Nosebleeds: Main Causes of Nasal Bleeding

Nasal bleeding, or epistaxis, is the flow of blood from the nasal cavity, more often through one nostril. Up to 60% of the population experiences it, but in most cases the cause is harmless. The peak occurs before age 10 and after 50.

Nosebleeds: why blood comes from the nose

The nasal mucosa is rich in small vessels, and they are easily damaged. Air dries out the lining, crusts form, and they bleed when irritated.

The source is almost always the same: in 90–95% of patients, bleeding comes from the anterior-inferior part of the septum, Kiesselbach's plexus. The remaining 5–10% involve the middle and posterior sections; such bleeding is harder to stop and occurs more often in adults.

In severe cases, blood rises through the nasolacrimal duct and exits through the orbit, while some flows into the stomach, causing nausea and vomiting. Fatal epistaxis is extremely rare: in the US in 1999, there were four cases out of 2.4 million deaths. Yet the scale is deceptive — like microphone overload: the source is tiny, but it can be heard throughout the hall.

Local causes: mucosa, trauma, dry air

• nasal trauma, including fracture, and foreign bodies, including the habit of nose-picking;
• inflammation: acute respiratory viral infections, chronic sinusitis, allergic rhinitis;
• dry and cold air, which dries out the mucosa;
• septal deviation, nasal surgery, barotrauma;
• nasal sprays, especially steroid ones, oxygen catheter, chemical irritants, cocaine inhalation.

In winter, episodes occur more often: there are more viruses, and indoor air is drier. Forceful nose-blowing is on the same list.

Systemic causes: pressure, vessels, blood clotting

Systemic causes include factors affecting the whole body. Among them are allergy, colds, arterial hypertension, heart failure, and vascular and connective tissue diseases.

A separate group is medications affecting clotting: warfarin, clopidogrel, aspirin, nonsteroidal anti-inflammatory drugs. Alcohol dilates vessels and is among the possible causes.

Blood diseases — anemias, hematologic malignancies, immune thrombocytopenia — and deficiency of vitamins C or K are included in the list of causes. With hypertension, bleeding lasts longer, and anticoagulants lengthen it even more noticeably.

In older age, the mucosa is thinner and drier, and vessels contract less well. Risk groups include children, adults over 45, pregnant women, and people with high blood pressure.

Runny nose with blood and blood clots

Acute respiratory viral infections, sinusitis, and allergy are among the causes of nosebleeds; crusts on the mucosa may bleed when irritated.

Clots are coagulated blood; fresh and coagulated blood may flow into the stomach and cause nausea and vomiting. Bleeding from the middle and posterior sections of the nose (5–10%) comes from deeper.

Sometimes blood in the nose is a manifestation of pulmonary bleeding (bright red, frothy blood) or gastrointestinal bleeding (dark, coagulated).

“Signal” bleeds are sudden, short, and profuse. Their cause is rupture of a large vessel in the nasal cavity or facial skull bones, rupture of an aneurysm, or a disintegrating malignant tumor.

Nosebleeds in a child

In children, such episodes are common and in most cases harmless. The causes are the same as in adults: mucosal irritation, dry air, a cold.

See a doctor if bleeding occurs in a child younger than two years. Frequent nosebleeds in a child are another reason to consult a doctor.

When a nosebleed requires evaluation

Recurrent bleeding may be a symptom of hypertension, a blood disease, or a tumor of the nose and paranasal sinuses. The doctor examines the nasal cavity and, if necessary, orders a complete blood count with platelet count, CT of the nose and sinuses, endoscopy, coagulation testing, and toxicology screening.

A reason for a visit is symptoms of anemia: rapid heartbeat, shortness of breath, pale skin. A second reason is taking medications that inhibit clotting, or a known clotting disorder such as hemophilia.

A nosebleed by itself is not a reason to call an ambulance; 103 or 112 are needed if bleeding lasts longer than 10–15 minutes, blood loss appears excessive, the person feels nauseated from swallowed blood, bleeding began after a blow to the head, or weakness, dizziness, or difficulty breathing appears.

This material is for reference: it explains how the phenomenon works but does not replace a doctor's consultation.

This content is for reference and does not replace a doctor's consultation. Medical disclaimer