Nosebleeds

Nose bleeds (also known as epistaxis) can occur at any age, but most commonly in young children aged 2-10 years and older adults from 50 years onwards. The nose contains many blood vessels originating from both the internal and external carotid arteries. Many of these vessels end at a specific area located on the lower part of the nasal septum (which is the wall which separates the two nostrils of the nose). This region is known as Little’s area and is especially susceptible to bleeding due to the thin nasal lining and high blood flow. Most nosebleeds coming out from the front of the nose occur from this area and are known as anterior nosebleeds. Occasionally nosebleeds can begin deep and high in the nasal cavity and the blood will flow backwards into the back of the mouth and throat. These posterior nosebleeds are usually more severe and tend to occur in older people, those with high blood pressure or taking anti-clotting medicines, or after nasal trauma or injury.

What are the causes of recurrent nosebleeds?

Vigorous nose blowing or nose picking which results in damage to the nasal lining and rupture of the superficial blood vessels

• Nasal allergies which are poorly controlled, resulting in frequent nose rubbing and picking
• Nasal infections such as rhinitis or sinusitis
• Drugs which interfere with clotting (such as warfarin or aspirin)
• Clotting disorders eg haemophilia, leukaemia
• Trauma or fractures to the nose

Tumours (both malignant and non-malignant) arising from the nasal cavity, sinuses or nasopharynx. Nasopharyngeal cancer (or NPC) is an important cause of nosebleeds in adults which needs to be ruled out.

When should you see an ENT surgeon and what will he do?

If the nosebleeds occur frequently or are severe, it may be necessary to consult an ENT surgeon. He will usually examine the nose with a headlight as well as a flexible nasoendoscope to visualize the entire nasal cavity. The procedure is both quick and painless, and is well tolerated even by small children. Endoscopy allows cautery to be accurately applied to the bleeding area to prevent further episodes of bleeding. In more severe cases with torrential bleeding, packing of the nose with cotton gauze or special packs called Merocel may be required to stop the bleeding. These packs usually have to be left in place for 24-48 hours to arrest the bleeding. In the severe cases, the patient may need to be admitted to hospital for further tests and may have to be brought to the operating theatre to undergo endoscopic examination and ligation of particular blood vessels which are causing the nosebleed.

Tips to stop an anterior nosebleed

• This is the most common cause for epistaxis in a young child.
• Firstly don’t panic! Stay calm as the bleeding may be more severe if the patient is agitated and restless. If the bleeding occurs in a young child, help him or her to stay calm by reassuring and comforting the child.
• Sit up and lean forward. Many people mistakenly lie on their backs or point their noses to the sky. This tends to result in blood flowing back into the throat and the patient may end up choking and coughing.
• Using the thumb and index finger, apply direct pressure by pinching the soft part of the nose between the tip of the nose and the bony nasal bridge. Hold the nose tightly for 5 minutes and ask the patient to breathe through his mouth. If the bleeding persists, continue to hold on for another 10 minutes.
• Apply ice in a plastic bag or wrapped in a towel to the nasal bridge and forehead. This causes the facial blood vessels to constrict and reduces the bleeding rate.
• Most anterior nosebleeds will stop with these first aid measures. If there is still persistent bleeding after 30 minutes, bring the patient to the nearest doctor.

Useful tips to prevent a recurrent nosebleed and maintaining a healthy nose

• Control and treat any underlying nasal allergies or infections
• Keep the nasal lining moist by applying a thin layer of petroleum jelly or Vaseline with a cotton bud three times a day and before bed.
• Encourage the child not to pick or blow his nose vigorously
• Avoid prolonged periods of exposure to dry air. Sleeping with the airconditioner every night dries out the nose!
• A saline nasal spray can be useful to keep the nasal lining moist
• Stop smoking! Inhaled smoke dries out the nasal membranes, irritates the nose and is associated with increased risk of cancer.

By Dr Andrew Loy Heng Chian
Consultant ENT-Head & Neck Surgeon
Adjunct Assistant Professor, Duke -NUS Graduate Medical School
Visiting Consultant, Tan Tock Seng Hospital
Fellow, American Head & Neck Society