Allergy, Nose & Sinus

The ultimate guide to nosebleeds (WARNING – GRAPHIC MEDICAL IMAGES AND VIDEOS)

February 10, 2020

Nosebleed (Epistaxis) is one of the most common ENT emergencies. Not knowing what causes nosebleed or what to do during an episode of nosebleed can be worrying for most people. In this blog, Dr Gan addresses some of the common questions on nosebleed.



What causes nosebleed?


The causes of nosebleed can be broadly divided into local and systemic causes. Some of the causes include:


Local causes:


  1. Enlarged blood vessels in the nose (Telangiectasia). This is the cause of over 90% of nosebleed encountered by Dr Gan (Figure 1)
  2.  Rhinitis (Sensitive nose)
  3. Sinusitis (Infection of the sinuses)
  4. Trauma (e.g frequent nose picking, road traffic accident, sporting injuries)
  5. Tumour



Figure 1- Telangiectasia (nnlarged blood vessels) on the left nasal septum)



Systemic causes:


  1. Uncontrolled high blood pressure
  2. Medication that thins the blood (e.g Aspirin, Warfarin, Plavix etc)
  3. Disorders that causes problem with blood clotting (Liver disease, platelet dysfunction, low platelet counts, low blood clotting factors etc)



What should I do if I have an episode of nosebleed?


The first thing that you should do if you have a nosebleed is to stay calm (and do not panic!). Try to sit down if possible. You should pinch your nostrils (soft part of your nose) together and tilt your head forward (not backwards as what most people would have been taught or asked to do!)(Figure 2a-b). By tilting your head forward, the blood can clot in the front part of your nasal cavity. If you tilt your head back or lie down, the blood will continue to flow down your throat and you will swallow some of them. Blood is an irritant to the stomach and you will end up vomiting (and that is when everyone panics!)



Figure 2a – The correct way to stop an episode of nosebleed is to pinch your nostrils together and tilt your head down



Figure 2b – The correct way of stopping an acute nosebleed



Is my nosebleed dangerous?


Majority of nosebleeds occur due to a burst blood vessel somewhere in the nasal cavity. Most of us would have had nosebleeds when we were younger.  Enlarged blood vessels on the nasal septum are common in children. Most of the enlarged blood vessels do become smaller or disappear as we age, but in some people, they do persist into adulthood.


While the cause of nosebleed is often not dangerous, large amounts of bleeding can be dangerous and even life-threatening. If your nosebleed flows out of your nose like running tap water and do not stop after 5-10 minutes of continuous pinching of your nostrils, you should visit the closest Accident & Emergency Department in a hospital as soon as possible.


Frequent nosebleeds can be annoying, disruptive and interfere with one’s day to day life especially if it happens at work or to  children. Hence, a consultation with an Ear, Nose & Throat (ENT) Specialist is recommended in such patients.



If I have a nosebleed, does that mean that I have cancer?


Many people are worried of a tumour causing nosebleed. Vascular tumours (tumours arising from blood vessels) or large cancer of the nose can cause significant nosebleeds. However, these are fortunately not common. Most cancer of the nose (medically known as nasopharyngeal carcinomas) presents with blood-stained mucous or blood in the saliva/phlegm, blocked ears and neck lumps. 



How is nosebleed treated?


The treatment of nosebleed depends on the underlying cause. Treatment of the underlying cause usually stops the nosebleed. Majority of intermittent small nosebleeds are due to enlarged vessels (telangiectasia) on the nasal septum (wall that divides the nose into right and left sides) that has burst. This can usually be “sealed” by applying a stick containing silver nitrate on its tip to the enlarged vessel (Figures 3a-d, Video 1). Silver nitrate cauterization of the nose is a simple procedure that is performed in the clinic under local anaesthesia. It is relatively painless (at most some patients complain of a stinging feeling in the nose) and the resulting “scab” usually drops off on its own within a few weeks.



Figure 3a – A silver nitrate stick



Figure 3b – Bleeding vessel on the right nasal septum



Figure 3c – Application of silver nitrate stick on the bleeding vessel



Figure 3d – “Scab” on the right nasal septum after silver nitrate cautery





Video 1 – Silver nitrate cautery of a nasal septum telangiectasia in the clinic


Sometimes the bleeding vessel can be big (arterial bleed) and cause significant amount of bleeding each time. A large bleeding vessel is often found high up on the nasal septum (sometimes almost close to the base of skull in the nose) and usually requires application of diathermy (electrical energy) to stop the bleed. Depending on the anatomy of the patient’s nose and patient tolerability, the bleeding vessel can still be sealed with application of diathermy in the clinic under local anaesthesia (Video 2)





Video 2 – Electrocautery (diathermy) of an arterial bleed on the nasal septum performed in the clinic under local anaesthesia


Rarely, the bleeding vessel is located in a very deep part of the nose which prevents visualization in the clinic. In such cases, the nose may have to be packed with a sponge (called Merocel) and the patient has to be brought to the operating theatre to identify and stop the bleeding vessel (Video 3).





Video 3 – Electrocautery (diathermy) of a very deeply seated blood vessel in the nose under general anaesthesia


In cases where the source of bleeding is not found, one of the major artery in the nose (called the sphenopalatine artery) can be tied or sealed off to reduce the chance of recurrent nosebleed. Fortunately, this is not commonly needed as most of the time, the source of bleeding can be found.



Best wishes,


Dr Gan Eng Cern
ENT Specialist Singapore

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