Why Does Nosebleed Occur? How to Stop It, What Helps?

Epistaxis, or nosebleed, is a condition frequently encountered in emergency healthcare. This medical issue is generally divided into two main types: anterior, which usually originates from the Kiesselbach plexus, and posterior, which is rarer but requires more serious intervention. Anterior nosebleeds account for the majority of cases and can often be controlled with simple measures. On the other hand, posterior nosebleeds arise from deeper vessels and may require urgent medical intervention. In both cases, proper management is crucial for stopping the bleeding and preventing more serious complications.

Medical Examination of Nosebleeds

Nosebleeds begin with damage to the nasal mucosa, with the Kiesselbach plexus being the most common bleeding point. This area is located at the front of the nasal septum, where several blood vessels intersect. Anterior nosebleeds are generally less serious and can be easily treated. However, posterior nosebleeds, though rare, can require more serious interventions and are more common in certain health conditions.

The nasal septum is the primary center of nosebleeds and contains five main arteries:

• Anterior ethmoidal artery
• Posterior ethmoidal artery
• Sphenopalatine artery
• Greater palatine artery
• Superior labial artery

These arteries form the Kiesselbach plexus and supply the nasal mucosa. The anterior nasal septum is highly exposed to external factors and is easily damaged. This makes it a region that quickly reacts to environmental changes or physical trauma, leading to frequent nosebleeds.

Anterior nosebleeds can typically be controlled with simple first aid measures at home. In contrast, posterior nosebleeds, which affect deeper and larger vessels, usually require professional medical intervention. Individuals taking anticoagulant medication, those with high blood pressure, or those with blood disorders are more prone to these types of bleeds.

The management of both types of bleeding depends on their severity and any accompanying medical conditions. Therefore, individuals experiencing a nosebleed should seek prompt and effective intervention from a healthcare facility. Appropriate intervention methods ensure the bleeding is stopped and potential complications are prevented.

Causes of Nosebleeds

Nosebleeds can be caused by various local, systemic, environmental, and medication-related factors. The most common local causes include physical interventions on the nose and anatomical abnormalities. Particularly, deviations or traumas in the nasal structure can trigger bleeding. Chronic use of nasal cannulas also falls under local causes.

• Nose picking
• Nasal bone deviation
• Trauma
• Chronic nasal cannula use

Systemic factors are internal factors affecting the body’s general health and causing nosebleeds. Chronic diseases like hypertension can damage blood vessels, making them prone to bleeding. Alcohol use can also dilate blood vessels and increase the risk of bleeding. Clotting disorders can lead to prolonged or frequent nosebleeds.

• Alcoholism
• Hypertension
• Vascular malformations
• Clotting disorders (von Willebrand disease, hemophilia)

Environmental factors, especially the effects of weather conditions on the nasal mucosa, are significant. Dry air during winter can dry out and crack the mucosa, making it more prone to bleeding. Allergies similarly cause mucosal irritation, leading to bleeding.

• Allergies
• Environmental dryness (more common in winter)

Medication-related causes particularly involve drugs affecting blood clotting mechanisms and certain supplements. Anti-inflammatory drugs, anticoagulants, and platelet aggregation inhibitors increase the risk of bleeding. Additionally, illegal drugs like cocaine can damage the nasal mucosa, leading to bleeding.

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Anticoagulants
• Platelet aggregation inhibitors
• Topical nasal steroid sprays
• Supplements or alternative medications (Vitamin E, ginkgo, ginseng)
• Illegal drugs (cocaine)

This variety necessitates a careful assessment in diagnosing and treating nosebleeds. Especially in recurrent or uncontrollable cases, a more detailed examination and intervention are required.

Prevalence and Risk Groups of Nosebleeds

Nosebleeds, though rarely resulting in fatal outcomes, are quite a common health issue. Only a small fraction of deaths occur due to nosebleeds. Statistics show that about 60% of people have experienced a nosebleed at least once in their lifetime. However, only 10% of these cases require serious medical intervention. Nosebleeds are more common in certain age groups:

• Children aged 2 to 10 years
• Adults aged 50 to 80 years

These two groups carry the highest risk for nosebleed cases. In children, they are more often due to physical activity and falls, while in older adults, factors such as weakened blood vessels and medication use play a role. These demographic data are crucial in identifying which segments of the population require more attention and protection.

The Onset and Process of Nosebleeds

Nosebleeds begin with the rupture of a blood vessel in the mucosa. This rupture can occur for various reasons. Typically, direct causes such as trauma or increased nasal dryness come to the forefront. Additionally, the use of blood-thinning medications like anticoagulants or high blood pressure can increase the severity and duration of the bleeding. Nosebleeds are divided into two main categories:

Anterior nosebleeds:

• Mostly occur in the Kiesselbach plexus.
• This area is easily accessible and treatable.
• Usually stoppable with simple measures at home.

Posterior nosebleeds:

• Less common but require more serious intervention.
• Originate from the Woodruff plexus.
• Involve bleeding from terminal branches of the sphenopalatine and posterior ethmoidal arteries.
• These bleeds are often difficult to control.

In anterior nosebleeds, blood usually flows out of the nostrils. However, in posterior nosebleeds, blood can flow both from the nostrils and into the nasopharynx. This can cause the blood to be swallowed or coughed up. Sometimes, it may present as hemoptysis.

Timely and correct intervention is crucial for both types of nosebleeds. The first intervention for a nosebleed typically involves gently pinching the nostrils and leaning the head forward. This prevents blood from flowing backward and helps stop the bleeding more quickly.

Different treatment methods are applied depending on the source of the bleeding. Anterior bleeds are usually controlled with simple tampon or cold application, while posterior bleeds may require medical intervention. Posterior bleeds can pose serious threats to the airway.

Diagnosis and Evaluation Methods of Nosebleeds

Managing nosebleed cases begins with a detailed patient history. Information such as the duration, severity, and frequency of the bleeding should be obtained. Additionally, which nostril the bleeding comes from and whether there are any triggering factors should be investigated. It is also important to know if the patient has had similar experiences before and what treatments were applied.

Medications used:

• Anticoagulants
• NSAIDs
• Topical nasal steroids

Family history:

• Coagulopathy
• Vascular or collagen diseases

Personal habits:

• Drug use
• Alcohol consumption

All necessary equipment must be prepared before the physical examination. This includes a nasal speculum, bayonet forceps, and a headlamp. Other required materials for an effective examination include:

Examination tools:

• Aspirator device
• Tampons
• Silver nitrate sticks
• Cotton tampons
• Topical vasoconstrictor and anesthetic

During the examination, the patient is seated in an examination chair in a room equipped with an aspir

ator. The nasal speculum is used to carefully open the nostrils and observe the bleeding site. If the bleeding source in the anterior region cannot be easily identified, aspiration is performed to clear the nasal cavity of clots, making it easier to identify the bleeding source.

Posterior nosebleeds are generally harder to detect due to the absence of a visible bleeding vessel. When active bleeding progresses to the posterior pharynx, more advanced examinations like nasal endoscopy are used. Nasal endoscopy is highly successful in identifying the bleeding source and provides critical information for appropriate intervention.

Diagnosis Methods for Nosebleeds

Accurate diagnosis of nosebleeds is essential for developing an effective treatment plan. Nosebleeds are examined as either anterior or posterior. Anterior nosebleeds are diagnosed by direct examination of the nasal septum using a nasal speculum and a light source. This method allows for a clear view of the bleeding source. These types of bleeds are typically controlled using topical sprays containing local anesthetics and epinephrine. These sprays constrict blood vessels, reducing the bleeding.

Diagnostic Tools:

• Nasal speculum
• Light source

Posterior bleeding is more challenging and is generally assessed when anterior measures are insufficient. This type of bleeding originates from deeper vessels in the nasopharynx and usually requires more serious intervention. Continuous bleeding from both nostrils is a sign of posterior bleeding. In this case, it may be necessary to check the patient’s blood values.

Laboratory Tests:

• Complete blood count
• Blood type and cross-matching
• Coagulation tests

These tests are important for evaluating the patient’s overall health and determining the appropriate treatment strategy. However, it is important to remember that intervention should not be delayed while waiting for test results in ongoing bleeding. Advanced diagnostic methods like imaging techniques are typically not recommended in urgent bleeding situations.

Treatment and Management Methods for Nosebleeds

In nosebleed cases, the first step is to ensure the airway is clear. The patient is then assessed hemodynamically, and appropriate interventions are planned based on the severity of the bleeding. Initial intervention usually involves direct pressure. Continuous pressure is applied to the cartilaginous part of the nose to control the bleeding. If this method is insufficient, various medications and products are used:

• Vasoconstrictors like oxymetazoline
• Thrombogenic foams or gels

During treatment, the clots in the nose are carefully removed first. Clearing the clots increases the effectiveness of medications and opens the area for subsequent treatment steps. If topical treatments are ineffective, identifying the vessel in the nose and cauterizing it with silver nitrate may be necessary. This procedure directly seals the bleeding source, providing an effective solution.

If the bleeding cannot be stopped, more advanced treatment methods are considered. Methods used for anterior nosebleeds include:

• Anterior epistaxis balloons or nasal tampons

These treatments mechanically stop the bleeding. When using silver nitrate, it is recommended to apply it only on one side of the septum to prevent septal perforation.

If the bleeding originates from deeper regions, posterior bleeding is evaluated. Some methods used in this case include:

• Long nasal tampons
• Foley catheters

Posterior application procedures require more experience and attention. This treatment method is considered a last resort in high-risk situations. The patient’s condition is closely monitored at this stage, and if necessary, intubation is performed to protect the airway.

If all these interventions are unsuccessful and the bleeding cannot be stopped, interventional radiology methods are considered the last option. These methods directly target the affected vessels to control the bleeding. In cases where interventional radiology services are not available, a head and neck surgeon may perform surgical ligation of the vessels. These methods can be life-saving in particularly challenging cases.

Additional Factors to Consider in Epistaxis

Nosebleeds can be associated with various health problems. One common condition is the presence of benign or malignant tumors inside the nose. These tumors can increase the risk of bleeding and require careful assessment. Additionally, bleeding disorders also play a role in epistaxis cases. These conditions include:

• Hemophilia
• Von Willebrand disease
• Disseminated intravascular coagulation (DIC)

Moreover, inflammatory diseases like rhinitis can also cause nosebleeds. Rhinitis is an inflammation of the nasal mucosa, making blood vessels more fragile. Foreign objects in the nose, which are common in children, can also trigger bleeding. Lastly, some medications increase the risk of bleeding, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) with blood-thinning effects. Each condition requires different approaches in the management and treatment of epistaxis.

Post-Surgery and Rehabilitation Process

It is important to continuously monitor the patient’s health status after treating a nosebleed. This process includes both physical recovery and the prevention of potential complications. The following measures should be taken during the post-surgery period:

• A follow-up appointment with an ENT specialist should be scheduled within the first week. This is crucial for evaluating the patient’s current condition and planning additional treatments if necessary.
• If nasal tampons are placed, they should not be touched for three to five days. The removal of the tampons should be performed by a healthcare professional.

To support the healing process, the patient should follow these steps:

• An antistaphylococcal antibiotic treatment should be started to reduce the risk of toxic shock syndrome.
• The following measures should be taken to manage underlying causes:
  • Tight blood pressure control should be maintained. The target systolic blood pressure should be kept below 120 mm Hg.
  • Any coagulopathy, if present, should be managed.
• Topical nasal saline should be used to keep the tampons moist and facilitate their removal. This can be applied to both nostrils and should be done regularly.

These measures make the patient’s post-surgery process more comfortable and safer while minimizing the risk of complications.