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  • Writer's pictureDr Amir Ajar

Nose Bleeds

BACKGROUND

Nosebleeds are among the most common ENT emergencies in the United States, presenting in approximately 7-15% of the general population every year. Bleeding can start from the front or back of the nose, but most commonly, bleeding originates from the front of the nose, along either side of the nasal septum (the structure that divides your nose into two nostrils, right and left. 

CAUSES

Causes of nosebleeds are many. Trauma - either a broken nose or self inflicted (nose picking) are most commonly seen causes. Other causes, such as high blood pressure, use of medication that thins the blood or tissue of the nose, excessive nasal dryness, foreign bodies (particularly in kids), allergies, infections and, at times- tumors, are also seen as well. It bears mention that nasal tumors are not commonly seen and should NOT be the first thing you think of when you have a nosebleed, so please, do not allow your mind to wander to this off the bat. Nosebleeds associated with persistent nasal congestion, pain, weight loss, or other symptoms not related to nose - are more concerning and should be promptly evaluated by an ENT specialist.

MANAGEMENT

This can be broken down into (1) what to do before you get help, and (2), what will happen if/once you seek help. The first and most important thing to do with a nosebleed is probably the hardest thing to do - stay calm. Nosebleeds never happen at a "good time" and it certainly does not help that it is common that those around you add to your stress by worrying that you are bleeding. Getting anxious and irritated however only increases your blood pressure, making the nosebleed harder to stop. Imagine a garden hose with a small hole in it. If the pressure of the water in the hose is high, the water shoots out. If the pressure of the water in the hose is low however, the water trickles out. Without exception, a trickle is always easier to manage. As part of staying calm, stop what you are doing (if possible) and sit down. Do not tilt your head back (the blood will only roll back into your throat); do not bend your head forward (your head held down will increase the pressure in the nose and exacerbate the bleed. Keep your head level - looking straight ahead. Pinch the soft, lower 1/3 of your nose on the side that is bleeding. It serves no use to squeeze the hard, bony top part of the nose when there is a bleed. Patients will commonly stuff kleenex of gauze up their nose - this can be a double edged sword. While packing a nose that continues to bleed is a mainstay of treatment (see below), keep in mind that stuffing the nose with material can further traumatize the delicate tissue in the nose and cause the nosebleed to worsen. In my practice, my advice to my patients is always "less is more" when it comes to self-packing the nose - though I do understand and appreciate the logic of doing this during a bleed. 

If a nosebleed is particularly brisk, or won't stop- the only next recourse is to seek help. Most all Urgent Cares and Emergency Rooms are capable of initiating care for a nosebleed. You can expect your blood pressure to be promptly taken on arrival at these clinics and addressed if it is too high; after which further evaluation and workup are contingent on the specific presentation of the patient and discretion of the provider who will be caring for you. Remember at this point while the nose is bleeding that it will stop - the only question is how involved the intervention needs to be to make it stop. 

It is most common to use either a medicated "pencil" to cauterize or burn the area that is actively bleeding. The term burn in this case does not involve a sensation of heat, though patients commonly will report a "stinging irritation" when this is happening. The "burn" is actually a chemical reaction that clots the blood and makes a scab over the bleeding site. Alternatively or in combination, the nose may be packed with one of several packing materials to help hold pressure on the nose from the inside, and get the area that is bleeding to eventually clot off. If packing is used, you will be prescribed pre-emptive oral antibiotics to avoid a secondary infection because of the foreign body (the packing material in this case) in your nose. Should these measures fail, more sophisticated measures including surgery to control the blood vessels feeding the nose would be an option. Alternatively, there are procedures that can be performed by doctors to "clot off" these same blood vessels from within the blood vessel itself. 

PREVENTION

As with all things, prevention is always the best medicine. Avoiding trauma to the nose (picking scabs etc), maintaining a hydrated nose (nasal gels, nasal saline, humidification in the bedroom at night if the air is dry), controlling your blood pressure (important for many reasons besides nosebleed), controlling nasal allergies, and perhaps most importantly and bearing mention separately - respecting medications that "thin" your blood. More specifically, these medicines interfere with your blood's ability to clot. While these medications certainly save lives in the context of heart disease and blood clots - they are common culprits in nosebleeds. Never stop these medications without consulting with a doctor first. On the other hand, it is always a good idea to engage the doctors who prescribe these medications when you see them in follow up to make sure you still need the medicine. 

SUMMARY

Nosebleeds are a very common ENT emergency. While most nosebleeds will stop with conservative measures, some ultimately need more involved interventions. Understanding how to avoid the bleed and how to manage the bleed should in most cases decrease the natural stress and anxiety nosebleeds are associated with. Ultimately, ENT specialists are available and best equipped to assist you and your other doctors should you need help with nosebleeds. 

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