NoseBleeds

Although a common occurrence, nosebleeds can sometimes be a sign of something more sinister. Know when you should seek medical help.

Nose bleeds, or epistaxis, is defined as bleeding from any part of the nose, including the nasal passages, the sinuses and the nasopharynx. Approximately 60% of the population will be affected by nose bleeds at some point in time. Although a common occurrence, nosebleeds can sometimes be a sign of something more sinister. Know when you should seek medical help.

Causes of Nosebleeds

Two groups of factors to consider.

Local factors

• Spontaneous epistaxis
• Facial and nasal trauma
• Inflammation/flu/common cold
• Nasal tumours
• Nose cancer
• Polyps
• Post-nasal surgery

Systemic factors

• Hypertension
• Use of anti-coagulants, aspirin, clopidogrel, warfarin, etc
• Bleeding and clotting disorders
• Other drugs such as chemotherapy, NSAIDS, steroids
• Artherosclerotic (hardened) blood vessels
• Blood vessel abnormality, eg heredity telangiectasia or hemangioma

Spontaneous epistaxis

The nasal passages are extremely vascular, with a massive network of blood vessels protected by a thin layer of mucous membrane. The largest network of blood vessels (the Kiesselbach’s Plexus) is situated at the anterior aspect of the nasal septum (the medial wall of the nose), just 1–1.5cm behind the opening of the nostril. This is the part of the nose that our fingernails or rolled-up tissue paper can reach. The size of these vessels varies from individual to individual. Large blood vessels in this particular area are exceptionally prone to epistaxis, from the slightest trauma, nose picking, flu, hypertension or prolonged exposure to dry and warm air. This is by far the commonest site of spontaneous epistaxis, especially in children.

Bleeding from the Kiesselbach’s Plexus may be mild to profuse, and often stops by itself within minutes. The blood usually drips from the nostrils when the patient is upright and may flow into the throat when the patient tilts his head upwards or when lying on his back.

Bleeding from the Kiesselbach’s Plexus may be easily stopped by pressing the lower soft part of the nose against the septum (medial wall) or pinching both lower soft parts of the nose together, then releasing the pinched nose intermittently to check if the bleeding has stopped. This usually takes no longer than several minutes. Many patients are incorrectly advised to pinch the hard or bony part of the nose, or to tilt the head back. Tilting the head back would only cause the blood to flow into the throat that may be swallowed (especially in children), making one believe that all is well. Any scab or blood clot that forms after bleeding ceases should not be removed immediately and should be left for some time before attempting to remove it if it is too uncomfortable. When removing the scab or blood clot, cup a handful of room-temperature water and flood the nostrils for 10–30 seconds to soften the clot or scab before gently blowing or pulling it out.

To prevent such bleeding, avoid picking the nose, rubbing it too vigorously, or blowing it too hard. Gentle application of a layer of Vaseline or antibiotic ointment to this area will often help to protect it. Such Kiesselbach’s Plexus bleeding may require an elective appointment to see an ENT specialist to exclude any underlying sinister pathology. In severely recalcitrant cases, a simple cautery of the blood vessels may be needed.

Something more severe

A more severe type of vascular bleeding is found in adults with hypertension, artherosclerotic (hardened) blood vessels, and in patients using anticoagulants or bleeding disorders. Such bleeding can be extremely profuse and can be life-threatening. Such bleeding is often from blood vessels in the deeper part of the nose and does not respond to pressure on the soft parts of the nose. If bleeding fails to stop, immediate medical attention and emergency treatment is needed.

The bleeding vessels can often be found by endoscopy and sealed by cautery or ligation, under local or general anaesthesia. If such facilities are unavailable, nasal packing can be done and the patient sent for ENT evaluation and treatment.

All adults with epistaxis should seek an ENT endoscopic examination to exclude pathologies such as infection, tumour, polyps or cancer, especially adults of Southern Chinese ethnicity (Cantonese, Hokkien, Teochew, etc) or who have a family history of nose cancer. The earliest symptom of nose cancer is blood-stained sputum in the morning or blood-stained mucus when blowing the nose. Other signs of nose cancer include a ‘blocked sensation’ or ringing sound in the ear, progressively stuffy nose, unexplained swelling (lymph node) in the neck, headache or double vision.