Understanding Nosebleeds with Dr. Mohamad Chaaban

Podcast Transcript

Cassandra Holloway:  Hi. Thanks for joining us. You're listening to the Health Essentials podcast brought to you by Cleveland Clinic. My name is Cassandra Holloway and I'll be your host for this episode. Today, we're broadcasting virtually as we are practicing social distancing during the coronavirus pandemic. We're joined virtually by Dr. Mohamad Chaaban. Dr. Chaaban, thank you so much for taking the time out of your day to talk to us.

Dr. Mohamad Chaaban:  Good morning. Thank you so much for having me today.

Cassandra Holloway:  In this episode, we're going to be talking about nose bleeds. Everything from who gets nose bleeds, to how to treat and prevent them, to more serious cases, and what it could mean for your health. Before we dive into the episode, we want to remind listeners that this is for informational purposes only and is not intended to replace your own doctor's advice.

Dr. Chaaban, I first want to start off by asking how you're doing, and if you'll tell us a little bit about your practice at Cleveland Clinic, and what types of patients do you see?

Dr. Mohamad Chaaban:  Thank you. I'm doing well. I see patients at the clinic mostly with sinonasal disorders. As an Ear, Nose, and Throat Surgeon, I also specialize in rhinology, which is a discipline of treating patients with sinus, nasal, and skull-base disorders.

Cassandra Holloway:  Most people will experience a minor nosebleed at some point in their life. It's pretty common. When someone is experiencing a nosebleed, what's actually happening? Where is the blood coming from?

Dr. Mohamad Chaaban:  Most of the nosebleeds, what we call epistaxis, is coming from the anterior part of the nose, which is the nasal septum, and this structure separates the two nostrils. Most of the times, it's from the front part of that structure which is the septum. By all means, it's usually spontaneous, so it's not usually triggered by any tumor or trauma, and that's the most likely cause of the nose bleeds.

Cassandra Holloway:  And then, you said usually it's from something more common like trauma or something. What about more serious nose bleeds where a nose bleed is pointing to something that's wrong?

Dr. Mohamad Chaaban:  There is about between 10 to 20% of nosebleeds can occur, we call them posterior nosebleeds which is way back of the nose. Those are the ones that can tend to be more serious where you get more blood draining back in the throat, and those are the ones that can be difficult to control. In addition, serious nosebleeds, I consider if there is a major cause such as like a tumor in the nose, that to me is, often, of course, serious, in addition to underlying comorbid conditions that could be associated with the epistaxis or the nose bleeds.

Cassandra Holloway:  With minor nosebleeds, on average, how long do those last? How long is normal?

Dr. Mohamad Chaaban:  Nose bleeds that are minor, usually, they should not last more than about 20 minutes. Sometimes, obviously, you can do some measures at home to control the nose bleeds, which can be simply just applying pressure to the front of the nose and so.

Cassandra Holloway:  Who is more likely to experience these minor nosebleeds from time to time? Is there conditions that puts you at risks? Are there certain people who are more prone to them?

Dr. Mohamad Chaaban:  I like to separate those in terms of either demographic risks, geographic risks, and seasonal risks as well, basically, or factors. In terms of demographics, we see this more as a bi-modal distribution in kids of 3 to 10 years of age mostly due to digital trauma, like nose-picking, basically. In the older patients as well, we see it. The older they are, the more likely it will be a severe or recurrent bleed that may require an ER visit. Male gender as well. Males are more prone to have at least recurrent bleeds requiring ER visits.

In terms of geographic, people living in Northern States are more likely to have nose bleeds, epistaxis. In terms of seasons as well, it's much more common in the winter months such as December and January as opposed to the summer months like July and August.

Cassandra Holloway:  Makes sense when the air is a little bit more dry, kind of in those winter colder months.

Dr. Mohamad Chaaban:  Yes.

Cassandra Holloway:  Are there any other common non-serious causes of nosebleeds that listeners should be aware of? Are there any medications or anything else that causes it that is interesting for listeners?

Dr. Mohamad Chaaban:  Yes. Anything that can make your nose dry can cause nose bleeds, which we talked about. The winter months and the dry air as well, like living in high altitudes another risk as well such that it causes nose dryness. If taking some medications that can make you dry like antihistamines, decongestants. Topical nasal sprays. If you're applying topical nasal sprays, sometimes the actual bottle can irritate the nose and also can dry the nose. Blood thinners, by and large at least will make you have longer nosebleeds should it happen. Patients who have allergies because they have a lot of nasal congestion, they're blowing their nose, they're sneezing, can cause nosebleeds. If patients have upper respiratory infections, exposure to chemicals as well as smoking, as an example, can increase.

Obviously, there are other reasons. Could be a tumor or after surgery. All those can also trigger nosebleeds as well.

Cassandra Holloway:  I think when you mentioned a tumor, I think it's really alarming to people, so I want to talk a little bit about that. How common is a nosebleed for a symptom such as cancer or a tumor? Is it something that people should be really concerned about? Is it just kind of a warning sign to keep an eye on? I wanted to kind of get your thoughts on that.

Dr. Mohamad Chaaban:  Yes. Basically, if it's a nosebleed that happens suddenly... Typically, I see it more associated with other symptoms like pressure in the face or numbness, then I would be very concerned about this being a tumor. Now, any nose bleed, if it's recurrent, should usually be examined for the source, the location is the most important. Whether it's in the front of the nose, back of the nose, or actually coming from a tumor. That usually requires, obviously, a visit to the ENT, Ear, Nose and Throat Physician.

Cassandra Holloway:  How do you define a re-occurring nosebleed? If someone is experiencing one or two, what's the number, I guess, for a red flag to go off in your head for, maybe this isn't right. Maybe I should get this checked out.

Dr. Mohamad Chaaban:  If they have one-time nose-bleed, usually, and it goes away and doesn't require any attention... I like to talk more about the severity, because the more severe they are, if they require a hospital like an ER visit, and we know it's not as common, about only .5% of nosebleeds will require a hospital visit, an ER visit, and only .2% will require a hospitalization, for example. So they're not as common to require that much attention. By and large, even if it's a recurrent nosebleed that's not severe, usually, could not alarming and could be treated at home without requiring you to go to the ER or seek attention.

Cassandra Holloway:  Got you. What about bleeding disorders or blood clotting disorders? Are bloody noses ever a symptom of that, of kind of a warning sign?

Dr. Mohamad Chaaban:  Yes. It's an interesting story. I had a patient one time who actually came to my office and had like four bottles of a blood thinner. She did not know that each one is a blood thinner, and some of them was exact same medication. She basically showed me the bottles and was taking a pill from every one. Blood thinners, if you take them without checking the blood levels in certain types, then it could be a very big risk of you developing nose bleeds. So yes, it's quite important. Also, when you see the patient and you diagnose them with a bleeding disorder, it's not only the nose. They could be at risk of bleeding from other places such as the brain, and that's why we need to stress out that people on blood thinners need to always watch and make sure they have a good diet that doesn't increase the bleeds such as greens, and also make sure that the levels are checked so they don't develop any other bleeding in other sites of the body.

Cassandra Holloway:  I assume with other medications, kind of just be aware of the side effects and if it's interacting weirdly with your body, just to have that conversation with your doctor. If a medication is causing you a nose bleed or anything like that, kind of just to be aware that it could be a symptom.

Dr. Mohamad Chaaban:  Yes, absolutely. Absolutely.

Cassandra Holloway:  I want to go back to a couple of the causes of nose bleeds. We mentioned people living in high altitude areas. Is it because just the air is drier and that kind of irritates the nose a little bit more?

Dr. Mohamad Chaaban:  Yes. The water vapor in high altitude is low, so there's more dry, and dryness can cause desiccation in the nasal mucosa and subsequently trigger the nose bleeds in those patients.

Cassandra Holloway:  People living in these areas, will they ever become accustomed to the altitude where maybe they're not getting as many bloody noses and they get used to it?

Dr. Mohamad Chaaban:  Yes. Mostly, the sudden changes, I've seen it cause nosebleeds as opposed to someone living there for a long time. Those changes can trigger more nose bleeds, temperature changes. The dryness, if it's more sudden, I see it more triggering nose needs as opposed to someone who has been there for a long time, has been chronically exposed.

Cassandra Holloway:  Sure. Makes sense. Here's a wild card question for you. Can pregnancy cause nose bleeds?

Dr. Mohamad Chaaban:  It's an interesting question. There's increased blood volume in pregnant females, and what happens is, due to also hormonal factors, they are at risk of bleeding, of bloody noses, yes.

Cassandra Holloway:  Interesting. I want to talk a little bit about treatment. If someone just has an occasional random nose bleed, how do they treat it? What should they keep in mind?

Dr. Mohamad Chaaban:  I also want to discuss severity in that situation. If it is severe nose bleed, even if a one time severe nosebleed that requires, for example, a visit to the emergency room, let's say, that usually, the patient ends up seeing me in clinic, for example, after a few days, without bypassing primary care physician, for example. Minor bleeds can definitely be treated at home at home, as you said, and patients, I would recommend leaning forward, pinching the nose. If they know which side it is, they can pinch only that one side, or both sides if they're not sure where it's coming from.

As we said, it's mostly from the front of the nose, so they pinch really hard, bend forward. We don't want the blood to trickle back, and then wait about 15 minutes, and then they can check and see if it's still bleeding or not. If they do have Afrin at home, they can always squirt Afrin and then pinch their nose as well, and that controls the bleed very, very well if they're at home. In the severe bleeds, obviously, when they come to see me, then they may have had a packing in the nose. I may have to take a look and see where the bleeding is coming from and then do a complete examination.

Cassandra Holloway:  If a patient makes their way to you and they're seeing you for re-occurring nose bleeds, what are some of those treatments? I know cauterization is something that I've seen. Walk us through how you would maybe treat a patient with re=occurring nose bleeds.

Dr. Mohamad Chaaban:  The location is the most important, the etiology and the location, I would say. If it was a septum bleed, like from the structure that we talked about, we take a look in the nose. Usually, the anterior bleeds which are the most common, you can cauterize them in the office. We can use silver nitrate for example, which is a simple procedure in the office and cauterize them. If it was more severe bleed, posterior bleed or middle of the septum arterial bleed, then sometimes it would require packing. If that fails, then you may have to go to surgery and cauterize them with electrocautery.

The posterior bleeds, sometimes if they're severe and they reoccur, we either tend to ligate the artery with a surgery that we do, or do embolization which is done by interventional radiology as well. But those are for patients with severe bleeds or recurrent bleeds, and it's just not for everyone. We have a protocol that we use for those kind of patients.

Cassandra Holloway:  Sure. Absolutely. If a listener is listening to this and they have these frequent nosebleeds, do they make an appointment with an ENT? What are their steps here?

Dr. Mohamad Chaaban:  One time nosebleeds, or nosebleeds that they can control and they're not as frequent, then obviously they can manage them at home. But if they recur, there's always good to check with the primary care physician simply because there are a lot of comorbidities that they need to pay particular attention. For example, hypertension, we know in many studies has been shown to be a risk factor. So they need to check the blood pressure. Other comorbidities like sleep apnea, diabetes, congestive heart failure can put them at risk of severe bleeds requiring them to go to the ER more often, like frequent visits to the ER.

So checking with the primary care doctor is always very beneficial to make sure the comorbidities are okay, there is no underlying condition. Sometimes it could be a genetic condition that could be predisposing them to cause bleeding that could be very severe and could happen in other parts of the body as well. It can happen any time of their life, by the way. It doesn't have to start when they're young or anything.

Always, I would start with the primary care just to make sure they have a good exam and making sure their comorbidities are checked. If they continue to have problems, or if they have severe nosebleeds, those two, they end up requiring to be seen by an ear, nose, and throat doctor, specifically to do a nasal scope so we can find out where the bleeding is coming from.

Cassandra Holloway:  Absolutely. It's just a message to listeners. Get it checked out if it doesn't feel right or if you're noticing something, always best to get it checked out, for sure.

I'm curious with today's crazy world that we're living in, can nose bleeds cause or be caused by stress and anxiety? Do you ever see any kind of correlation between that?

Dr. Mohamad Chaaban:  This has been studied multiple times before. I think I always see them co-exist, at least. I have rarely seen a patient, unfortunate, that comes to your office that has a nose bleed and that's not stressed out about what is causing the nose bleed, how to stop the nose bleed. It's a very stressful situation. What happens with stress is your blood pressure goes up and your heart rate goes up, so it's not actually helping the condition, your bleeding. Many patients when they come to the ER and I come to see them after they consult me, for example, as soon as we calm them down, the bleeding stops, usually. It's a vicious circle. You get the bleeding, you're more anxious, and the blood pressure and heart rate goes up and you bleed more. Once we break that cycle, patients calm down and at least they feel also they're safer when they're being taken care of at the medical office or in the ER, for example.

Cassandra Holloway:  Sure, and it's jarring. There's usually a rush of blood and then a rush to contain it. It's scary, for sure.

Dr. Mohamad Chaaban:  Absolutely. Absolutely.

Cassandra Holloway:  With re-current nosebleeds, I'm curious, do those ever cause iron deficiency? Is that something that people should be concerned about?

Dr. Mohamad Chaaban:  Absolutely. I have seen iron deficiency in patients who have recurrent nosebleeds, particularly patients that may delay care for these conditions, especially severe cases or in recurrent nosebleeds, even if not severe, but they're not taken care of, they're not stopped. That recurrent bleeding, over time, if it's frequent, then can cause iron deficiency, and if they have other bleeding disorder or they're bleeding from other sources as well, that could cause iron deficiency.

Cassandra Holloway:  Is that just treated with your typical iron pills, or does it depend?

Dr. Mohamad Chaaban:  It depends, absolutely. Depends on if it's just iron deficiency or other conditions that the patients have anemia from. What I would recommend, usually, those patients with recurrent bleeds, they need to see their primary care doctor to look at their comorbidities and to look at other sources of bleeds if they have iron deficiency. If it's truly just iron deficiency, obviously, they will put them on iron pills.

Cassandra Holloway:  When talking about nose bleeds in general, I'm curious, how serious can a nosebleed be? Is there people that should be concerned about a serious, severe nose bleed?

Dr. Mohamad Chaaban:  The good news is, nosebleeds rarely require... As we said, only .5% ER visit and .2% hospitalization. Also, very rare to be severe, like causing to be fatal or death, very severe. I would be concerned in patients who are like older patients with posterior nosebleeds that did not seek care and it continues to bleed, obviously. Those require, usually, obviously, packing and ER, at least an ER visit for taking care of it, and controlling their comorbid conditions, including diabetes, for example, sleep apnea. Those are risks for them to develop as we've seen in our study, recurrent visits to the ER with bleeding, again, with re-bleeding.

Other than that, I would also be concerned in patients who have potentially tumors in their nose, or vascular tumor in their nose. Those are the ones that I'd be very concerned about them bleeding again, and profusely bleeding. Obviously, after sinus surgery, I would be also concerned if there's a bleeding that is also uncontrolled as well.

Cassandra Holloway:  Again, not very common?

Dr. Mohamad Chaaban:  No, no, not common. It's very, very uncommon. That's the good news. Most nosebleeds are, as we said, they are spontaneous and they don't require an ER visit by and large. They're not severe.

Cassandra Holloway:  With drier winter months quickly approaching us, for our listeners who experience dryness in their nose or irritation in their sinuses, what are some at-home remedies they can do to kind of cut back on the dryness and the irritation that they feel in their nose?

Dr. Mohamad Chaaban:  Thank you for that question. What I recommend if patients, obviously, are at-risk of nosebleeds is to have a humidifier at home that could obviously decrease the dryness. What I recommend as a regimen for my patients when they're known to have recurrent bleeds during the dry winter months is to actually apply an ointment twice daily. It's a water soluble ointment. Some of them could be over the counter as well, and that's applied twice daily. During the day, they can also use a nasal saline spray to keep the nose moist.

If they are using nasal sprays, drying nasal sprays or any nasal sprays, I always want to make sure they're using it the right way which is aiming the spray towards the cheek on each side. I would say right hand the left nostril, left hand to the right nostril so you're not aiming it to the septum which is the structure that we talked about that usually is where the bleeding happens.

In addition, obviously, if you keep your nose moist and avoid nose-picking, obviously, and avoid any nose-blowing, straining and sneezing, so if you control your allergies if you have allergies, that would also avoid this and avoid you from getting recurrent nosebleeds, in addition to avoiding chemical irritation such as smoking and such.

Cassandra Holloway:  I think it's a good reminder just to be gentle when you're blowing your nose, or you're dealing with your nose, especially if it's already irritated.

Dr. Mohamad Chaaban:  Absolutely.

Cassandra Holloway:  The last thing I want to talk about today is prevention. We mentioned not smoking. For listeners listening to this, how can they prevent nose bleeds from happening, especially if they're more prone to them?

Dr. Mohamad Chaaban:  Most important is, as we said, the most common are the spontaneous anterior bleeds mostly due to dryness and obviously colder temperature. So by keeping the nose moist, perhaps having a humidifier, applying a lot of saline, and sometimes I use ointments in the nose that would be helpful and could provide some moisturizing effects. Avoiding irritants, like you said, smoking. Avoiding that. Obviously, if you work in a place with a lot of chemical exposure, perhaps having some protective equipment would be very helpful in that case.

In children and some patients, avoid nose-picking or digital trauma is very helpful. In allergy patients, maybe controlling the allergy is important. This way, you don't have to be sneezing as hard or blowing your nose and avoiding this irritation that can cause bleeding. These are all factors that could be... And also more important, if you're on blood thinners, make sure that the levels are acceptable so you don't end up losing a lot of blood.

Cassandra Holloway:  Absolutely. Great advice to end on. Thank you for taking the time to talk to us today, Dr. Chaaban. You've shared a lot of really great insight and advice. I know listeners will be find this very valuable.

Dr. Mohamad Chaaban:  Thank you so much. Thank you for having me.

Cassandra Holloway:  To make an appointment with a Cleveland Clinic Ear, Nose and Throat Specialist, call (216) 444-8500. If you want to listen to more Health Essentials podcasts from experts at Cleveland Clinic, subscribe wherever you get your podcasts from, or visit clevelandclinic.org/hepodcasts. Also, don't forget to follow us on Facebook, Twitter, and Instagram at ClevelandClinic, all one word, to stay up-to-date on the latest health news and information. Thanks for listening and stay safe.