Some people get nosebleeds rather often, and others rarely get them. There may be just a trickle of blood or a strong stream. If people swallow the blood, they often vomit it because blood is irritating to the stomach. Swallowed blood may pass through the digestive tract and appear in the stool as black tarry stools.
Anterior nosebleed
Nosebleeds usually come from the front part of the nose (anterior nosebleed). The bleeding comes from small blood vessels in the cartilage that separates the two nostrils (called the nasal septum). The nasal septum contains many blood vessels, and bleeding from this site may result in a lot blood. Thus, most anterior nosebleeds are more frightening than serious.
Posterior nosebleed
Bleeding from blood vessels in the back part of the nose (posterior nosebleed), although uncommon, is more dangerous and difficult to treat. Posterior nosebleeds usually involve larger blood vessels than anterior nosebleeds. Because these vessels are in the back of the nose, they are hard for doctors to reach for treatment.
Posterior nosebleeds tend to occur in people who
Have atherosclerosis (which reduces or blocks blood flow in arteries)
Have bleeding disorders
Are taking medications that interfere with blood clotting
Have had nasal or sinus surgery
Causes of Nosebleeds
clotting disorder, or who have hardening of the arteries (arteriosclerosis) are more likely to develop nosebleeds.
Common causes
The most common causes of nosebleeds are
Trauma (such as nose blowing and picking)
Drying of the moist inner lining of the nose (as occurs in winter)
Less common causes
Less common causes of nosebleeds include
Nasal infections
Tumors of the nose or sinuses
Bleeding disorders (coagulopathies)
Bodywide (systemic) disorders
High blood pressure (hypertension) is unlikely to cause a nosebleed, but in people with high blood pressure, the nosebleed may last longer than expected.
Some Causes and Features of Nosebleeds
Cause* | Common Features† and Tests‡ |
|---|---|
Common | |
Blowing or picking the nose A blow or other injury to the nose | Typically evident during a doctor's evaluation |
Drying of the moist membranes lining the nose, as may occur in cold weather | Usually dryness that is seen during the examination |
Less common | |
Usually in older people | |
Bleeding disorders (coagulopathies) | In people who have had nosebleeds or other bleeding in other areas, such as the gums Blood tests, such as a complete blood cell count and tests to measure how quickly blood clots |
A foreign object (body) in the nose, mainly in children | Often recurring nosebleeds and/or a foul-smelling discharge from one nostril |
A hole (perforation) in the nasal septum (which divides the interior of the nose in two) | A hole that can be seen during the examination |
Nasal discharge, sometimes thick or discolored, and crusting in the nostrils Often irritation of the moist membranes lining the nose | |
Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome) | Dilated small blood vessels (telangiectasias) on the face, lips, membranes lining the mouth and nose, and tips of the fingers and toes Usually in people with family members who have the disorder |
Systemic disorders, such as severe liver disease or AIDS | In people who are known to have such disorders Changes in the membranes lining the nose |
Tumors (noncancerous or cancerous) of the nose or sinuses | Sometimes a mass that can be seen inside the nose Bulging of the side of the nose Sometimes CT |
* Conditions that can cause nosebleeds are more likely to cause nosebleeds in people who also have a bleeding disorder or who take medications that interfere with blood clotting. In such people, bleeding is often more severe and difficult to treat. | |
† Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. | |
‡ Although a doctor's examination is always done, it is mentioned in this column only if the diagnosis can sometimes be made by the doctor's examination alone, without any testing. | |
CT = computed tomography. | |
Evaluation of Nosebleeds
The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
Warning signs
In people with a nosebleed, certain symptoms and characteristics are cause for concern. They include
Signs of excessive blood loss (such as weakness, fainting, or dizziness when standing up)
Use of medications that interfere with blood clotting
Signs of a bleeding disorder or a known bleeding disorder (such as hemophilia)
Bleeding that is not easily stopped—for example by direct pressure
Several recent episodes of nosebleeds, particularly with no clear cause
Signs of a bleeding disorder include
Numerous small, red or purplish spots on the skin (petechiae)
Many large bruises
Easily bleeding gums
Bloody or tarry stools
Coughing up blood
Blood in the urine
Excess bleeding while brushing the teeth, having blood tests, or getting minor cuts
Heavy menstrual periods in women
When to see a doctor
People who cannot get the nosebleed to stop by pinching the nose should go to the hospital right away. Even if the bleeding has stopped, people who have warning signs should also go to the hospital right away. People without warning signs who had a nosebleed that stopped (with or without treatment) and otherwise feel well should call their doctor. They may not need to be seen.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination often suggests a cause of the nosebleed and the tests that may need to be done.
During the medical history, doctors ask about the following:
Obvious triggers (such as sneezing, nose blowing or picking, and recent upper respiratory infections)
The time and number of previous nose-bleeding episodes and how they were stopped
Whether the person (or a family member) has a bleeding disorder or other disorders that sometimes cause problems with blood clotting
Whether the person takes any medications that interfere with blood clotting
Disorders that can cause problems with clotting include severe liver disease (such as cirrhosis or hepatitis) and certain cancers.
During the physical examination, doctors first look for signs of extensive blood loss (such as a fast heart rate and low blood pressure) and for markedly high blood pressure.
Doctors then focus on the nose, looking for the bleeding site. They also check the person's skin for signs of bleeding disorders, including petechiae, large bruises, and dilated small blood vessels in and around the mouth and on the tips of the fingers and toes.
An anterior bleeding site is usually easy for the doctor to see with a handheld light and an instrument used to hold the nostrils open. Sometimes the doctor uses a headlamp or head mirror to reflect light into the nose, To see a posterior bleeding site, doctors need to use a flexible viewing scope (nasal endoscope). However, an actively bleeding posterior site produces too much blood for the doctor to see anything, even with a viewing scope.
Testing
Laboratory testing is not usually required. If people have symptoms of a bleeding disorder and/or signs of significant blood loss or severe or recurring nosebleeds, blood tests are done. Computed tomography (CT) may be done if a foreign object, a tumor, or sinusitis is suspected.
Treatment of Nosebleeds
Doctors initially treat all nosebleeds as they would treat an anterior nosebleed. The few people who have lost a large amount of blood are given fluids by vein (intravenously) and rarely blood transfusions. Any known or identified bleeding disorder is treated.
Anterior nosebleed
Bleeding from blood vessels in the front part of the nose usually can be controlled at home by pinching the nostrils together for 10 minutes while the person sits upright. People should not pinch over the bony upper part of the nose. It is important to hold the nose with a firm pinch and not let go even once during the 10 minutes. Other at-home techniques, such as ice packs to the nose, wads of tissue paper in the nostrils, and placing the head in various positions, are not effective.
Posterior nosebleed
Bleeding from blood vessels in the back part of the nose is very difficult to stop and can be life threatening. For this type of nosebleed, the pinch technique does not stop the bleeding. Pinching simply makes the blood run down the throat instead of out the nose. For a posterior nosebleed, doctors may place a specially shaped balloon in the nose and inflate it to compress the bleeding site. However, this and other types of posterior nasal packing are very uncomfortable and interfere with the person’s breathing. Doctors usually give people sedatives by vein before inserting this kind of balloon and packing. Also, people who have had this type of packing are admitted to the hospital and given oxygen and antibiotics to prevent an infection of the sinuses or the middle ear. The packing remains in place for 4 to 5 days. This procedure causes discomfort, but the discomfort can be relieved with treatments.
If the balloon or packing does not work, doctors need to directly close the bleeding vessel. Doctors typically do a surgical procedure in which an endoscope is used to examine the interior of the sinus. The endoscope enables the doctor to reach and close off (typically with a clip) the larger artery that feeds the bleeding vessel. Occasionally, doctors use x-ray techniques to pass a small catheter through the person’s blood vessels to the bleeding site and inject material to block the bleeding vessel (embolization).
Key Points
Most nosebleeds occur from the front part of the nose and are easily stopped by pinching the nostrils together.
People should try the 10-minute pinch technique to stop a nosebleed.
If pinching the nostrils does not stop the bleeding, people should seek medical attention.
