Nosebleeds

There are lots of very fine blood vessels right beneath the mucous lining in the front of the nose. They can be easily damaged, which can cause a nosebleed.

It is often not possible to say what the cause of a sudden nosebleed is. One common cause is picking your nose. But the lining of the nose can also dry out or be damaged if you have a cold or allergies, or by heated air. Nasal sprays to reduce swelling can also affect the mucous lining of the nose if they are used for longer periods of time. This is also the case for nasal sprays containing steroids.

Other possible causes include:

• a fall or blow to the nose,
• surgery in the nose-throat region or the insertion of a gastric tube through the nose,
• anticoagulant medications such as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”), clopidogrel or phenprocoumon (known under the trade names “Marcumar” and “Falithrom”),
• using cocaine,
• a blood clotting disorder or liver disease.

There is no evidence that high blood pressure makes nosebleeds more likely.

Young children often also put objects in their noses, which can damage the lining of the nose and cause nosebleeds.

Pregnant women have nosebleeds more often, too. That's because more blood flows in the mucous membrane in the nose during pregnancy, making it more prone to nosebleeds.

In very rare cases, nosebleeds are caused by leukemia (cancer of the white blood cells) or deformed blood vessels, as is the case with hereditary hemorrhagic telangiectasia (HHT). If male teenagers have constant nosebleeds, physicians sometimes check whether they may have juvenile nasopharyngeal angiofibroma. That is a benign tumor in the throat region.

More than half of the population have had a nosebleed at least once in their lifetime. Children under the age of ten years and people over the age of about 70 are affected especially often.

If you have an acute nosebleed, your doctor will first check how much blood you’ve lost and whether your breathing and circulation are stable. They will try to find out what caused the nosebleed and will also ask about any medical conditions you have or medications you might be taking.

You will normally be given a local anesthetic before the examination to prevent pain. Your doctor will usually give you a medication that reduces swelling in the mucous membrane in the nose so that they can see into your nose better. They then use a special instrument (nasal speculum) to widen the nostrils, examine the inside of the nose and look for where the bleeding is. Sometimes an endoscope is used, allowing them to see the rear nasal cavity. Some instruments have an integrated camera that can show a magnified image of the mucous membrane in the nose.

If you have constant nosebleeds, your physician will check whether it has a more serious cause such as cancer. Along with examining the inside of the nose and throat region, a CT (computer tomography) scan or an MRI ( magnetic resonance imaging) scan can be done of the sinuses to rule out problems such as tumors. A blood sample is also taken and tested to see if there is a blood clotting disorder.

People who want to prevent (more) nosebleeds can pay attention to the following:

• Keep the mucous lining of the nose moist, by using a nasal lotion or saline nasal spray, for example.
• Keep the indoor air moist, by using damp laundry, bowls of water on top of heaters, house plants, or a humidifier, for instance.
• Blow your nose carefully and avoid blowing it too strongly, and ideally avoid blowing your nose at all in the first seven to ten days after a nosebleed.
• Do not pick your nose.

Sudden nosebleeds can be frightening, especially for children. That’s why it’s even more important to keep calm and comfort and reassure children. You can normally stop nosebleeds by

• sitting up straight and leaning forward slightly. Leaning forward slightly helps to stop the blood from getting into the throat or the airways. Any blood can be spit out if needed. You can sit children with a nosebleed on your lap.
• pressing the nostrils together. Keep the lower third of the nose pressed together for 10 to 15 minutes (adults) or 10 minutes (children). Continue breathing through the mouth.
• keeping the nape of the neck as cool as possible. Cool packs are particularly good for that. Or you can hold a flannel or small cloth under cold water, wring it out and then lay it on the back of the neck.

Medical assistance is needed if this doesn't stop the bleeding. It’s best to call the emergency services (112 in Germany and many other countries, 911 in the U.S.). Keep pressing your nostrils together until they have arrived. If you’re not sure about what to do, you can call the on-call doctors' information hotline in Germany (ärztlicher Bereitschaftsdienst) at 116117.

Doctors then have various treatment options:

• Medications to reduce swelling and constrict the blood vessels: They are usually sprayed into the nose or applied with a cotton bud. Medications that reduce swelling such as the active ingredient xylometazoline help to locate the source of bleeding, and medications that constrict the blood vessels reduce blood flow.
• Cauterization: This is an option if the source of the bleeding has been found. The blood vessels are closed under a local anesthetic using laser, electricity, or a chemical substance such as silver nitrate. It only takes a few seconds to cauterize the blood vessels.
• Nasal tampon: A special nasal tampon is inserted into the nose and fixed from the outside with a plaster if the source of the bleeding isn’t visible or if cauterization didn’t work. Your doctor will take it out again after one or two days. Depending on the severity of the bleeding, you might stay in the hospital for observation.

You only rarely need to stay in the hospital for several days to stop the bleeding. That may be necessary if the bleeding is in the back of your nose. The bleeding vessel can then be closed surgically with a clip or using electricity. If surgery is not possible or wasn’t successful, a medication that closes blood vessels can be injected into the affected vessel (embolization).

When people are ill or need medical advice, they usually go to see their family doctor or pediatrician first. Ear, nose and throat doctors are well suited for handling nosebleeds.

In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your visit to the doctor.