Epistaxis – Causes of Nose Bleed, Bloody Mucus & Bleeding

A nose bleed (nosebleed) is the presence of blood exiting from the nose on its own or in nasal mucus secretions. Often referred to as a ‘bloody nose’, nose bleeds can vary from a few spots of blood when wiping the nose, profuse bleeding through the nasal passages or sneezing blood stained mucus.

A bleeding nose is often a cause for concern as the sight of blood can be quite disturbing especially when it occurs for no known reasons. A bloody nose is usually associated with sudden trauma to the nose and face, as in banging the nose on to an object or assault to the face, but nose bleeds may occur as a secondary symptom of other underlying conditions.

Fresh blood, bright red and ‘watery’ blood is usually a sign of immediate or current bleeding within the nasal passages or upper respiratory tract. Darker blood, appearing thicker or ‘solid’ as clots is indicative of an earlier bleed or clot lodged within the nasal passage or respiratory tract that may be dislodged when coughing, sneezing or attempting to blow the nose forcefully.

Most nosebleeds originate from the anteroinferior (lower front) area of the nasal septum, the cartilage dividing the nostrils. This area (also called the Kiesselbach’s area)¬† is rich in blood vessels (a network of vessels called the Kiesselbach’s network) and is prone to injury and irritation, especially from damage by the finger nails (‘nose picking’).

In cases of infections, excessive mucus production or nasal congestion either by swelling of the nasal lining or blockage due to mucus, the nasal lining may rupture resulting in bloody mucus. Bloody mucus should be differentiated from bleeding from the nose and is a common occurrence in many upper respiratory tract infections where excessive mucus production is one of the symptoms.

Nosebleed Causes

  • Physical injury often caused by fingernails (picking the nose) and trauma to the nose (banging into an object, being punched in the nose) is a common cause for nose bleeds that occur almost immediately after the injury.
  • Dry air or any factor that may cause drying of the nasal mucus membranes may result in a bleeding nose.
  • Nasal and upper respiratory infections (like the common cold or ‘flu’) are also a common cause of nose bleeds and bloody mucus. The most common local infections that may cause a bleeding nose include :
  1. Nasal vestibulitis is an infection of the nose vestibule (the front area of the nose around the nose tip) and is often seen as bleeding crusts inside the nose or on the entrance of the nose. Most of these infections are not severe (low grade) and vestibulitis may also be associated with folliculitis and small boils (furuncles) of the area. A red, swelling of the nose (tip or nostrils) may be noticed in vestibulitis.
  2. Rhinitis is a common acute upper respiratory tract infection and symptoms include profuse nasal discharge (‘runny nose’) and nasal congestion. In rhinitis, the mucus membranes may swell (edema) and the tiny blood vessels of this lining dilates (opens wider). This makes the nasal lining prone to bleeding. Rhinitis may be chronic especially in allergic rhinitis (hay fever) and other causes of swelling of the nasal lining.
  3. Sinusitis where the sinuses of the face (particularly the paranasal sinuses) become inflamed due to an infection. Symptoms of sinusitis include nasal congestion with yellow to green mucus, pain and tenderness around the areas of the sinuses and cause a headache. In cases of a severe infection, a fever may also be present as well as visual disturbances (sore eyes or red eyes with a poking pain).

Other less common causes of nose bleeds  but may be the cause of chronic or recurring nose bleeds. These causes require further investigation and medical treatment and should not be passed off as an acute (short term) nosebleed.

  • Hypertension
  • Side effects of medication – warfarin, aspirin and other anticoagulants (blood thinners)
  • Inhalants – drug usage (cocaine ‘sniffing’) to excessive use of nasal sprays
  • Aplastic anemia
  • Leukemia
  • Thrombocytopenia
  • Liver disease
  • Scarlet fever
  • Typhoid fever
  • Malaria
  • Liver disease
  • Hereditary bleeding disorders like hemophilia
  • Telangiectasias

References

1. Nosebleeds. Merck

2. Frequent Nosebleeds. Mayoclinic