Epistaxis

Few experiences are as unsettling as a sudden nosebleed. Whether it's a minor trickle or a more dramatic gush, the sight of blood can be alarming, prompting immediate concern. Medically known as epistaxis, nosebleeds are a very common occurrence, affecting people of all ages. While most nosebleeds are benign and resolve quickly with simple first aid, they can sometimes indicate an underlying health issue or become recurrent, significantly impacting quality of life. 

Understanding epistaxis – what causes it, how to manage it, and when to seek medical attention – is crucial for effective self-care and knowing when to get professional help. This detailed guide provides clear, accessible information for anyone looking to better understand this common yet often disquieting condition.

Epistaxis is the medical term for a nosebleed. It occurs when the delicate blood vessels lining the inside of the nose rupture, leading to blood flowing out through the nostrils, and sometimes down the back of the throat. The nose is particularly prone to bleeding because its lining contains a rich network of tiny, fragile blood vessels that are close to the surface. These vessels are easily damaged by trauma, dryness, or other underlying conditions. While often startling, the vast majority of nosebleeds are not serious and can be managed effectively at home. However, recurrent or very heavy nosebleeds warrant medical evaluation to identify and address the cause.

Epistaxis affects a large proportion of the population. It is estimated that up to 60% of people will experience at least one nosebleed during their lifetime, with about 10% of these cases being severe enough to warrant medical attention. While nosebleeds can occur at any age, there are two distinct peaks in incidence:

• Children aged 2 to 10 years: Often due to minor trauma, nose picking, or dryness.
• Adults aged 50 to 80 years: Often related to underlying medical conditions like high blood pressure, anti-clotting medications, or drier nasal membranes associated with ageing. Although common, epistaxis is rarely life-threatening, with a very low mortality rate.

Nosebleeds are classified into two main types, based on the location of the bleeding:

• Anterior Epistaxis: This is the most common type, accounting for about 90-95% of all nosebleeds. It originates from the front part of the nasal septum (the wall dividing the two nostrils), specifically from a network of blood vessels known as Little's area or Kiesselbach's plexus. Bleeding from this area usually flows out of one nostril, is typically less severe, and often responds well to simple first aid measures like direct pressure.
• Posterior Epistaxis: This type is less common but generally more serious. It originates from larger blood vessels located in the back part of the nose, deeper within the nasal cavity. Blood from a posterior nosebleed often flows down the back of the throat and can be difficult to control with standard first aid. It usually requires medical intervention and may involve heavier bleeding. This type is more prevalent in older adults and those with underlying medical conditions or on certain medications.

The causes of nosebleeds are varied, ranging from simple environmental factors to more complex underlying medical conditions.

Common Causes of Anterior Epistaxis:

Trauma:

• Nose Picking: This is one of the most common causes, especially in children, as it irritates and breaks delicate blood vessels.
• Direct Blow to the Nose: Such as from a fall, sports injury, or accident.
• Vigorous Nose Blowing: Especially during a cold, allergy attack, or sinus infection.

Dry Air:Living in a dry climate or using central heating/air conditioning can dry out the nasal membranes, making them more fragile and prone to cracking and bleeding.

Irritation:

• Allergies or Colds: Inflammation and repeated blowing can irritate the nasal lining.
• Nasal Sprays: Overuse of decongestant nasal sprays can dry out the nose.
• Chemical Irritants: Exposure to fumes or dust.

Foreign Body in the Nose: More common in children, where an object lodged in the nostril can cause irritation and bleeding.

Common Causes of Posterior Epistaxis and more severe Anterior Epistaxis:

High Blood Pressure (Hypertension): While not a direct cause, uncontrolled high blood pressure can prolong bleeding and make it harder to stop.

Blood-Thinning Medications (Anticoagulants): Drugs like warfarin, aspirin, clopidogrel, and newer direct oral anticoagulants (DOACs) reduce the blood's ability to clot, significantly increasing the risk and severity of nosebleeds.

Bleeding Disorders: Conditions such as haemophilia, Von Willebrand disease, or platelet disorders impair the body's ability to form clots, leading to recurrent or difficult-to-stop bleeding.

Nasal or Sinus Infections: Inflammation and irritation from infections can cause bleeding.

Structural Abnormalities: A deviated nasal septum (a crooked wall between the nostrils) or nasal polyps can increase susceptibility to bleeding.

Nasal Surgery: Bleeding is a common side effect following nasal or sinus surgery.

Alcohol Consumption: Excessive alcohol can impair blood clotting and dilate blood vessels.

Rare Causes:

• Nasal Tumours: Both benign and malignant growths in the nose or sinuses can cause recurrent nosebleeds.
• Hereditary Haemorrhagic Telangiectasia (HHT) / Osler-Weber-Rendu Syndrome: A genetic disorder causing abnormal blood vessel formation, leading to recurrent and often severe bleeding from various sites, including the nose.

The most obvious symptom of epistaxis is blood flowing from one or both nostrils. The blood can range from a light trickle to a heavy gush. Other symptoms that may occur include:

• Blood dripping down the back of the throat, leading to a sensation of choking or needing to swallow.
• Nausea or vomiting if a significant amount of blood is swallowed.
• Dizziness or light-headedness in cases of significant blood loss.
• Weakness or paleness (especially with heavy or prolonged bleeding).
• Anxiety or panic due to the sight of blood.

In most cases of simple anterior epistaxis, a formal diagnosis beyond visual confirmation of bleeding isn't necessary. However, for recurrent, severe, or posterior nosebleeds, a doctor will conduct an examination to determine the cause and origin of the bleeding.

Diagnostic steps may include:

Medical History: The doctor will ask about the frequency, duration, and severity of your nosebleeds, any associated symptoms, recent trauma, medications (especially blood thinners), and family history of bleeding disorders.

Physical Examination:

• Nasal Examination: The doctor will use a light source (otoscope or nasal speculum) to examine the inside of your nose, looking for the bleeding site, any abnormalities (such as polyps, foreign bodies, or a deviated septum), and signs of infection.
• Blood Pressure Measurement: To check for hypertension.

Blood Tests:

• Full Blood Count (FBC): To check for anaemia if there has been significant blood loss.
• Coagulation Profile (Clotting Tests): To assess your blood's ability to clot, especially if a bleeding disorder or medication-related issue is suspected.

Endoscopy: In some cases, an ear, nose, and throat (ENT) specialist may perform a nasal endoscopy, using a thin, flexible tube with a camera to get a more detailed view of the deeper parts of the nasal cavity.

Imaging Scans (Rarely): CT or MRI scans may be used in very rare cases if a tumour or other structural abnormality is suspected as the underlying cause.

The treatment for epistaxis depends on the type, severity, and underlying cause of the nosebleed.

First Aid for Anterior Nosebleeds (at home)

• Stay Calm: Panic can increase blood pressure and worsen bleeding.
• Sit Upright and Lean Forward: This prevents blood from flowing down the back of your throat, which can cause nausea or choking. Do not lie down or tilt your head back.
• Pinch the Soft Part of Your Nose: Using your thumb and forefinger, firmly pinch the soft, fleshy part of your nose just above the nostrils (below the bony bridge).
• Breathe Through Your Mouth: Continue pinching for at least 10-15 minutes, without releasing pressure to check.
• Apply a Cold Compress: Placing a cold pack or ice wrapped in a cloth on the bridge of your nose or back of your neck can help constrict blood vessels.
• Avoid Blowing Your Nose: For several hours after the bleeding stops, to prevent dislodging the clot.

Medical Treatments (when first aid is insufficient or for recurrent/posterior bleeds)

• Cauterisation: If the bleeding point can be identified (usually in anterior bleeds), the doctor may cauterise it. This involves using a chemical (silver nitrate) or an electrical current to burn and seal the bleeding blood vessel.
• Nasal Packing: For more severe or persistent anterior bleeds, or for posterior bleeds, the nose may be packed with gauze, sponges, or inflatable balloons. This puts direct pressure on the bleeding vessels. The packing usually stays in place for 24-72 hours.
• Medications: Medications like Tranexamic acid (Brands available: Trenaxa, Pause) are sometimes prescribed for frequent nosebleeds.
• Medication Adjustments: If blood-thinning medications are contributing, your doctor may adjust the dosage or suggest an alternative, in consultation with the prescribing physician.
• Topical Treatments: Nasal sprays containing decongestants (e.g., oxymetazoline) can help constrict blood vessels, but should only be used as directed by a doctor due to potential side effects with prolonged use. Topical application of petroleum jelly or antibiotic ointment inside the nostrils can help keep membranes moist and protect fragile vessels.
• Surgical Ligation: In rare, severe cases of posterior epistaxis that don't respond to packing, surgery may be performed to tie off the blood vessels supplying the nose (e.g., internal maxillary artery ligation or anterior ethmoidal artery ligation).
• Treatment of Underlying Conditions: Addressing conditions like high blood pressure, bleeding disorders, or structural abnormalities is crucial for long-term management.

While alternative therapies are generally not recommended as primary treatments for active nosebleeds, some individuals explore complementary approaches for nasal health and general well-being, though scientific evidence is limited for direct epistaxis management:

• Humidifiers: Using a humidifier, especially in dry environments or during winter, can help keep nasal passages moist and reduce dryness-related nosebleeds.
• Saline Nasal Sprays/Rinses: Regular use of isotonic saline nasal sprays like Naseline Saline Spray or rinses can help keep the nasal lining hydrated and clear of irritants.

• Dry or cold climates.
• Nose picking or rubbing.
• Upper respiratory infections (colds, sinusitis).
• Allergies.
• Deviated nasal septum or other nasal deformities.
• Blood-thinning medications.
• High blood pressure.
• Bleeding disorders (e.g., haemophilia).
• Older age.
• Excessive alcohol consumption.
• Certain medical conditions (e.g., liver disease, kidney disease).

• Significant Blood Loss (Rare): Can lead to anaemia, fatigue, or shock in severe cases.
• Aspiration of Blood: Blood flowing down the throat can be inhaled into the lungs, leading to coughing or choking.
• Infection: From nasal packing.
• Nasal Septal Perforation: Damage to the septum from recurrent cauterisation or trauma.
• Anxiety and Fear: Especially with recurrent or severe nosebleeds.
• Social Embarrassment: Can affect daily activities and self-esteem.

• Maintain Nasal Hydration: Regularly use saline nasal sprays or apply a small amount of petroleum jelly just inside your nostrils, especially before bed.
• Avoid Trauma: Be mindful of nose picking, vigorous nose blowing, and avoid situations that might lead to nasal injury.
• Carry a Nosebleed Kit: Keep a small kit with tissues, a small towel, and perhaps some nasal decongestant spray (consult doctor first) for quick management.
• Educate Family/Friends: Inform those close to you about proper first aid for nosebleeds so they can assist calmly if needed.
• Identify and Address Triggers: Keep a diary to note potential triggers (e.g., certain activities, dry weather, specific foods) and try to minimise exposure to them.

"You should tilt your head back during a nosebleed." 

This is incorrect and potentially dangerous. Tilting your head back can cause blood to flow down your throat, leading to choking, nausea, or aspiration. Always lean forward.

"Nosebleeds are always a sign of something serious, like a brain tumour." 

While recurrent nosebleeds warrant medical evaluation, the vast majority are caused by benign factors like dryness or minor trauma. Serious underlying conditions are rare.

"Eating certain foods can cause nosebleeds." 

There's no scientific evidence that specific foods directly cause nosebleeds. However, deficiencies (like Vitamin K, though rare) or conditions exacerbated by diet (like high blood pressure) can indirectly play a role.

While most nosebleeds stop with simple first aid, you should see a doctor if:

• The nosebleed lasts longer than 20 minutes despite direct pressure.
• The bleeding is very heavy, or you are losing a significant amount of blood.
• You feel dizzy, light-headed, weak, or faint.
• The nosebleed is recurrent and frequent.
• You have recently started taking a new medication, especially a blood thinner.
• You have a known bleeding disorder or a family history of such disorders.
• The nosebleed occurs after a head injury.
• You are concerned about your nosebleeds.

• What is the most likely cause of my nosebleeds?
• What steps can I take at home to prevent future nosebleeds?
• Are there any medications I am taking that could be contributing to the nosebleeds?
• Do I need any specific tests to identify the cause?
• What are the treatment options if home remedies aren't enough?
• Should I be concerned about anaemia due to blood loss?
• When should I seek emergency medical attention for a nosebleed?

• Stay Calm and Reassuring: Your calm demeanour can help reduce their anxiety, which can worsen the bleed.
• Guide Them Through First Aid: Clearly instruct them on the proper steps (sit up, lean forward, pinch nose).
• Offer Help: Provide tissues, a bowl for blood, or a cold compress. Offer to clean up afterwards.
• Encourage Medical Attention: If the bleeding is prolonged or severe, or if it's recurrent, gently encourage them to seek medical advice.

Epistaxis, or nosebleeds, is a remarkably common condition that, while often alarming, is usually benign and self-limiting. Understanding the difference between anterior and posterior bleeds, knowing effective first aid techniques, and being aware of potential underlying causes are key to managing this condition effectively. For most, simple measures like nasal hydration and gentle handling can prevent recurrences. However, recurrent, heavy, or difficult-to-stop nosebleeds warrant medical attention to identify and treat any underlying issues, ensuring both physical health and peace of mind. Remember, a little knowledge goes a long way in turning a moment of panic into a manageable situation.