Nose Bleeds – Epistaxis

Connecticut Pediatric Otolaryngology

 

Nose bleeds are very common, occurring in up to 60% of the general population.  In most situations, nose bleeds are simply a nuisance.  However, they can be frightening if the bleeding is difficult to control or if they occur frequently.  They tend to occur more frequently in younger children (<10 year olds) and older adults (>50 year olds).

 

Nosebleeds are classified into two different types based on the location of bleeding: 

anterior nosebleeds or posterior nosebleeds. 

 

Anterior Nosebleeds: This type of nosebleed comes from the front of the nose and begins with a flow of blood out one nostril.   The most common site of bleeding is from superficial (on the surface) blood vessels on the lower part of the septum (semi-rigid wall that separates the two nostrils of the nose).   This area of the nose (often referred to as Kiesselbach’s plexus or Little’s area) contains many blood vessels that can easily be broken with nose blowing or local trauma (ie. fingernails, rubbing hand). Anterior nosebleeds are very common in dry climates or dry environments (heated or air conditioned, dry indoor air dehydrates the nasal membranes).  Dryness may result in crusting, cracking, and bleeding of the nasal septum.

Posterior Nosebleeds:  Although uncommon in children, posterior nosebleeds (back of nasal cavity) are the more dangerous and difficult to control and will usually require medical care.  They occur more commonly in older adults, individuals with high blood pressure, and in some cases of facial or nasal trauma.

The bleeding site is often related to vessels high and deep within the nose.  Bleeding in this location can be controlled with posterior packing or endoscopic vessel ligation.

 

Figure 1

 

 

Nosebleeds can occur for various reasons.

  1. Exposure to dry climates or environments (dry heat/air conditioning).
  2. Allergies, infections, or dryness that cause itching and local trauma.
  3. Nose picking or other local trauma.
  4. Vigorous nose blowing that ruptures superficial blood vessels.
  5. Bleeding or clotting disorders.
  6. Some medications may predispose an individual to increased bleeding.
  7. Fractures of the nose or of the base of the skull (should be regarded seriously when the bleeding follows a head injury).
  8. Oxygen administration via nasal prongs.
  9. Rarely, tumors (both malignant and nonmalignant) may be considered.

Treatment and Prevention (Anterior Nosebleeds)

  1. Lubrication is key.  The nose can be lubricated by placing a small dollop of lubricating cream or ointment (Vaseline, bacitracin, Eucerin, A and D ointment all work well) to the front middle portion of the nose (septum).                                                             Frequency of lubrication depends on the child.  If they are experiencing frequent nosebleeds, than it should be done twice daily until they have not had a nose bleed for several days.  Otherwise, lubrication can be used as needed.  Note:  Once an anterior nosebleed has occurred, the area is much more sensitive to rebleeding until the area has completely healed.  As a result a common cycle occurs.  A child may go weeks between nosebleeds -- then the nasal mucosa becomes injured and the child may have 4 or 5 nosebleeds in a row, until that tissue has had a chance to heal.
  2. Ensure hydration.
  3. Avoid trauma to nasal septum.
  4. Use of a humidifier may help.  Ensure appropriate cleaning of the system on a regular basis.
  5. Use of nasal saline (gel or spray) may be beneficial to help to moisten the mucous membranes, especially for children with frequent colds, nasal congestion or allergies.    **** If the nosebleeds persist, you child should be evaluated by an Ear Nose and Throat Specialist. 

To stop an anterior nosebleed:

  1. Stay calm, and help the child to stay calm.
  2. Pinch the soft part of the nose together between your thumb and forefinger.
  3. Apply firm but gentle pressure upward toward the face, and hold for 5 minutes.        "Don't let go at all for a full five minutes--no peeking!"
  4. Ensure the child is sitting or standing with his head above the level of the heart.
  5. Optional— In some situations, applying ice to the nose and cheeks may be helpful, but not if it causes the child more agitation.

To prevent rebleeding once it has stopped:

  1. Avoid nose blowing for a couple of hours.
  2. Avoid heavy lifting or physical activity for a couple of hours.
  3. Lubrication and humidification (see prevention notes).

If rebleeding occurs:

  1. Blow nose in an attempt to clear all blood clots.
  2. Spray nose two times in the bleeding nostril(s) with a decongestant spray such as Afrin (generic name is oxymetazoline).
  3. Pinch the soft part of the nose together between your thumb and forefinger.
  4. Apply firm but gentle pressure upward toward the face, and hold for 5 minutes.        "Don't let go at all for a full five minutes--no peeking!"  
  5. Seek medical attention is if bleeding persists.

 

 

PLEASE CALL 203-245-0496 IF YOU WOULD LIKE US TO EVALUATE YOUR CHILD