Bleeding from Nose (Epistaxis) – Acute, Sudden and Chronic (Persistent)

What is epistaxis?

A nose bleed (nosebleed) is the presence of blood exiting from the nose on its own or in nasal mucus secretions. The medical term for bleeding from the nose is epistaxis. 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.

The most common causes of a bloody nose are trauma, usually due to nose picking or nose blowing due to a runny nose and sneezing, and it also occurs as a result of dry, cold weather. Frequent nosebleeds however, are less common and if it is recurring, it is important to investigate for a number of conditions that may case a chronic bloody nose. It is important to identify whether the bleeding is persistent and continues despite one’s effort to stop the bleed.

Location of Nose Bleed

The nasal mucosa is a thin delicate membrane that lines the nasal cavity. A vast network of underlying blood vessels are prone to rupture and is the source of most nosebleeds. Rarely, the bleeding may stem from a neighboring site and drain through the nose.

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.

Causes of Acute Nosebleeds

• 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).

Causes of a Chronic Bloody Nose

The more common causes of a recurring nosebleed that needs to be excluded is :

• Compulsive nose picking (rhinotillexomania)
• Dry cold weather – adaptation to the environment will eventually result in a cessation of bleeding.
• Rhinitis – usually allergic rhinitis (perennial more than seasonal).

Other causes of a chronic nosebleed are less common :

• Chronic or recurring infections of the nose, nasal cavity and sinuses. Predisposing causes like immune deficiency needs to be considered if the condition is unresponsive to treatment. Other infections may include scarlet fever, typhoid fever, malaria and rheumatic fever
• Foreign bodies lodged in the nasal cavity will usually result in a one-sided obstruction (one blocked nostril), tenderness, offensive discharge and diminished sense of smell (hyposmia). This is more likely to be seen in children.
• Tumors of the nasopharynx or paranasal sinuses may be the source of the bleed. This includes both benign tumors, including nasal polyps, and malignant tumors.
• Bleeding disorders that affect coagulation (clotting). This may also be a result of using anticoagulants (‘blood thinners’) like warfarin. Other blood disorders that may cause a chronic nosebleed includes leukemia, aplastic anemia, polycythemia vera and thrombocytopenia although a bloody nose is an uncommon symptom.
• Excessive use of inhalants (nasal sprays).
• Perforated septum – cocaine sniffing or the inhalation of abrasive dusts in the work environment needs to be considered in persistent cases.
• Hypertension
• Arteriosclerosis
• Telangiectasias – Rendu-Osler-Weber syndrome.
• Systemic disorders – AIDS, sarcoidosis, systemic lupus erythematosus (SLE).

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.

• Aplastic anemia
• Leukemia
• Thrombocytopenia
• Liver disease
• Scarlet fever
• Typhoid fever
• Malaria

References

1. Nosebleeds. Merck
2. Frequent Nosebleeds. Mayo Clinic

Last updated on 8 August 2018.