Symptoms
In a nosebleed, there is active bleeding in the nasal cavity. Blood flows through the nostrils to above the lip and chin. Less commonly, blood drains from the back portion of the nasal cavity into the throat and neck. This causes symptoms such as nausea, bloody vomiting, coughing up blood, and blackening of the stool. Nosebleeds are common in children under 10 years of age and therefore can be categorized as a pediatric disease. Nosebleeds are also common in older adults and during the cold season. Nosebleeds interfere with personal and business activities, and the blood can contaminate clothes and surroundings. It can lead to anemia and, in very rare cases, death because of the large amount of blood lost.
Causes
Two important functions of the nose are to warm and humidify the inhaled air. Therefore, the nasal mucosa is well supplied with superficial vessels. In most cases, nosebleeds result from local injury to vessels of the anterior nasal septum (Kiesselbach’s plexus, Figure 1). It may have local or systemic causes. It is also frequently idiopathic with no apparent cause. 1. local causes:
- Dry nose due to staying in air-conditioned rooms or the dry air in winter.
- Cold, rhinitis, crusting, infections, sinusitis, hay fever, rhinitis medicamentosa.
- Foreign bodies, nasal polyps, tumors.
- Injury, broken nose, surgeries, intubation, perforation of the nasal septum, nose picking, blowing, physical exertion.
- Vascular diseases and anomalies
- Irritants such as cigarette smoke or acids
- Nasal agents such as glucocorticoid nasal sprays, antihistamines, decongestant nasal sprays, nasally applied intoxicants such as cocaine, mephedrone, alcoholism
2. systemic causes:
- Hemophilia and other blood clotting disorders.
- Leukemia, thrombocytopenia
- Liver disease
- Hypertension
- Pregnancy
- Infectious diseases such as the hemorrhagic fevers.
- Medications, for example, phenprocoumon (Marcoumar), heparins or acetylsalicylic acid (Aspirin cardio).
3. idiopathic nosebleeds:
- Without apparent cause
Diagnosis
The diagnosis can be made easily. However, if it occurs in the posterior portion of the nasal cavity, the clinical picture is not so clear and an asymptomatic course is possible. In a second step, the deeper cause should be clarified under medical treatment, especially in the case of recurrent symptoms.
Prevention
The effectiveness of preventive measures for recurrent nosebleeds have been insufficiently studied (e.g., Burton, Dorée, 2004). Avoidance of specific triggers is recommended. Dry mucous membranes should be kept moist with sprays, rinses, inhalations, nasal ointments, or a humidifier. Grease- or mineral oil-based nasal ointments should not be overused because of the rare occurrence of lipid pneumonia. Children should refrain from picking their noses. Healing after the bleeding is over takes several days to weeks. During this time, the nose should be spared: Do not blow your nose violently, do not pick your nose, do not engage in vigorous physical exertion; avoid heat and other triggers. The mucous membrane should be protected from drying out.
Non-drug treatment
The patient should sit quietly and tilt the head slightly forward to prevent the blood from draining backward. The blood should be spit out rather than swallowed, as it can cause nausea and vomiting and obstruct the airway. If available, hemostatic absorbent cotton can be placed in the nostrils (see below). Alternatively, a paper tissue, gauze compress, ready-to-use nasal tamponade or similar may be used. The nostrils should be pressed well together with the thumb and index finger for 10 to 20 minutes. If these measures have not stopped the bleeding after 20 minutes, the patient should seek medical attention immediately. Other reasons for visiting a doctor are repeated nosebleeds, a suspected systemic cause, injuries, a broken nose, nosebleeds in elderly people or taking anticoagulant medication.Local cold can have a beneficial effect by triggering vasoconstriction, for example by applying ice packs or cold compresses locally to the nose or neck.
Drug treatment
Hemostatic agents are used to treat acute nosebleeds. Underlying conditions must be treated separately. Hemostatic absorbent cotton:
- The hemostatic absorbent cotton available in pharmacies or drugstores is not made of cellulose, but of calcium alginate fibers, the calcium salt of alginic acid. It is a purified vegetable product obtained from algae that promotes blood clotting. The required amount is pulled from the vial with clean tweezers and cut with scissors. Usually 5 to 10 cm is sufficient. It is applied nasally and is a common remedy for the treatment of nosebleeds in self-medication. Adverse effects are not known so far, fibers do not remain but dissolve. Hemostatic absorbent cotton can also be used for other bleeding. In medical treatment is also used hemostatic absorbent cotton made of other materials, for example, cellulose or gelatin (so-called gelatin sponge).
Decongestant nasal sprays:
- Decongestant nasal sprays contain active ingredients such as oxymetazoline, phenylephrine or xylometazoline and cause nasal vasoconstriction. In a small study, they have been shown to help stop bleeding in some cases. In medical treatment, the vasoconstrictor and additional local anesthetic cocaine is also used.
Tannins:
- A nasal tamponade can be soaked with a vegetable tanning solution such as witch hazel water to enhance the hemostatic effect. Shepherd’s purse (blood herb) is commonly used in folk medicine. We have no data on clinical efficacy. In the trade are also available nasal ointments with tannins, which are used for prevention.
Medical treatment:
- Nosebleeds in the anterior nasal cavity can usually be treated easily. This is done by locating the origin of the bleeding with a lamp or endoscope and stopping the bleeding with appropriate means (e.g., cauterization with silver nitrate or electrocautery). In a treatment of severe nosebleeds or bleeding in the posterior nasal cavity, modern tamponades, wound dressings, balloons or surgical methods are also used.
