Nosebleeds, or epistaxis for those who want to be fancy, are a common occurrence, affecting 60% of Americans at some point in their lives. Though it can be an alarming sight, the vast majority of nosebleed cases are spontaneous and self-resolving and a little blood from the nose can serve to make the rugged hero look all the more hardcore after he’s successfully defeated the enemy in mortal combat. Nosebleeds are also useful to indicate the early stages of fatal disease in tragic Korean dramas.

Nosebleeds seem to occur more frequently in children under the age of 10 and the elderly over 70 years old. Because epistaxis is typically recognized as a benign condition, only about 10% of patients seek medical attention.

The lining of the nose is rich in blood vessels and can be quite delicate, making recurrent nosebleeds a possibility for susceptible individuals. Epistaxis may be divided into two categories based on the origin of the bleed – anterior or posterior. Anterior nosebleeds arise from blood vessels lining the septum, the wall separating the two nostrils. This accounts for 90% of all epistaxis cases and is typically not serious. The remaining 10% of nosebleeds are posterior, originating from the artery that supplies blood to the nose. These nosebleeds are usually heavier and more difficult to control, with a risk of blood flowing down the throat. Older patients are more likely to experience a posterior nosebleed.

What Causes a Nosebleed?
85% of nosebleeds happen for no reason, a situation known as “idiopathic” or a primary nosebleed. Secondary nosebleeds have an identifiable cause, the most common being trauma (such as nose picking, or, for the fancy, digital trauma), foreign objects stuck up the nostril, and prolonged exposure to dry air.  Epistaxis cases are found to be more common during dry seasons, and can also be related to the body’s natural cycle throughout the day, peaking in morning and late afternoon. Other causes of nosebleeds include:

  • Certain over-the-counter and prescription medications. Nasal decongestant sprays can predispose the lining of the nose to rupture and bleeding, but other systemic medications can also pose a risk for nosebleeds. Blood-thinning and anti-clotting medications such as aspirin, non-steroidal anti-inflammatories (NSAIDs), warfarin, and clopidogrel can cause nosebleeds. Alternative medications and nutritional supplements may also have unintended anti-coagulant effects, which can increase the risk of epistaxis. Though the medical literature is not unanimous on the link between unusual bleeding and intake of these supplements, fish oil and turmeric are known to have blood-thinning properties.
  • Bleeding disorders. These include von Willebrand disease, hemophilia, and immune thrombocytopenia.
  • Irritation from chemicals such as ammonia, cigarette smoke, or recreational drugs, specifically cocaine.
  • Allergic or non-allergic rhinitis involving a lot of nasal congestion, sneezing, and forceful nose-blowing.
  • Head or nose surgery.
  • Nasal tumors or polyps.
  • Alcohol consumption has been linked to nosebleeds as it is thought alcohol may temporarily prevent blood clotting and prolong the bleed.
  • Abnormalities to the septum of the nose, whether congenital or from past injury (deviated septum).
  • Hereditary hemorrhagic telangiectasia. This is an inherited condition involving anomalous connections between blood vessels, which have the potential to rupture and bleed. Spontaneous and recurrent nosebleeds are the most common symptom.
  • Leukemia.

The association between hypertension and nosebleeds is not well understood. Elevated blood pressure rarely causes the bleed but severe hypertension may possibly worsen an existing epistaxis episode.

What to Do About a Nosebleed
Active nosebleeds can be managed with the good old time-tested nose pinch technique. After gently clearing the nostril of clotted blood, with finger and thumb firmly pinch the nostrils together. The patients should remain upright with the head flexed slightly forward, whether sitting or standing, as lying down encourages blood flow to the nose and can prolong bleeding. The recent nosebleed guidelines from the American Academy of Otolaryngology-Head and Neck Surgery suggests holding the compression for a minimum of 5 minutes.

A good nosebleed first-aider should also take a history to identify any possible underlying causes that may need to be addressed urgently – was there a preceding trauma? Is the patient taking blood thinning medications or has a known blood-clotting disorder? Was the patient recently engaged in mortal combat? If blood can be tasted down the throat despite firm compression of the nose or the bleeding is ongoing even after 20 minutes, this may be a sign of a posterior nosebleed and a visit to the hospital may be necessary. Patients who have had a history of requiring hospitalization or blood transfusions for epistaxis, or more than 3 recent episodes of nosebleeds should be referred for prompt evaluation by a doctor.

In a medical clinic, the doctor may use nasal packing in the form of gauze, sponges, or other biosynthetic materials in order to be able to examine the nose or if there is a high risk of excessive bleeding. Patients with a posterior nosebleed can benefit from nasal packing but should be supervised by an ENT doctor and monitored for heart and breathing complications.

If an anterior bleeding site can be identified, the doctor may control the bleeding with a topical medication to constrict the blood vessels of the nasal lining (interestingly, an example of such a vasoconstrictor is cocaine). Lubricants and moisturizers applied to the nostril can help prevent further bleeding. Anterior nosebleeds can also be controlled with a procedure known as cautery, which uses chemicals, heat, or electrical currents to seal off the offending blood vessel in the nose.

Posterior nosebleeds that do not respond adequately to nasal packing may require a procedure called arterial ligation. Under general anesthetic, the specific artery supplying the nose (and the bleed) is clipped or coagulated. This technique has a reported success rate as high as 98% for managing posterior nosebleeds.

It is important to remember that nosebleeds are commonplace (especially in Korean dramas) and calm application of first-aid will most likely fix the problem. This being said, as a small percentage of epistaxis cases can be a sign of something more serious, severe or unusual nosebleeds should be checked out by a doctor just in case (especially if you’re in a Korean drama).