Nosebleed (Epistaxis)

Overview

What is a nosebleed?

Simply put, a nosebleed is the loss of blood from the tissue that lines the inside of your nose.

Nosebleeds (also called epistaxis) are common. Some 60% of people will have at least one nosebleed in their lifetime. The location of the nose in the middle of the face and the large number of blood vessels close to the surface in the lining of your nose make it an easy target for injury and nosebleeds.

Are nosebleeds serious?

Although seeing blood coming out of your noise can be alarming, most nosebleeds are not serious and can be managed at home. Some, however, should be checked by your doctor. For instance, if you have frequent nosebleeds, see your doctor. This could be an early sign of other medical problems that needs to be investigated. A few nosebleeds start in the back of the nose. These nosebleeds usually involve large blood vessels, result in heavy bleeding and can be dangerous. You will need medical attention for this type of bleed, especially if the bleeding occurs after an injury and the bleeding hasn’t stopped after 20 minutes of applying direct pressure to your nose. (Read on to learn the steps for how to stop a nosebleed.)

Are there different kinds of nosebleeds?

Yes. Nosebleeds are described by the site of the bleed. There are two main types and one is more serious than the other.

An anterior nosebleed starts in the front of the nose on the lower part of the wall that separates the two sides of the nose (called the septum). Capillaries and small blood vessels in this front area of the nose are fragile and can easily break and bleed. This is the most common type of nosebleed and is usually not serious. These nosebleeds are more common in children and are usually able to be treated at home.

A posterior nosebleed occurs deep inside the nose. This nosebleed is caused by a bleed in larger blood vessels in the back part of the nose near the throat. This can be a more serious nosebleed than an anterior nosebleed. It can result in heavy bleeding, which may flow down the back of the throat. You may need medical attention right away for this type of nosebleed. This type of nosebleed is more common in adults.

Who gets nosebleeds?

Anyone can get a nosebleed. Most people will have at least one in their lifetime. However, there are people who are more likely to have a nosebleed. They include:

  • Children between ages two and 10. Dry air, colds, allergies and sticking fingers and objects into their nose make children more prone to nosebleeds.
  • Adults between ages 45 and 65. Blood may take longer to clot in mid-life and older adults. They are also more likely to be taking blood thinning drugs (such as daily aspirin use), have high blood pressure, atherosclerosis (hardening of the walls of arteries) or a bleeding disorder.
  • Pregnant women. Blood vessels in the nose expand while pregnant, which puts more pressure on the delicate blood vessels in the lining of the nose.
  • People who take blood-thinning drugs, such as aspirin or warfarin.
  • People who have blood clotting disorders, such as hemophilia or von Willebrand disease.

Symptoms and Causes

What causes nosebleeds?

Nosebleeds have many causes. Fortunately, most are not serious.

The most common cause of nosebleeds is dry air. Dry air can be caused by hot, low-humidity climates or heated indoor air. Both environments cause the nasal membrane (the delicate tissue inside your nose) to dry out and become crusty or cracked and more likely to bleed when rubbed or picked or when blowing your nose.

Other common causes of nosebleeds include:

  • Nose picking.
  • Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing and nose blowing.
  • Blowing your nose with force.
  • Inserting an object into your nose.
  • Injury to the nose and/or face.
  • Allergic and non-allergic rhinitis (inflammation of the nasal lining).
  • Blood-thinning drugs (aspirin, non-steroidal anti-inflammatory drugs, warfarin, and others).
  • Cocaine and other drugs inhaled through the nose.
  • Chemical irritants (chemicals in cleaning supplies, chemical fumes at the workplace, other strong odors).
  • High altitudes. The air is thinner (lack of oxygen) and drier as the altitude increases.
  • Deviated septum (an abnormal shape of the wall that separates the two sides of the nose).
  • Frequent use of nasal sprays and medications to treat itchy, runny or stuffy nose. These medications – antihistamines and decongestants – can dry out the nasal membranes.

Other, less common causes of nosebleeds include:

Management and Treatment

How do I stop a nosebleed?

Follow these steps to stop a nosebleed:

  • Relax.
  • Sit upright and lean your body and your head slightly forward. This will keep the blood from running down your throat, which can cause nausea, vomiting, and diarrhea. (Do NOT lay flat or put your head between your legs.)
  • Breathe through your mouth.
  • Use a tissue or damp washcloth to catch the blood.
  • Use your thumb and index finger to pinch together the soft part of your nose. Make sure to pinch the soft part of the nose against the hard bony ridge that forms the bridge of the nose. Squeezing at or above the bony part of the nose will not put pressure where it can help stop the bleeding.
  • Keep pinching your nose continuously for at least 5 minutes (timed by clock) before checking if the bleeding has stopped. If your nose is still bleeding, continue squeezing the nose for another 10 minutes.
  • If you’d like, apply an ice pack to the bridge of your nose to further help constrict blood vessels (which will slow the bleeding) and provide comfort. This is not a necessary step, but you can try this if you want.
  • You can spray an over-the-counter decongestant spray, such as oxymetazoline (Afrin®, Dristan®, Neo-Synephrine®, Vicks Sinex®, others) into the bleeding side of the nose and then apply pressure to the nose as described above. WARNING: These topical decongestant sprays should not be used over a long period of time. Doing so can actually cause an increase in the chance of a nosebleed.
  • After the bleeding stops, DO NOT bend over, strain and/or lift anything heavy. DO NOT blow or rub your nose for several days.

When should I go to the emergency room if I have a nosebleed?

Call your doctor immediately or have someone drive you to the nearest emergency room or call 911 if:

  • You cannot stop the bleeding after more than 15 to 20 minutes of applying direct pressure on your nose as described in the steps above.
  • The bleeding is rapid or the blood loss is large (more than a cup).
  • You are having difficulty breathing.
  • You have vomited because you’ve swallowed a large amount of blood.
  • Your nosebleed has followed a blow to your head or serious injury (fall, car accident, smash to your face or nose).

Call your doctor soon if:

  • You get nosebleeds often.
  • You have symptoms of anemia (feeling weak or faint, tired, cold, short of breath, pale skin).
  • You have a child under two years of age who has had a nosebleed.
  • You are taking blood thinning drugs (such as aspirin or warfarin) or have a blood clotting disorder and the bleeding won’t stop.
  • You get a nosebleed that seems to have occurred with the start of a new medication.
  • You get nosebleeds as well as notice unusual bruising all over your body. This combination may indicate a more serious condition such as a blood clotting disorder (hemophilia or von Willebrand disease), leukemia or nasal tumor and will need to be checked by your doctor.)

What should I expect when I go to my doctor with a nosebleed?

The doctor will ask you questions about your nosebleed including:

  • Length (in minutes) of your nosebleed.
  • Approximate amount of blood that was lost.
  • How often you get nosebleeds.
  • Did the nosebleed involve one or both nostrils.

Your doctor will also ask about medications you are taking – including over-the-counter blood thinning drugs, such as aspirin, and drugs for colds and allergies. They will also ask if there is a family history of blood disorders and ask about your use of alcohol or any illegal drug use in which the drug was sniffed up your nose.

Next, your doctor will examine your nose to determine the source of the bleed and what may have caused it. They will use a small speculum to hold the nostril open and use various light sources or an endoscope (lighted scope) to see inside your nasal passages. Your doctor may use topical medications to anesthetize (numb) the lining of the nose and to constrict blood vessels. The doctor is also likely to remove clots and crusts from inside your nose. This can be unpleasant but is not painful. Your blood pressure and pulse will likely be taken. Occasionally, x-rays or CT scan or blood tests may be ordered to check for bleeding disorders, blood vessel abnormalities or nasal tumors.

What are the treatments for nosebleeds?

Treatments depend on the cause and could include:

  • Nasal packing. Gauze, special nasal sponges or foam or an inflatable latex balloon is inserted into your nose to create pressure at the site of the bleed. The material is often left in place for 24 to 48 hours before being removed by a healthcare professional.
  • Cauterization. This procedure involves applying a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel. A local anesthetic is sprayed in the nostril first to numb the inside of your nose.
  • Medication adjustments/new prescriptions. Reducing or stopping the amount of blood thinning medications can be helpful. In addition, medications for controlling blood pressure may be necessary. Tranexamic (Lystedaâ), a medication to help blood clot, may be prescribed.
  • Foreign body removal if this is the cause of the nose bleed.
  • Surgical repair of a broken nose or correction of a deviated septum if this is the cause of the nosebleed.
  • Ligation. In this procedure, the culprit blood vessel is tied off to stop the bleeding.

Prevention

What can I do to prevent nosebleeds?

  • Use a saline nasal spray or saline nose drops two to three times a day in each nostril to keep your nasal passages moist. These products can be purchased over-the-counter or made at home. (To make the saline solution at home: mix 1 teaspoon of salt into 1 quart of tap water. Boil water for 20 minutes, cool until lukewarm.)
  • Add a humidifier to your furnace or run a humidifier in your bedroom at night to add moisture to the air.
  • Spread water-soluble nasal gels or ointments in your nostrils with a cotton swab. Bacitracin®, Vaseline®, or Ayr Gel® are examples of over-the-counter ointments you can use. Be sure not to insert the swab more than ¼ inch into your nose. These gels and ointments can be purchased in most pharmacies.
  • Avoid blowing your nose too forcefully.
  • Sneeze through an open mouth. Always sneeze into tissue or into the bend of your arm.
  • Avoid putting anything solid into your nose, including fingers.
  • Limit your use of medications that can increase bleeding, such as aspirin and ibuprofen. Please remember that any adjustment to medication, especially prescribed medication such as warfarin (Coumadin®), and non-steroidal anti-inflammatory drugs (NSAIDs), should only be done under your doctor’s supervision.
  • See your doctor if your nasal allergy symptoms are not easily controlled with over-the-counter or prescription medications. Make sure you closely follow the directions when using over-the-counter products. Overusing them can cause nosebleeds.
  • Quit smoking. Smoking dries out your nose and irritates it.
  • Wear protective head gear if involved in activities that could result in an injury to your face and nose.
  • Keep your child’s fingernails short.

If you have any questions or concerns, do not hesitate to call your physician.

Outlook / Prognosis

When is a nosebleed a serious event?

Seeing blood coming out of your nose is a scary sight for many people. The good news is that most nosebleeds are not serious and can be managed at home. However, see your doctor or get emergency medical attention if you are losing a heavy amount of blood, if you cannot stop your nosebleed after 20 minutes of trying or have had an immediate injury to your head, face or nose. Make an appointment to see your doctor if you have frequent nosebleeds.

Living With

I get frequent nosebleeds. What’s the cause? Should I be concerned?

There are many non-serious reasons why you may be getting frequent nosebleeds. The most common are:

  • Frequent use of nasal sprays for treatment of allergy symptoms or colds/congestion. You may need to stop using these drugs for a short period of time or may need to stop them altogether. Talk with your doctor if you use these products.
  • Living in dry air conditions.
  • Snorting drugs into your nose.

In rare cases, repeated nosebleeds could be a sign of a bleeding disorder or other more serious conditions. If you have frequent nosebleeds, please see your doctor.

What causes nosebleeds while sleeping?

The reasons for nosebleeds during sleep are the same as the reasons why they occur during the daytime – dried nasal membrane caused by dry air, allergies and colds and other upper respiratory infections that damage the delicate nasal membrane lining your nose. Sleeping with your head to the side also may put direct pressure on the nasal cavity and may be another reason for nosebleeds at night.

Why do I see blood every time I blow my nose?

If you blow your nose frequently or blow with force, you can damage the delicate blood vessels in your nose, causing them to bleed.

Last reviewed by a Cleveland Clinic medical professional on 10/23/2019.

References

  • American Academy of Otolaryngology—Head and Neck Surgery. Accessed 10/2/2019.Nosebleeds. (https://www.enthealth.org/conditions/nosebleeds/)
  • Senecal EL. Chapter 77. . In: Sherman SC, Weber JM, Schindlbeck MA, Rahul G. P. eds. Clinical Emergency Medicine, 1e New York, NY: McGraw-Hill; 2014. Accessed 10/2/2019.Epistaxis (https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=55139195&bookid=991&jumpsectionID=55142214&Resultclick=2#1101228338)
  • Diamond L. Managing Epistaxis. J Am Acad Physician Assistants 2014;27(11):35-39.
  • Merck Manual Consumer Version. Accessed 10/2/2019.Nosebleeds. (https://www.merckmanuals.com/home/ear,-nose,-and-throat-disorders/symptoms-of-nose-and-throat-disorders/nosebleeds#v28572888)
  • Viehweg TL, Roberson JB, Hudson JW. J Oral Maxillofac Surg 2006;64(3):511-518. Accessed 10/2/2019.Epistaxis: Diagnosis and Treatment. (https://www.sciencedirect.com/science/article/pii/S027823910501815X?via%3Dihub)
  • Patient Education Series. Nosebleeds Nursing 2012;42(10):31. Accessed 10/2/2019.. (http://ovidsp.dc2.ovid.com/sp-4.02.1a/ovidweb.cgi?WebLinkFrameset=1&S=MHCEFPAFODEBDGIGIPCKPEPEFCBOAA00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.43.51%257c0%257c00152193-201210000-00012%26S%3dMHCEFPAFODEBDGIGIPCKPEPEFCBOAA00&fromjumpstart=0&directlink=http%3a%2f%2fovidsp.dc2.ovid.com%2fovftpdfs%2fFPEBIPPEPEIGOD00%2ffs047%2fovft%2flive%2fgv024%2f00152193%2f00152193-201210000-00012.pdf&filename=Nosebleeds.&link_from=S.sh.43%7c46&pdf_key=FPEBIPPEPEIGOD00&pdf_index=/fs047/ovft/live/gv024/00152193/00152193-201210000-00012&D=yrovft)

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