAIDS), which include Aspirin or Ibuprofen (Advil tm, Nuprin tm and others).  Of these, aspirin is the most potent and can substantially impair clotting for 10 days after surgery, even as little as ½ tablet. The other “non-steroidals” have a similar effect, but they wear off much sooner, usually within a day of stopping the medication.  Fortunately, Tylenoltm has no effect on clotting.  Obviously, other drugs such as Coumadin or Warfarin, which are taken specifically to slow clotting, have a similar effect.

Common Types of Nosebleeds

“Anterior” nosebleed.   The most common type of nosebleed in children and young adults is bleeding from the front part of the septum and is related mainly to dryness.  The mucosa covering the front part of the septum becomes dried out due to low humidity. The thin, dry mucosa in this area becomes brittle and even more fragile. When a piece of crusty dried mucous adhering to the mucosa is removed from the nose, it breaks the skin and exposes a fragile blood vessel which then bleeds.  After the bleeding stops, a clot forms and then a scab forms over the crack in the skin.  The blood comes out of the front of the nose or goes down the back of the throat depending on whether the head is tilted forward or backward. The presence of blood going down the back of the throat does not necessarily mean the bleeding is coming from the back of the nose. The bleeding usually stops after about 15-20 minutes, the length of time it takes for a clot to form. Bleeding can last longer if a large blood vessel has broken, but rarely is there enough bleeding to be dangerous. The scab then dries out and forms a lumpy crust sticking to the fragile mucosa and underlying blood vessel.  When this lump causes irritation in the nose, the person may unconsciously pick it, once again cracking the skin and starting the bleeding again. This process of bleed-crust-pick-bleed is then repeated over and over until the skin is allowed to heal up.  A very common time for this unconscious picking of the nose, especially for children, is at night in bed.

 

“Posterior” nosebleed. A less common type of bleeding from the nose is bleeding from the middle or back of the nose.  In this case, dryness causing the mucosa to become more fragile may be a factor especially if there is a dilated blood vessel over a particularly crooked portion of the septum, but most of the time bleeding is related to an episode of high blood pressure. In these cases, bleeding may last until the blood pressure is reduced or the bleeding site is “cauterized” or burned with electric current.  Occasionally, the nose may need to be packed or surgery may be needed to stop the bleeding.  This kind of bleeding is obviously more serious and should be managed directly by a doctor.

Treatment of Nosebleeds

Stopping a bleeding nose.   Most nosebleeds are a nuisance, but are not dangerous if they can be controlled within about 10-15 minutes and if the total blood loss is about a cup or less.  Since most nosebleeds come from blood vessels just inside the nose, they can usually be stopped immediately by squeezing the nose, which puts pressure directly on the bleeding vessel. The correct way to do this is to squeeze the soft part of the nose firmly for 15 minutes without letting go.  Do not squeeze the bony part of the nose, as this area cannot be compressed and has no effect on the bleeding. Make sure you squeeze all of the soft part of the nose from the base of the nostrils up to the bones of the nose and from the tip of the nose all the way up to the bony surface of the face. This assures the bleeding site will be compressed under your fingers. Although some blood that has already bleed into the nose may trickle down the back of the throat, no more blood will come out of the blood vessel the instant that pressure is applied. Although it is not harmful to swallow blood, a large volume can cause nausea and you may wish to spit this blood out. After pressure is applied, it is important to hold firm pressure without letting go for at least 15 minutes.  If bleeding is controlled in this fashion, as is almost always the case, there is no need for immediate medical assistance. If significant bleeding occurs after 3-4 cycles, then you should contact the emergency Room.  Although it is much less common, if significant bleeding down the back of the throat continues despite correct finger pressure, it is probably coming from farther back in the nose (if bleeding continues from the front of the nose, then you aren’t squeezing the nose properly).  In this event, one other thing you can do is to blow out all of the blood clots and spray a decongestant nose spray in the nose to shrink the blood vessels. This includes Afrintm, Neo-Synephrinetm or similar generic versions.  These can take up to 15 minutes to have their full effect.  Another thing you can do if you have high blood pressure is to elevate the head and make sure you have taken the appropriate dose of blood pressure medication. Obviously if the bleeding is ongoing, you should seek medical assistance.

 

Healing the recurring nosebleed:   The most important factor in curing nosebleeds from the front of the nose is keeping the mucosa moist so it can heal and stop the “crust-pick-bleed-crust” cycle.  The most effective way to do this is by simply keeping the area covered with Bacitracin ointment, which you can by at any pharmacy or grocery store, at all times until the mucosa is healed.  Plain Vaseline will work just as well but may allow a slightly unpleasant odor to develop and Bacitracin will prevent this.  A humidifier may help too, but is much less important than keeping the area covered with ointment.  The correct way to do this is to use the soft part of the little finger to smear ointment on the septum gently as far into the nose and the finger will reach.  A Q-tiptm can be used, but the finger is better because it’s smoother and scratches the inside of the nose less.  This must be repeated as many as 10 or more times per day to make sure that the area is covered at all times, 24 hours a day.  Applying ointment only 3-4 times a day is usually not enough to keep the mucosa from drying out. It is a good idea to carry a small tube of ointment at all times and apply more whenever the nose feels it is not “greasy”. You cannot overdose on the ointment and it will not hurt you to swallow a small amount of it.  The only mistake is not using it frequently enough.  This must be continued until the area heals, usually within 10 days, but may take 2-3 weeks if it is severe. During the healing phase, a large blob of moist crust will form over the cracked mucosa.  This is the healing scab and must be left along. If it is picked out, it will start the cycle all over again. Blowing the nose is usually safe and will not disturb the healing scab.  During the period a nose is healing, it still may occasionally bleed.  If this occurs, just stop the bleeding as described above and continue to use the ointment until it is completely healed.  If the dilated blood vessels continue to bleed after treatment, they may need to be destroyed by cauterizing them after numbing the nose in the doctor’s office.  Even after this has been done, the nose must be kept moist with Vaseline in the same fashion until the scab heals completely in 2-3 weeks.  You may need to use ointment in the nose to some degree during periods of particular dryness to prevent the recurrence of cracking of the mucosa, but you probably will not need as much as when healing an already dry, cracked and bleeding nose.

 

Back