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Nosebleeds (Epistaxis)

  • A condition that occurs when a blood vessel inside the nose bursts
  • Types: front or back of the nose
  • Treatments include nasal sprays and sealing off or applying pressure to the bleeding vessel
  • Involves Sinus & Allergy Program and Otolaryngology

Overview

You’re in a public place, maybe a supermarket, and you suddenly realize your nose is bleeding—and you don’t have a tissue. It’s embarrassing, but surprisingly common. Nosebleeds occur when a blood vessel inside your nose bursts. The medical name for nosebleeds is epistaxis. Each year, up to 60 million people in the United States have nosebleeds. They are mostly likely to occur in the winter, when cold weather and indoor heating dry the nasal passages.

Most nosebleeds are minor and the bleeding stops on its own, but some people will need medical attention. If you have chronic nosebleeds, it’s a good idea to be evaluated by a specialist, says Peter Manes, MD, a Yale Medicine otolaryngologist. “We have extensive experience with all types of nosebleeds, from the simple to the exceedingly complicated,” Dr. Manes says.

What causes nosebleeds?

The nose has an especially rich supply of blood vessels that are located close to the surface, where they can easily break and bleed.

Minor nosebleeds typically start in the front of the nose (an anterior nosebleed), or from the nasal septum, the cartilage that separates the nostrils. Most of these nosebleeds come from one nostril at a time.

A common cause of nosebleeds is dry indoor air, especially problematic in the winter. You can head off this kind of a nosebleed by regularly using a humidifier or by applying over-the-counter saline nose drops in each nostril a few times a day. You can also prevent dryness by rubbing a water-based lubricant on the inside of the nose.

Nosebleeds may be a side effect of using nasal sprays, or cold and allergy medicines. Nosebleeds can also be caused by a bump or blow to the nose.

If you often or regularly take nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin or warfarin, which hinder clotting, your nosebleeds may be especially difficult to stop.

The more severe type of nosebleed typically starts in larger blood vessels in the back of the nose (posterior nosebleed). The blood may flow back toward the mouth and throat as well as out the nostrils. Posterior nosebleeds are far less common than anterior nosebleeds and they require prompt medical attention because they can signal an underlying medical condition. Hypertension is the most common disease associated with severe nosebleeds. In rare cases, nosebleeds can be a sign of an aneurysm or underlying cancer.

When should you see a doctor for a nosebleed?

If your nosebleed is coming from the front of your nose, you can usually care for yourself at home. While sitting down, gently squeeze the soft portion toward the bottom of your nose between your thumb and finger. Do this for about 15 minutes. Do not tilt your head back, since this can cause the blood to flow back down your throat. It’s important to sit up straight, keeping your head higher than your heart. If your nosebleed lasts more than 20 minutes, or if you are having nosebleeds frequently, see your doctor.

Some nosebleeds require immediate emergency care. This is true for a nosebleed that happens after a major trauma, such as a car accident; if your nosebleed is accompanied by feeling dizzy or lightheaded; if the amount of blood coming from your nose is excessive; or if your nosebleed interferes with breathing. You also want to seek emergency care for a child younger than 2 years old who is having a nosebleed.

How are nosebleeds diagnosed and treated?

The medical specialty that provides care for the ear, nose and throat is otolaryngology. To understand what’s causing your nosebleed, your doctor will begin with a physical exam. He or she will look inside the nose using an endoscope, a tube with a tiny camera at the end of it. The specialist may also want a CT scan of the nose and sinuses, or other tests.

Treatment of a serious nosebleed or chronic ones is highly individualized. Your doctor will consider such factors as how severe the bleeding is, other medical conditions and treatments that may be causing the bleeds, and whether you use blood thinners.

Most nosebleeds can be treated without surgery and without going to the hospital, using one of the following approaches:

  • Nasal sprays
  • Topical therapies
  • Cautery, which is a procedure that involves applying heat to seal a bleeding vessel shut
  • Nasal packing, placing a gauze-like material or an inflatable balloon in the nose to put pressure on the bleeding vessel

When is surgery recommended for nosebleeds?

Posterior nosebleeds (toward the back of the nose) and nosebleeds that don’t respond to nonsurgical treatments may require surgery.  Minimally invasive surgery can isolate and repair a blood vessel that is the cause of bleeding.

The surgical procedure starts with insertion of an endoscopic tube through the nostrils. The goal is to find and treat the artery that is causing the problem. “The blood vessel has many different branches—the challenge, frankly, is making sure you’re finding all the branches,” says Dr. Manes. “If you don’t find them all, you haven’t done the job.”

Endoscopic surgery can be done without an incision and often leaves no scars. Pain is usually mild and recovery quick.  While most nosebleed surgery can be done on an outpatient basis, people with more severe conditions may require an overnight hospital stay.

Yale Medicine surgeons are specialists in trans-nasal endoscopy. They use a thin endoscope less than 6 millimeters in diameter—about the width of three stacked nickels. The procedure is easy for patients to tolerate and can be performed without anesthesia.

Does Yale Medicine offer any particular advantages in the treatment of chronic or severe nosebleeds?

While a nosebleed is usually a simple problem that can be treated without surgery, some patients’ conditions are complicated. A doctor may need to consider other medical conditions an individual may have, or consider whether the patient is using medications such as blood thinners.

 “We have a variety of different treatments—both medical treatments and surgical treatments that aren’t easy to find elsewhere,” says Dr. Manes. For complex cases, Yale Medicine’s otolaryngologists consult with interventional radiologists, hematologists, imaging experts and other top Yale Medicine specialists to ensure that all related problems a patient may have are being addressed.

Dr. Manes says that with proper care from an experienced specialist, people who are treated for nosebleeds and related complications can expect an excellent prognosis.