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Nosebleed
Medical expert of the article
Last reviewed: 04.07.2025
Nosebleed (epistaxis) is bleeding that occurs when the integrity of the vessels located in the nasal cavity, paranasal sinuses, nasopharynx is compromised, as well as bleeding from the vessels of the cranial cavity when the integrity of the upper wall of the nasal cavity is compromised.
Causes of nosebleeds
Often, nosebleeds are idiopathic. In older people, nosebleeds are usually caused by degenerative changes in the arteries and hypertension. Local causes of nasal congestion may include atrophic rhinitis, hereditary telangiectasia, tumors of the nose and sinuses. Of course, we should not forget that nosebleeds may be a manifestation of hemorrhagic diathesis.
Local nosebleeds are most often caused by the anatomical features of the arterial plexus (plexus Kisselbachii), located in the anterior part of the nasal septum, formed by the terminal branches of the sphenopalatine, nasopalatine, and ascending palatine arteries.
The above-mentioned anatomical features include the thinness of the mucous membrane in the area of the Kiesselbach plexus, local increase in arterial pressure caused by the fact that several arterial trunks anastomose in this area. Contributing factors are microtraumas of the mucous membrane of the nasal septum, resulting from the action of dust particles contained in the inhaled air, aggressive gases, as well as atrophy of the mucous membrane and its age-related changes. Often, spontaneous local bleeding occurs after physical exertion, general overheating of the body and during menstruation. Repeated bleeding may result in ulceration of the mucous membrane of the nasal septum with the subsequent occurrence of the so-called creeping ulcer of the nasal septum (ulcus serpens septi nasi). Sometimes in the area of the anterior nasal septum, a so-called bleeding polyp of the nasal septum is formed, consisting of arteriovenous anastomoses and angiomatous tissue (but histologically - angioma or angiofibroma), bleeding from which occurs with a runny nose, sneezing, and also spontaneously. The presence of a leech or other blood-sucking parasites in the nasal cavity or on the back wall of the pharynx, which can get into the upper respiratory tract during swimming or drinking water from open water bodies, is sometimes confused with a bleeding tumor.
Local bleeding should be differentiated from bleeding that occurs with malignant tumors, juvenile angiofibromas of the nasopharynx, and some general diseases.
Nosebleeds of general genesis
Often, nosebleeds caused by general causes are a very serious complication, the outcome of which is not always favorable. Among the general causes, the most common is hypertensive syndrome (50%), in which nosebleeds play a kind of therapeutic role, "unloading" the brain vessels and preventing hemorrhagic complications in it. Nosebleeds of hypertensive genesis are profuse and often, if untimely intervention is not performed, can lead to significant blood loss and hypoxic collapse.
According to V.B. Trushin et al. (1999, 2000), V.B. Trushin (2001, 2004), the so-called autonomic dysfunction plays a major role in the development of general nosebleeds, which is characterized by disturbances in the autonomic regulation of cardiovascular system functions, as established by studying the Kerdo autonomic index in an orthostatic test. The latter allow predicting recurrence of nosebleeds. To prevent nosebleeds in autonomic dysfunction, V.B. Trushin (2004) recommends transcranial exposure to combined pulsed and direct current in a ratio of 1:2 at a frequency of 77 Hz with a pulse duration of 3.75 ms. With adequate or excessive sympathetic support, the orthostatic test uses a current of 0.1-0.2 mA; with adequate - for 5 minutes, with excessive - 10 minutes. With insufficient sympathetic supply, the current strength is increased to 0.5 mA with an exposure duration of up to 30 minutes.
Other causes of general nosebleeds include mitral valve stenosis, pulmonary emphysema, liver cirrhosis, kidney and blood diseases, occupational intoxication, vitamin C deficiency, Osler's disease (multiple hereditary telangiectasias of the skin and mucous membranes, localized mainly on the lips and nasal mucosa; frequent nosebleeds, often hemoptysis, bloody vomiting; secondary post-thermia anemia usually develops; often hepatomegaly with subsequent liver cirrhosis), agranulocytosis (syndrome of complete or partial disappearance of granular leukocytes from the blood; genesis - myelotoxic and immune), etc. Often, nosebleeds caused by general causes are accompanied by hemorrhages in internal organs, subcutaneous fat and other areas.
Nasal bleeding of traumatic origin
This type of bleeding accompanies nasal trauma in 90% of cases and can range in intensity from minor to profuse, requiring emergency intervention. However, unlike "general" nosebleeds, which are almost impossible to treat radically, this type of nosebleed is often stopped by the simplest methods. Nosebleeds can be observed with skull base fractures, and in particular with damage to the cribriform plate. In these cases, nosebleeds are often accompanied by nasal liquorrhea.
The doctor's tactics for traumatic nosebleeds are as follows. First of all, it is necessary to assess the nature of the injury (bruise, wound, presence or absence of brain injury, general condition of the victim), the intensity of bleeding (weak, moderate, profuse). Then, appropriate measures are taken to provide emergency care to the victim, which consists primarily of stopping the bleeding and, if necessary, combating traumatic shock. In case of a nasal injury, surgical treatment of the wound with primary rhinoplasty and nasal tamponade is performed. In this case, broad-spectrum antibiotics and appropriate hemostatic drugs are prescribed to prevent purulent complications.
Epidemiology of nosebleeds
Nosebleeds are the most common spontaneous bleeding. The share of nosebleeds ranges from 3 to 14.3% in the overall structure of patients hospitalized in ENT hospitals and is 20.5% of those hospitalized for emergency indications.
Most nosebleeds originate from vessels located on the nasal septum. In relatively young people (under 35 years of age), nosebleeds may originate from a vein located behind the columella (septum) of the nasal vestibule. In older people, nosebleeds are often arterial from Little's area, where the anterior ethmoidal artery, the septal branches of the sphenopalatine artery, the superior labial artery, and the greater palatine artery converge.
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Treatment of nosebleeds
First of all, three conditions must be met: timely recognition of shock and, if necessary, replacement blood transfusion, identification of the source of bleeding and stopping the bleeding itself. In elderly people, nosebleeds often lead to shock, which can be fatal. If the patient shows signs of shock, he must be hospitalized and a blood transfusion must be started. Usually, people with nosebleeds are seated on a chair (this reduces venous pressure) and assistance is provided in this position. If the patient is in shock, he should be laid down to maximize cerebral perfusion. If there is no shock or it has been stopped, then the main medical attention should be directed to combating the bleeding. First of all, squeeze the nostril with the thumb and forefinger and hold it for at least 10 minutes; it is advisable to place a bag of ice on the bridge of the nose and ask the patient to clamp, for example, a bottle cork (wine) with his teeth - this may be enough to stop the nosebleed. If the above method does not stop the nosebleed, then the blood clot should be removed from the nose with Luke tweezers or suction. The nasal mucosa should be treated with an aerosol of 2.5-10% cocaine solution - this will anesthetize it and reduce the blood flow to it by contracting the blood vessels. Any bleeding point should be cauterized.
If the bleeding point cannot be found and the nosebleed continues, tamponade the nose with a 1 or 2.5 cm wide strip of gauze soaked in a paste of paraffin and iodoform. The tampon is inserted with special forceps (Tilley). After you perform anterior nasal tamponade, the bleeding stops and the patient can be sent home. The tamponade should not be removed for 3 days. If the nosebleed continues despite the anterior tamponade, posterior nasal tamponade is necessary. It is performed as follows: after removing the anterior tamponade from the nose, a Foley catheter is inserted through the nostril, with its 30-milliliter balloon positioned in the nasopharyngeal space, then the balloon is inflated and the catheter is pulled forward. After this, tamponade the anterior part of the nose. Posterior nasal tamponade is performed for 24 hours, during which the patient must remain in the hospital. If the nosebleed continues, repeated packing of the nose is necessary, but this is a very painful procedure and usually demoralizes the patient. In rare cases, it is necessary to resort to ligation of the arteries [the approach to the maxillary artery in case of bleeding from the greater palatine artery and sphenopalatine arteries is carried out through the maxillary (maxillary) sinus; to the anterior ethmoid artery - through the orbit]. To stop ongoing nosebleeds, it is sometimes necessary to ligate the external carotid artery.