Overview
Nosebleeds (epistaxis) are very common and usually minor. Most arise from the front of the nose (anterior epistaxis) at Little's area, a cluster of small blood vessels inside the nostril. Posterior nosebleeds originate deeper in the nose and are less common but more difficult to control. The vast majority of nosebleeds have no serious underlying cause.
How common is it?
Nosebleeds affect about 60% of people at some point in their lives. They are most common in children (age 2 to 10) and older adults (age 50 to 80). Serious nosebleeds requiring hospitalisation are uncommon.
Causes and risk factors
Most nosebleeds result from drying of the nasal mucosa, trauma, or picking, causing rupture of superficial blood vessels.
Common risk factors
- Nose picking (most common cause in children)
- Dry air and low humidity (dries nasal mucosa)
- Nasal blowing or blowing forcefully
- Trauma to the nose
- Anticoagulant medications (warfarin, aspirin, direct oral anticoagulants)
- Hypertension (does not directly cause nosebleeds but prolongs them)
- Nasal sprays (drying effect)
- Coagulation disorders (haemophilia, von Willebrand disease)
- Hereditary haemorrhagic telangiectasia (multiple telangiectatic vessels)
- Nasal tumours (rare, usually unilateral, recurrent posterior bleeds)
Symptoms
- Bleeding from one or both nostrils
- Blood draining into the throat if posterior
- May be associated with trauma, picking, or dry environment
When to see a doctor
Go to A&E immediately for bleeding lasting more than 20 minutes despite first aid, large volumes of blood, swallowing a lot of blood, or feeling faint. See a doctor for frequent recurrent nosebleeds, nosebleeds on anticoagulants, or unilateral nosebleeds without obvious cause.
Diagnosis
Nasal endoscopy to identify the bleeding point. Blood pressure measurement. Full blood count, clotting screen if coagulation disorder suspected. CT or MRI for suspected posterior lesion.
Treatments
First aid (pinch and lean)
Pinch the soft part of the nose (not the bony bridge) firmly for 10 to 15 minutes while sitting leaning slightly forward. Breathe through the mouth. Apply ice pack to the bridge of the nose. Do not tilt the head back.
Silver nitrate cautery
Chemical cautery of the bleeding vessel under direct vision using a silver nitrate stick. Performed in primary care or A&E. Highly effective for anterior epistaxis with a visible bleeding point.
Nasal packing
Absorbable packs (Rapid Rhino) or non-absorbable ribbon gauze packing control posterior or refractory anterior bleeds. May require overnight admission.
Endoscopic ligation or embolisation
Endoscopic sphenopalatine artery ligation or embolisation via interventional radiology for refractory posterior epistaxis not controlled by packing.
Self-care and lifestyle
- Use a saline nasal spray or moisturiser (petroleum jelly applied to the inner rim) in dry environments
- Avoid nose picking
- Use a humidifier in winter months
- Review anticoagulant dose if nosebleeds are frequent
Prevention
Nasal moisturisation, avoiding dry environments, and not picking the nose prevent most anterior nosebleeds.