Introduction 

Nosebleeds can be frightening. However, they are fairly common, particularly in children, and can often be treated at home.

The medical name for a nosebleed is epistaxis.

During a nosebleed, blood flows from one nostril, or sometimes both nostrils. It can be heavy or light and last from a few seconds to more than 10 minutes.

When to see your GP

Most nosebleeds are minor and usually stop with some self care. You only need to visit your GP if you have heavy or frequent nosebleeds.

Bleeding may be heavier or last longer if you have high blood pressure (hypertension), heart failure, a condition where your blood doesn't clot (thicken) properly, or if you're taking medication that thins your blood (anticoagulants), such as warfarin or aspirin.

If you have a nosebleed that lasts longer than 30 minutes, go to your nearest accident and emergency (A&E) department as soon as possible.

What causes nosebleeds?

The inside of your nose is full of tiny blood vessels which can bleed if they're disturbed by a minor injury, such as when picking or blowing your nose.

Nosebleeds can also occur if the moist lining (mucous membrane) inside your nose dries out and becomes crusty. This can be caused by an infection, cold weather or the drying effect of central heating. If the mucous membrane becomes inflamed or cracked, it's more likely to bleed if it is disturbed.

 

Who gets nosebleeds?

Anyone can get a nosebleed, but they most commonly occur in the following:



young children



the elderly



pregnant women



people who regularly take aspirin and blood thinning medication, such as warfarin



people with blood disorders



 

Treating nosebleeds

You can usually stop a nosebleed yourself by pinching your nose just above your nostrils for 10 minutes. Leaning forward and breathing through your mouth will drain blood down your nose instead of down the back of your throat.

If you seek medical help because your nosebleed hasn't stopped bleeding after 20 minutes, a procedure called cauterising may be used to stop the bleeding. This involves sealing the bleeding area by using a low level of heat or a tiny dab of silver nitrate (which can be painful).

If cauterising doesn't work, your nose may be packed with ribbon gauze or a nasal sponge until the bleeding has stopped. This will need to be removed by your GP or a healthcare professional who will then examine your nose.

Are nosebleeds serious?

Nosebleeds aren't usually serious. However, frequent or heavy nosebleeds may indicate more serious health problems, such as high blood pressure, and should be checked.

A nosebleed can be more serious for older people whose blood takes longer to clot because they are at risk of losing more blood.

If your GP suspects a more serious problem, they may refer you to an ear, nose and throat (ENT) specialist for further tests.

Excessive bleeding over a prolonged period of time can lead to anaemia. Frequent nosebleeds (more than once a week) or heavy nosebleeds can make anaemia worse if you're losing a lot of blood.

Preventing nosebleeds

Things you can do to prevent nosebleeds include:



avoid picking your nose and blowing your nose hard if it's blocked due to a cold or hay fever



wear a head guard while playing sports in which your nose could get injured, such as boxing or rugby



always follow the instructions that come with nasal decongestants



talk to your GP if you're prescribed blood-thinning medicines (anticoagulants) and you have a history of nosebleeds



After having a nosebleed, a "crust" will form inside your nose. This may be unpleasant, but try not to remove it as it is part of the healing process and will help prevent nosebleeds from re-occurring.

While your nose is healing, it's more vulnerable to infection, so avoid people with coughs and colds. Also avoid alcohol, smoking and hot drinks because they expand the blood vessels in the lining of your nose.


 



Nosebleeds are fairly common, particularly in children, and can vary in duration from a few seconds to more than 10 minutes 





Emergency services

 

During a nosebleed, blood will flow from one nostril or sometimes both nostrils. It may last anywhere from a few seconds to more than 10 minutes.

Nosebleeds can also occur while you're asleep.

You may feel liquid in the back of your throat before blood runs from your nose. This usually happens while you're lying down.

When to seek medical assistance



heavy bleeding from your nose



an irregular heart beat (palpitations)



shortness of breath



you turn pale



you swallow large amounts of blood that makes you vomit



If a nosebleed continues for longer than 30 minutes, go to the nearest hospital’s accident and emergency (A&E) department as soon as possible.

Bleeding may be prolonged and harder to stop if you have high blood pressure (hypertension), heart failure, a blood clotting disorder, or if you're taking anticoagulants (blood-thinning medicines), such as warfarin or aspirin.

If you're taking warfarin and have heavy or re-occurring nosebleeds, you should also seek medical advice immediately.

Causes of a nosebleed 

 

Nosebleeds can start just inside your nostrils (anterior) or at the back of your nose (posterior).

Anterior nosebleeds

An anterior nosebleed comes from the wall between the two nose channels (the lower septum), just inside your nose. This part of the nose, sometimes known as Little's area, contains many delicate blood vessels, which can be easily damaged.

The cause of anterior nosebleeds is sometimes unknown, but they can be caused by a number of things, including:



picking your nose, particularly if you scratch the inside of your nose with a sharp fingernail



blowing your nose very hard



a minor injury to your nose



a crooked nose that's either present from birth (congenital) or the result of an injury (a deviated septum)



a cold or flu (influenza)



sinusitis – an infection of the small, air-filled cavities inside your cheekbones and forehead



a blocked or stuffy nose often caused by an infection



a dry nose caused by dry air in a hot climate or heated indoor air



hay fever or other allergies



high altitude



excessive use of nasal decongestants



use of illegal drugs that are snorted – such as cocaine



Posterior nosebleeds

Posterior nosebleeds can be more serious than anterior nosebleeds. They are more common in adults than children. In this type of nosebleed, bleeding is heavier and comes from the back of your nose. Medical attention may be required.

During a posterior nosebleed, bleeding originates from branches of arteries that supply blood to the space inside your nose between the roof of your mouth and your brain (nasal cavity).

If your nosebleed is the result of a blow to your head, or a fall, seek medical attention because your nose may be broken. 

Other possible causes of posterior nosebleeds include:



recent nasal surgery



high blood pressure (hypertension)



hardened arteries (from fat, cholesterol or other substances that build up in your arteries)



exposure to irritating chemicals



a tumour in the nasal cavity



certain medicines – such as aspirin, medicines for arthritis and blood-thinning medicines (anticoagulants), such as warfarin and heparin



In some cases, nosebleeds can be a symptom of another condition, such as:



a blood clotting abnormality – such as haemophilia (an inherited condition affecting the blood’s ability to clot) or von Willebrand disease (an inherited disorder that causes bleeding and bruising)



leukaemia (although this is rare and you're likely to have other symptoms as well)



hereditary haemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease (an inherited condition that causes abnormalities in the blood vessels) - thought to affect between one in 5,000 and one in 10,000 people.



Treating a nosebleed 



 

 
Most nosebleeds can be stopped without the need for medical attention.

To stop a nosebleed:



sit down and firmly pinch the soft part of your nasal cavity, just above your nostrils, for 10 minutes



lean forward and breathe through your mouth; this will drain blood down your nose instead of down the back of your throat



stay upright, rather than lying down as this reduces the blood pressure in the veins of your nose and will discourage further bleeding



place a covered ice pack on the bridge of your nose 



maintain the pressure on your nose for up to 30 minutes (time this on the clock) so that your blood clots - if the bleeding doesn't stop after you've maintained pressure for 30 minutes go to the nearest accident and emergency department (A&E) as soon as possible



After a nosebleed, avoid blowing your nose, bending down and strenuous activity for at least 12 hours; try to keep your head above the level of your heart during this time

If your child gets regular nosebleeds from persistent crusting of the inside of their nostrils, you can try using ointment, such as petroleum jelly (Vaseline), to soften the inside of the nose.

You should see your GP if you:



often have more than one nosebleed a week (it may be due to an undiagnosed underlying condition)



have had an injury to your head, such as a blow or a fall (you may have broken your nose)



are taking a blood-thinning medicine (anticoagulant), such as warfarin, and the bleeding doesn't stop or it occurs regularly



Nasal packing

If you seek medical help, your nose may be packed with ribbon gauze or a special nasal sponge. The aim is to apply pressure to the source of the bleeding to stop the flow of blood.

Your GP, or the healthcare professional treating you, will explain the process and tell you how long you need to keep the pack in place. You should also be given an appointment to have it removed. After the bleeding has stopped, and your nose is unpacked, it will be examined.

Avoid any over-exertion while your nose is packed and for one to two weeks afterwards. 

Further tests

Your GP may check your blood pressure and pulse rate to determine what caused the nosebleed.

Frequent or heavy nosebleeds can be a symptom of a blood disorder, such as haemophilia. The doctor may arrange for you to have a blood test to check whether your blood is clotting properly.

If your nosebleeds are found to be caused by medication that you're taking, such as blood-thinning medicines (anticoagulants) like aspirin, warfarin or heparin, or an anti-inflammatory medicine, your GP may need to change or adjust the dose.

If your nosebleed is caused by an infection, such as sinusitis, you may be prescribed antibiotics.

In severe cases, you may need surgery to prevent the nosebleeds happening again (see below). In this case, your GP will refer you to an ear, nose and throat (ENT) specialist.

 

Nasal fractures

Nasal fractures (cracks or breaks in the bones of the nose) account for nearly 50% of all facial fractures. Most are simple and won't need an X-ray. However, if you have a more serious injury, an X-ray of your entire face and skull may be taken.

Fractures can cause a considerable amount of swelling around the nose. It may take five to seven days for the swelling to go down enough to allow a full examination. Once the swelling has settled, there's often little change to the shape of your nose, and it can be left to heal.

Surgery for recurring nosebleeds

Your ENT specialist may recommend surgery if you have frequent nosebleeds and the cause can be identified. There are a number of possible procedures, which are outlined below.

Septal surgery

Your septum (the wall between the two nose channels) can be crooked from birth or become crooked following injury. If it causes nosebleeds, you can have septal surgery to straighten it.

The surgery is carried out under local anaesthetic or general anaesthetic. It should take less than an hour.

As the surgery is inside your nose, it shouldn't leave any external scars. During the operation, some of the bone and cartilage inside your nose is removed and the septum moved back into the middle of your nose.

Afterwards, a dressing is placed on your nose for a day or two to keep it in place and prevent bleeding. You'll need to rest for one week, or for two weeks if your job involves heavy lifting or carrying.

After the operation, you may experience:



bleeding for up to 10 days



a blocked nose for two weeks, although it can take up to three months for your breathing to clear completely



an infection in your nose (although this is rare)



Your ENT specialist will explain the procedure to you in more detail.

Cautery

Cautery is a minor procedure that cauterises (burns) the blood vessel where the bleeding is coming from. It can be an effective method of stopping recurring nosebleeds.

Cautery is carried out either using:



an electric current running through a wire, such as platinum (electrocautery)



a chemical, such as silver nitrate, on the end of a wool swab (chemical cautery)



The bleeding area is touched for around 10 seconds to burn and seal it.

Cautery has some associated problems. For example:



silver nitrate cautery can be painful, particularly for children, even with the use of a local anaesthetic



it's not always effective as bleeding can occur around the cauterised area



it can only be used if a specific bleeding point can be identified



 

Ligation

If other treatments don't work, ligation may be recommended. This involves endoscopic surgery using fine instruments to tie off the ruptured blood vessel. In rare cases, the main artery from which the bleeding blood vessel branches off may need to be tied off.

If the bleeding blood vessel is far back in the nose, or difficult to compress, further surgery may be required.

Possible side effects of ligation include:



re-bleeding (the blood vessel still causes nosebleeds)



swelling, numbing or bruising of the face



a dry or runny nose