Causes of frequent nosebleeds and what to do about them

21-year-son has frequent nosebleeds (Straits Times health column)

Q: Recently, my 12-year -old son has been having more nosebleeds. Previously, his nose would bleed about once a week but, recently, the bleeding has become almost a daily occurrence.

One morning, he woke me up at 4 am to tell me that his nose was bleeding again.

The bleeding stopped after I applied slight pressure on his nose.

How can I reduce the frequency of his nosebleeds and do I need to take him to see an ear, nose and throat specialist?

A: The most likely cause of your son’s nosebleed is trauma to delicate blood vessels on the midline nasal bone near the nostrils.

Trauma caused by nose picking or stuffing tissue up the nose – to reduce the nose itch or to clear nasal discharge – is common in a child with allergic rhinitis.

The risk of nosebleeds is also increased if the midline nasal bone is deviated.

Rarer but more sinister causes of frequent nosebleeds include blood disorders or nasal tumours.

Applying pressure with the fingers on both sides of the lower nose for five to 10 minutes usually stops the bleeding. Your child should sit up and breathe through his mouth while this is being done.

A consultation with an ear, nose and throat specialist is recommended.

The specialist can identify any offending inhalant allergens through a skin prick test, to see if your child has allergic rhinistis.

He can also check for tumours and sinusitis (infection of hollow cavities in the nose) through nasoendoscopy, which is done using a small flexible tube with a camera.

Finally, the doctor can order blood tests to see if there is a blood disorder.

If the bleeds are due to allergic rhinitis, your child’s condition will improve if he avoids nose picking and the identiifed allergens. He can also find some relief by taking allergy medication and using an antibiotic or lubricant ointment for the nose.

ASSOCIATE PROFESSOR Lynne Lim, a senior consultant at the department of otolaryngology – head and neck surgery at National University Hospital

Here’s the advice on what to do from kidshealth.org during nosebleeds:

Stopping the Gush

Try these simple tips to stop your nosebleed:

• Get some tissues or a damp cloth to catch the blood.
• Sit or stand so your head is above your heart.
• Tilt your head forward and pinch the soft part of your nose (the nostrils) together just below the bony center part of your nose. Applying pressure helps stop the blood flow and the nosebleed will usually stop with 10 minutes of steady pressure — don’t keep checking to see if the bleeding has stopped.

If you get a nosebleed, don’t blow your nose. Doing so can cause additional nosebleeds. Also, don’t tilt your head back. This common practice will cause blood to run into your throat. This can make you cough or choke, and if you swallow a lot of blood, you might begin vomiting.

If you’ve tried the steps above twice and the bleeding continues after the second attempt, you’ll need to see your school nurse or a doctor.

Once you’ve stopped the initial nosebleed, don’t lift heavy objects or do other activities that cause you to strain, and try not to blow your nose for 24 hours.

Now that your nosebleed is over, let’s take a look at what a nosebleed is and what can cause it.

:::

Even mild nosebleeds nothing to sniff at

The Yomiuri Shimbun, Sep 24, 2016

A 14-year-old boy in Saitama Prefecture had been suffering from nosebleeds since January. Blood suddenly dripped from his left nostril when he was sleeping or practicing with the school’s tennis club.

The nosebleeds sometimes occurred twice a day. Even though he cooled down his nose, pinched between his eyebrows or stuffed his nose with tissues, the nosebleeds continued for more than 15 minutes. His mother waited to see how things would go, but gradually began to fear her son was suffering from a serious disease.

The boy had his blood tested at a family pediatric clinic in spring and learned that he had allergies. The pediatrician explained that, due to itchiness, the boy unconsciously picked his nose, damaging the mucous membrane and causing it to bleed.

He tried oral medicine and nasal drops that were meant to relieve the itching, but they failed to work. He then was examined at an ear, nose and throat clinic where a tool was used to spread his nostrils so the doctor could examine them in detail. Scratches were found inside his left nostril and the boy was told of an appropriate way to stop the bleeding at home.

Applying pressure is the main method to stop bleeding. Pinch both sides of the nose with the thumb and index finger for five to 15 minutes. Young children need only pinch the nostril that is bleeding since they often have difficulty breathing. Sufferers need to sit down and keep their heads lowered so they do not swallow blood.

Although the Saitama boy treated his nosebleeds for about a week with the method he learned from the doctor, the bleeding continued. After another examination, the inside of his nose was anesthetized, and the damaged membrane was cauterized with a high frequency current. The treatment took only a few minutes.

Since then, the nosebleeds have stopped.

“It must had been very stressful for my son. I should have taken him to an ear, nose and throat specialist earlier,” the boy’s mother said.

Most nosebleeds that children experience come from the front of the nose rather than the rear. Children often damage the mucous membrane by rubbing it with their fingers. Depending on the severity of the damage, the problem may be harder to cure and nosebleeds could start every time the damaged membrane comes into contact with air or whenever elevated body temperature stimulates blood flow. There are also seasonal influences, and nosebleeds are more likely in winter when the air becomes dry.

However, in rare cases, tumors or blood diseases that more commonly occur in puberty may be the cause. It is important to have a specialist examine the nostrils and determine the bleeding area in order to identify the cause.

“For children, if the nosebleed is from the front of the nose, it will stop in about five minutes if you take care of it properly at home,” said Manabu Komori from the otorhinolaryngology department at the National Center for Child Health and Development in Setagaya Ward, Tokyo. “If nosebleeds occur several times a week, consult a specialist.”

Deep nasal bleeding

In mid-April, a 59-year-old company employee in Hiroshima woke up at dawn and felt something flowing from his right nostril. When he turned on the light, he saw that his pajamas and bedding were dyed red.

Holding a bucket his wife brought to him, the man was taken by ambulance to Hiroshima University Hospital.

Since blood also had come from his mouth through the back of his throat and the bleeding did not stop, the doctor diagnosed it as not being from the area at the front of the nostrils known as Kiesselbach’s plexus, but rather that either his sphenopalatine artery, a thick blood vessel at the back of the nose, or a branched blood vessel also to the rear of the nose had broken.

There are several ways to stop deep nasal bleeding. An otolaryngologist can insert an endoscope through the nostrils and cauterize the sphenopalatine artery with a laser or pinch it with a clip.

Another option is endovascular treatment, which radiologists and other experts perform inside the blood vessel, using medical imaging. They insert a fine tube into a blood vessel in the thigh, guide it up to the sphenopalatine artery and then close the artery with a spongy gelatin. Since the procedure is performed while the body is being X-rayed, the patient will be exposed to radiation. However, an experienced doctor can perform the procedure quickly and it is less of a burden on patients.

The hospital offers both treatments. The man consulted with an otolaryngologist and received endovascular treatment. The broken blood vessel was confirmed through imaging and repaired. The bleeding stopped and he was released after three days. Within a week he had returned to work. The amount of blood he lost was estimated to be slightly less than a liter.

“I never thought I would have such a terrible experience from a nosebleed,” he said.

It is difficult to stop deep nasal bleeding since it originates from thick blood vessels. It becomes even more difficult when patients have high blood pressure, a liver disease that prevents the coagulation of blood, or are on medication that thins the blood. The Hiroshima man had neither a chronic disease nor was he on medication.

The number of patients who have emergency examinations for nosebleeds peaks in the 50-70 age bracket for both men and women.

“Blood vessels become more brittle as one ages,” said Sachio Takeno, an associate professor of the otorhinolaryngology department at Hiroshima University. “The patient as well as people around them are surprised at the profusion and intensity of the bleeding. To make sure they don’t panic, I advise them to remember that medical institutions offer various approaches to stop bleeding.”

Medication side effects

Side effects from medication may cause frequent nosebleeds that are difficult to stop. Anti-thrombotic drugs, which make it harder for blood to coagulate, are a typical cause.

From the autumn of 2015, a 73-year-old Tokyo woman suffered nosebleeds from her right nostril.

Even though they stopped for a while, the nosebleeds started again after a few days. Since suffering a stroke in 2010 she had been taking an anti-thrombotic drug to prevent a relapse. As she was advised that the medication would make it hard to stop the nosebleeds, she stopped using it for a while to see how things went.

One day, the woman had a nosebleed while at her part-time cleaning job. As it did not stop for quite a while, she left work early. Thinking that it would cause trouble for her coworkers if the nosebleeds continued, she had an examination at the neighboring Togoshi Ear, Nose and Throat Clinic in Shinagawa Ward, Tokyo, in December 2015.

The clinic director, Takeshi Kobayashi, spotted a small scratch at the front of her right nostril. As soon as he gently touched it with a cotton swab, it started bleeding. Considering the influence of the medication and her condition, the doctor believed the bleeding was highly likely to occur again, so he used a high frequency current to cauterize the area.

Since then, the bleeding has stopped. The woman was overcome with joy, saying, “I didn’t have to quit my part-time job, which I started for health reasons after I suffered the stroke.”

Over the past two years, a little over 30 percent of patients with nosebleeds at this clinic — who received hemostatic treatment like the 73-year-old woman or were referred to other hospitals because the bleeding would not stop — were taking anti-thrombotic drugs.

“The number of people who take anti-thrombotic drugs has increased due to the aging of society, and I now often see cases of nosebleeds that are difficult to stop,” Kobayashi said.

Hidehiro Takekawa, secretary of The Japan Stroke Association and an associate professor in the Department of Neurology at Dokkyo Medical University in Mibu, Tochigi Prefecture, warns, “Do not stop taking medication at your own discretion, even if you start bleeding.”

Even if patients stop the bleeding by not taking their medication, they are at higher risk of strokes or heart attacks.

When people suffer a nosebleed, even mild bleeding, it is important to visit a doctor. There are cases in which symptoms subside by switching to a different medication

 

Further reading

Radiation in Japan: Chronic Nosebleeds, Diarrhea, Lack of Energy in Children in Koriyama City, Fukushima | Japanese newspaper Tokyo Shinbun (paper edition only, 6/16/2011)  article posted here | Fukushima radiation alarms doctors (.aljazeera.net 18 Aug 2011)

What are the causes of frequent nosebleeds?

Nosebleeds and radiation poisoning: Radiation exposure and contamination (muscosal bleeding as a symptom, The Merck Manual) | Nuclear Radiation and its Biological Effects: Cell Damage  | Effects of Hiroshima & Nagasaki bombing (Hiroshima Day Committee)