Nosebleeds: When It’s Time to Get Medical Attention
Doctors call it epistaxis; the rest of us call it a nosebleed.
Most adults have experienced a nosebleed at some point in their lives, and the nosebleeds are usually isolated incidents that stop on their own.
But for some—about 15% of people—nosebleeds are a regular occurrence. “Frequent nosebleeds are a reason to see a primary care doctor or an ENT (an ear, nose, and throat) specialist,” says David A. Gudis, MD, associate professor of otolaryngology/head & neck surgery at Columbia University Vagelos College of Physicians & Surgeons and chief of the Division of Rhinology & Anterior Skull Base Surgery at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital.
“When nosebleeds are frequent, they can really get in the way of daily activities and be a significant hindrance to having a normal and healthy quality of life.”
Recurrent nosebleeds can often be managed by simply holding pressure on the nose, but in some cases, medical or surgical intervention is necessary. In rare cases, Gudis says, frequent nosebleeds may be a sign of a more significant health issue, so it’s important to see a specialist to determine the underlying cause of the problem.
And some nosebleeds involve such a significant amount of blood loss that they can result in airway obstruction or a life-threatening emergency.
We spoke with Gudis, who recently published an article with a video in the New England Journal of Medicine discussing the proper evaluation and treatment of recurrent nosebleeds. Here’s what you need to know:
Blame your Kiesselbach’s plexus.
Nosebleeds usually come from the area of the front of the nasal septum known as the Kiesselbach’s plexus, where a number of arterial branches converge. The vessels keep the area well supplied with blood, which is critical for the health of the sinuses. But it can result in frequent nosebleeds.
In adults, turbulent airflow can lead to nosebleeds.
Especially in the case of a deviated nasal septum, the inner part of the nose can be a place of turbulent airflow. “Even though it's essentially unnoticeable to the average person, over time it can cause trauma to the mucous membrane that covers Kiesselbach’s plexus and cause recurrent nosebleeds,” Gudis says. Cold, dry air can also be a trigger.
Individuals who take aspirin to prevent heart attacks or have a platelet condition that impairs their ability to form blood clots are also more likely to have recurrent nosebleeds.
“I often see patients who are taking some kind of antiplatelet or anticoagulant medication,” Gudis says. “It's easier for us to manage nosebleeds than to manage a stroke or a heart attack, so I would rather treat their nosebleeds aggressively so that patients can stay on their anticoagulant or antiplatelet medications.”
In kids, fingers are often the culprit.
Kiesselbach’s plexus also happens to be where the fingers of little kids have easy access.
“We refer to that medically as digital trauma," Gudis says. "Basically, you’ve poked your nose with your finger too much, and that’s a common way the region becomes traumatized.”
See an ear, nose, and throat specialist if nosebleeds are very frequent.
What constitutes very frequent nosebleeds? “I would really defer to the patient,” Gudis says. “If nosebleeds are troublesome for the patient, upsetting, or interfering with daily activities, it's worth seeing a specialist.”
A specialist can rule out a few diagnoses by examination or taking a history. One condition, called hereditary hemorrhagic telangiectasia, or HHT, is a genetic condition that causes abnormal blood vessel formation.
“These aren't the kind of nosebleeds that most people have experienced before,” Gudis says. “These people can lose a pint of blood every time they take a really hot shower or bend over to tie their shoes.” The most frequent symptom of HHT is severe nosebleeds, but the condition also causes abnormal blood vessels in other parts of the body. “Even in the absence of a family history, spontaneous mutations can cause this condition, so it’s a diagnosis that needs to be considered in patients who have frequent or recurrent epistaxis.”
Other things to consider are tumors, both benign and malignant, that can form in the nose or the sinuses.
If you lose about a cup of blood, seek immediate medical attention.
If a nosebleed just gets a few tissues or paper towels wet and then eventually stops, “that might feel like a lot of blood,” Gudis says, “but in terms of the body's volume of blood, that is not really a severe nosebleed.”
Gudis tells patients that if the nosebleed could fill a cup with blood, that’s a severe nosebleed that needs attention. “If it's like a leaky faucet dripping from the nose, nothing is stopping it, medical attention is required,” he says. “That might mean a trip to the emergency room or to a primary care doctor's office.
“If a nosebleed is severe enough that it can fill up a cup with blood, then we are in the territory of something where urgent medical attention is necessary. And occasionally these can turn into life-threatening emergencies.”
Some home remedies work; others don’t.
If a patient has frequent nosebleeds, without any other concerning signs or symptoms, topical moisturizing agents for the nose—nasal saline gel spray or a little bit of petroleum jelly in the front of the nose—can protect the lining of the nose and minimize nosebleeds. Humidifiers in the bedroom or office can be very helpful for preventing cold dry air from irritating the lining of the nose.
One common home remedy—putting a copper penny on the forehead or the nose—is probably not effective. “I'm not aware of any evidence that it helps,” Gudis says. “But sometimes cold things on the nose can constrict the blood vessels, so there is a little bit of truth to the concept.”
If home remedies don’t work, silver nitrate cauterization can stop the bleeds.
For more troublesome cases, a quick application of silver nitrate in the doctor’s office can put a stop to the nosebleed.
“Silver nitrate is a chemical that's been used in medicine for hundreds of years for lots of different purposes, and one thing it does very well is cause sclerosis of blood vessels,” Gudis says. “Essentially the silver ions in the silver nitrate are released around the blood vessels and cause an inflammatory reaction that creates scarring in the little arteries and veins in the nose. With the scars, blood doesn't flow as much through the vessels, and they’re far less likely to bleed.”
The procedure is simple, quick, and very effective. But it does hurt briefly.
“I tell patients it's going to sting. Usually it's five or 10 minutes of discomfort and by the time the patient's out the door, it doesn't hurt anymore. I have had a handful of patients who have had pain for a couple days afterwards. That's extremely rare and usually can be managed with over-the-counter pain relievers.”
The treatment does not disturb a patient’s sense of smell. “Every once in a while, patients will get a gray or silver discoloration to the front of their nostril that takes a day or two to go away,” Gudis says.
"Nasal Cauterization with Silver Nitrate for Recurrent Epistaxis," by David A. Gudis (Columbia) and Zachery M. Soler (Medical University of South Carolina) was published June 24, 2021, in the New England Journal of Medicine.