Allergy, Nose & Sinus

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

February 10, 2020
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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

When Should You See An ENT Specialist In Singapore?

  • Any Ear, Nose or Throat symptoms that you are troubled with or concerned of
  • Persistent blocked nose with mouth breathing or snoring

Dr Gan Eng Cern

Dr Gan Eng Cern is a fellowship trained Consultant Ear, Nose & Throat (ENT) Surgeon. He completed his ENT training in Singapore and obtained his subspecialty training in Rhinology and Endoscopic Skull Base Surgery at the world renowned St Paul’s Sinus Centre, University of British Columbia, Vancouver, Canada. He was also a Senior Clinical Lecturer at Yong Loo Lin School of Medicine at the National University of Singapore. Dr Gan was an avid researcher with numerous publications in reputable international ENT journals. He was also an invited speaker and surgical dissection teacher in many ENT conferences and courses.

Awards

  • 2020 – Reader’s Choice Gold Award for Best ENT Specialist
    (Expat Living Singapore)
  • 2016 – Best Educator Award (Eastern Health Alliance)
  • 2016 – “Wow” Award (Patient Compliment)
  • 2014 – Eastern Health Alliance Caring Award – Silver
  • 2014 – 19th Yahya Cohen Memorial Lectureship (awarded by the College
    of Surgeons, Academy of Medicine Singapore for best scientific surgical
    paper)
  • 2012 – Human Manpower Development Award (Ministry of Health,
    Singapore)
  • 2007 – Singhealth Best Doctor Award

Qualifications

  • MBBS - Bachelor of Science, Bachelor of Medicine, Bachelor of Surgery (University of New South Wales, Sydney, Australia)
  • MRCS (Edin) - Member of the Royal College of Surgeons Edinburgh, United Kingdom
  • MMed (ORL) - Master of Medicine in ENT (National University of Singapore)
  • FAMS - Fellow of the Academy of Medicine Singapore

Why Choose Dr Gan Eng Cern

1

Reliable & Reputable ENT Expert

Experienced and patient ENT Specialist who has your best interests at heart. We aim to provide you with accessible and specialized care for any ENT condition in a comfortable setting.

2

Friendly & Helpful Clinic Staff

Our friendly staff will assist you to the best of our ability and we are happy to accept most insurance providers and assist with E-filing with relevant insurance providers or Medisave.

3

Advanced ENT Equipment & Fully Equipped Facility

Our ENT Specialist, Dr Gan Eng Cern, will be able to diagnose and offer personalised treatments for your specific ENT condition. You can expect a high level of ENT care in a spacious setting with in-house minor surgical, endoscopy, allergy testing and microscopy services.

4

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There are various financial options available for you to ensure that you are able to receive the most optimal treatment and care. Our ENT clinic staff will be able to assist you with your medical insurance claims and work with your chosen healthcare organization to minimize the hassle and paperwork required. In some cases, you may be able to utilise the funds in your Medisave account to defray part of the costs of your treatment. As our clinic is accredited by the Medisave board, we are able to process your claims from your Medisave for certain clinic procedures.

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