Our noses are one of our most distinctive features and their shape and anatomy can vary widely among individuals. Their main function beside smelling -which is very weak in humans compared to animals- is respiration. The only excuse for not breathing through your nose while healthy is if you are snorkeling. While standing, our noses are the most anterior part of the male human body and the second most in females following their breasts. This makes the nose one of the commonest sites of trauma. It doesn’t matter if it was into a super clean glass door, during a fight or into a telephone pole while texting, chances are you have hit your nose hard at least once or twice.
Understanding nasal anatomy
The nose is accommodated to serve its function best by supplying the body with clean, warm and humid oxygen all day long. The nose is formed of a cartilaginous part in front and a bony part at the back and is formed of two nostrils separated by a septum. On both sides of the nose, there are three wide shelves of bones called turbinates covered by a mucous layer to help keep dry air humid while the septum is supplied by a rich network of blood capillaries to help keep the air warm. This rich blood supply of the septum forms a network of vessels called Kiesselbach’s plexus and this is the main site of bleeding per nose. The combination of a thin layer of tissue covering these capillaries and the repeated trauma that the nose is exposed to makes the nose one of the commonest sites of bleeding in the human body.
Bleeding from Kiesselbach’s plexus is called anterior bleeding which forms more than 90% of nasal bleeds while about 10% occur further behind in the nose from greater arteries and branches of the sphenopalatine artery. Bleeding from this site is usually more dangerous and profuse.
» Now, let’s discuss the causes of nosebleed.
What causes our noses to bleed?
To better understand the causes of nasal bleeds, we have to understand that under normal conditions, arteries and veins of the body have an intact wall with a competent coagulation system that even if injury occurs to a blood vessel, coagulation will occur quickly enough to prevent any serious loss of blood. Therefore, causes of nasal bleeds include:
1) Trauma
Trauma is by far the most common cause of nasal bleeding, be it a punch during a fight, walking into a telephone pole or even vigorous nose picking. Here, the most common site of injury is the nasal septum or the nasal bridge. Unless the trauma is severe like in road traffic accidents, no serious blood loss occurs and bleeding stops within minutes. If the trauma was enough to break the nasal bone, then more serious bleeding can occur especially posterior bleeding.
2) Foreign bodies
This is most commonly seen in children, but even adults can do strange things such as sticking small objects in their noses. If the foreign body gets back enough, then it hides within the turbinates and cannot be retrieved by the individual. The foreign body irritates the mucous covering in a chronic fashion and bleeding occurs in episodes. Infection can also occur on top of it causing bleeding.
3) Certain drugs
Many anti allergic drugs stop sneezing and nasal blockage by decreasing nasal glands secretions. This helps alleviate symptoms, but these secretions also keep the nose humid and the mucus lining healthy. Excessive nasal dryness can occur with local steroids and antihistamines. Steroids have a more pronounced effect since they directly decrease mucosal healing. Cocaine inhalation can also cause a more severe effect since cocaine is a severe vasoconstrictor. It can be potent enough to cut all blood supply to the nasal septum causing gangrene and nasal septal perforation.
4) Severe hypertension
Blood pressure inside vessels can cause them to rupture if high enough. This is especially seen in chronic hypertensive patients whose blood vessels become stiff from atherosclerosis that they can’t withstand the increased pressure. In this case, bleeding is profuse, and the patient is at a high risk of intracranial bleeding (bleeding into their brain) and aggressive measures to lower blood pressure are needed. In this case, bleeding from the posterior blood vessels is more common making blood aspiration and airway compromise life-threatening.
5) Platelet deficiency
Blood platelets are cellular fragments which plug any defect in blood vessels after injury. Platelet deficiency can occur from a variety of causes including bone marrow suppression, viral infections, cancers or autoimmune diseases. The hallmark of platelet deficiency is bleeding from mucous surfaces like the gums, nose and vagina.
6) Coagulopathy
Coagulation factors deficiencies rarely cause spontaneous bleeding, but they can cause bleeding from minor trauma and can make a bleeding go on for a longer period. Such deficiencies can be genetic like hemophilia or acquired like in liver diseases or due to some drugs like heparin and warfarin.
7) Nasal septum deviation
Nasal septum deviation is common, and its degree differs among individuals, but a significant septum deviation causes more than just cosmetic problems. The airflow pattern will cause air to not flow through one nostril causing its mucus lining to dry, crust and eventually bleed.
8) Upper respiratory tract infections
This is also commonly seen in children. Infections as mild as common cold can cause bleeding per nose owing to the thin, fragile walls of blood vessels in this age group.
9) Dry nose
Living in areas where the air is excessively dry like air conditioned offices can cause the humid nasal lining to become dry and irritated causing it to bleed easily.
What to do when you have a nosebleed?
Nosebleeds are a daily occurrence and chances are you will experience the situation either by yourself or to someone you see. There are simple instructions to follow and warning signs to look for.
- Sit down: If you noticed the bleeding while standing up, it is a good idea to sit down. Some people can be frightened by the sight of blood which can trigger a vasovagal attack and cause fainting which can in turn cause more injury.
- Ask for help: Ask the closest person to you for help in case you can’t control your bleeding, extra hands are always a good idea.
- Do not tilt your head back: This is a common misconception that this method will stop the bleeding, rather it will allow blood to flow in another direction causing you to swallow or aspirate it. Swallowed blood can irritate the stomach causing vomiting and aspirated blood can cause severe respiratory distress. Lean your head slightly forwards to make sure that all blood flows outwards.
- Apply compression: The first thing is to pinch your nostrils. This will compress the blood vessels of Kiesselbach’s plexus and decrease blood flow. The blood will then coagulate faster and the bleeding will stop.
- Apply cold compresses or ice: If you can reach for a cold pack then applying it over the nose can be a good idea. Cold causes blood vessels to constrict, decreasing blood flow.
- Use vasoactive nasal drops: Some nasal drops like Sudafed (Pseudoephedrine) which are normally used as decongestants can help constrict blood vessels. You can apply them directly or better still, apply them on a piece of cotton and place it in your nose. Do not use a small piece or push it too deep.
- Seek medical care: If the bleeding doesn’t stop or if you feel that you are light-headed, call the emergency services in your country or visit the nearest ER.
When to worry about nosebleeds?
Nosebleeds are a benign condition that is usually self-limited and needs no medical care, but in some cases, it can be a sign of an underlying disease that requires medical care. These signs should alert you that your bleeding nose isn’t simply a bleeding nose:
- Your bleeding doesn’t stop: In minor trauma, bleeding should stop within a few minutes, if it doesn’t or if you feel like the blood is moving down your throat in excessive amounts, this may be a danger sign and medical care is needed.
- If you feel like your nose is broken: If you sustained a severe trauma and feel like your nose is misaligned, your nasal bone may be broken, and you should visit an ER.
- If there are other sites of bleeding: If your nasal bleeds occur with bleeding per gums, easy bruising, bloody urine or vaginal secretions, this could point towards a coagulation problem and investigations need to be done.
- If you are have chronic hypertension: Despite the popular misconception that severe hypertension presents with headache, hypertension is actually almost always asymptomatic and a bleeding nose in a chronic hypertensive especially if the patient is above 60 is an enough reason to visit a hospital.
- You are on an anticoagulant medication: Some medications like warfarin used in patients who underwent heart replacement surgery or those with recurrent deep venous thrombosis alter the blood’s ability to coagulate, and therefore any excessive nosebleed in such patients may necessitate a visit to the ER.
- You cough blood or feel choked: If bleeding occurs in the posterior part of the nasal septum, it tends to be severe and to move down the throat. This can cause severe choking and aspiration which is life-threatening and emergency control of bleeding is needed.