Stuart N. Thomas, MD
Central Park Ear, Nose and Throat, LLC

I. LOCATION

a. Anterior
Modern Medicine divides the lining of the nose into a front portion, or anterior aspect, and a rear portion, or posterior aspect. Most nosebleeds (or “Epistaxis” in medical jargon) occur in the rich vascular plexus that underlies the thin, delicate mucus membrane along the front of the nasal septum (the “party wall” between the two nostrils). These are typically easier to treat and prevent.

b. Posterior
In older patients and those with significant hypertension (high blood pressure), the source of bleeding is frequently in the posterior aspect of the nose and along the much more complex, lateral nasal wall. These bleeds tend to be MUCH more difficult to locate and control. Surgical intervention in these cases is not uncommon.

II. CAUSES

a. Trauma
The thin mucus membrane (or mucosa) of the lining of the nose is perfectly designed to handle the flow of air across it. It is not designed for frequent abrasion from fingers, tissues, or other foreign bodies. Activities like frequent nose-blowing, picking, rubbing the outer aspect of the nose, or swabbing the nose out to “clean” it, damage this delicate membrane and will secondarily lead to damage to the rich plexus of blood vessels beneath it. It is actually possible to “pick” a hole in the septum or even sidewall of the nose from frequent, repetitive trauma.

b. Drying
Nosebleeds are much more common during the winter. This is because the relative humidity inside buildings drops significantly when heating is used. This causes drying of the nasal mucus membrane which leads to cracking and disruption, in turn tearing or rupturing the underlying blood vessels.

c. Infection
Chronic staphylococcal (“Staph”) infections of the front portion of the nose (nasal vestibule—where the nose hairs arise) seem to create nose bleeds in some cases. Much less commonly, chronic sinusitis can cause nosebleeds as well.

d. Prescription Nasal Sprays
Many prescription nasal sprays, like nasal steroids (Flonase™, Nasonex™, etc) can create nosebleeds—usually mild, but occasionally severe. This is especially true in the presence of one of the other noted risk factors for nose bleeds.

e. Anticoagulants
Patients on medication that “thins” their blood—or anticoagulants (this includes daily Baby Aspirin, Warfarin, Coumadin, Plavix, Eliquis, etc) are at a significantly increased risk of nose bleeds and should be especially vigilant to avoid any unnecessary trauma to the nose

f. Hypertension
Patients with high blood pressure—especially those that are older—are at significantly higher risk of a posterior nosebleed. The addition of an anticoagulant to these patients increases this risk even further.

III. HOW TO AVOID HAVING NOSEBLEEDS

a. Alkalol
Alkalol™ (www.alkalolcompany.com) is a non-prescription, non-toxic nasal irrigant solution that makes an excellent nasal moisturizer when misted into the nose. It seems to form an oily barrier over the nasal mucosa which makes drying and resulting bleeding much less likely when the product is used regularly and consistently. It can be hard to locate, but Walgreen’s and CVS both seem to carry it at all their locations.

I recommend decanting undiluted Alkalol into an empty nasal spray bottle (like a nasal saline spray bottle) and then spraying 2-3 squirts of the Alkalol mist into each nostril at least four times per day.

b. Nasal irrigations
In lieu of nose blowing or other traumatic nasal cleaning rituals, saline irrigations of the nasal passages is safe and atraumatic. This will not increase the risk of nose bleeds. Common devices readily available at all pharmacies and many grocery include the NeilMed™ irrigation system (www.neilmed.com). We highly recommend this to any patient with any chronic nasal condition, including repetitive nosebleeds.

c. Avoidance of trauma/manipulation
Avoiding trauma to the nose is an absolutely critical component of therapy for recurring or persistent nose bleeds. This includes avoiding any nose blowing, picking, or rubbing. For many, nasal “cleaning” becomes subconscious and almost ritualistic. These can be very hard habits to break.

In children, this behavior will frequently occur at night, while the child is asleep. Trimming the child’s finger nails short and placing socks over their hands can help this.

d. Humidification
Keeping the lining of the nose moist significantly reduces the risk of bleeding as noted above. A humidifier or vaporizer next to the bed at night time can help achieve this.

e. Antibiotics
In some cases, a prescription antibiotic ointment that specifically treats staphylococcal infections, can be prescribed.

IV. HOW TO STOP A NOSEBLEED

a. Home therapy

i. General
When a nosebleed first begins, it is important to take a moment and relax. It is a very scary thing to see blood dripping out of you and there is a tendency to panic. This is in turn causes the blood pressure to rise, which only worsens the situation. Remember that most nosebleeds are minor problems and will stop spontaneously or with a minimum of treatment.

It’s also worth paying attention to which side is bleeding. Although if the bleeding is heavy, it may seem to be coming from both sides of the nose, it never is. All nosebleeds originate from only one side of the nose. Knowing which side of the nose is bleeding will be important if further steps are necessary to control it.

ii. Pressure
After assessing which side is bleeding and taking a moment to calm one’s nerves, the next step is direct pressure. This is a classic medical concept in the control of bleeding anywhere in the body: pressing directly on the site that is bleeding should compress the ruptured blood vessel and allow coagulation (clotting) to occur, stopping the bleeding.

In nosebleeds, the thing to do is pinch the front of the nose firmly (as if there is a bad odor you don’t want to smell) and for a prolonged period of time. I will usually recommend at least 10 minutes of this nasal compression, and 20 minutes is better.

iii. Afrin™
Should nasal pinching/compression fail to stop the bleeding, the next step is to use Afrin™ (active ingredient known generically as “Oxymetazoline”—the same ingredient in 4-way™, Duration™, Vicks™, etc). These nose sprays are non-prescription nasal decongestants that work by causing significant and long-duration blood vessel constriction (vasoconstriction). This in turn shrinks the lining of the nose which helps people with stuffy noses breath better. But it is also amazingly effective at short term control of nosebleeds. It is intended that the bottle be held upright and the then squeezed which ejects a light mist of the medication into the nostril it is held under.

I recommend you GENTLY blow the clots out of the side of your nose that is bleeding (remember that it is only one side). Immediately after doing so, take the Afrin bottle and invert it. Tilt your head back and hold the tip of the spray bottle immediately outside of the bleeding nostril and fire 2-4 long sprays of the Afrin into the bleeding nostril. The goal is to coat (or wet) all the surfaces in that nostril with Afrin. You will doubtless swallow a large amount of Afrin and blood. While not ideal, this should cause no harm. At this point, you should lean your head forward and pinch your nose shut again for another 10-20 minutes. Should this fail, you may repeat it once.

iv. Rest
Assuming that you have succeeded in stopping the nosebleed, it is important not to restart it by engaging in any vigorous activity (ie—physical exercise).

v. What doesn’t work
Ice packs on the back of the neck, across the bridge of the nose, etc

b. When to call us
If you try the “Afrin protocol” as listed above and it fails, you need to contact us. If we are open, dial our main number and press “0” for the Operator. If it is after hours, press the button to be connected with the Answering Service. Tell them what is happening and our doctor on call will contact you shortly with instructions. If, for some reason we are unable to answer, please proceed to Medical Center of Arlington Emergency Room