Epistaxis - Treating a nosebleed

Most nosebleeds can be stopped without the need for medical attention.

To stop a nosebleed:

• sit down and firmly pinch the soft part of your nasal cavity, just above your nostrils, for 10 minutes
• lean forward and breathe through your mouth; this will drain blood down your nose instead of down the back of your throat
• stay upright, rather than lying down as this reduces the blood pressure in the veins of your nose and will discourage further bleeding
• maintain the pressure on your nose for up to 30 minutes (time this on the clock) so that your blood clots
• place a covered ice pack on the bridge of your nose
• avoid blowing your nose, bending down and strenuous activity for at least 12 hours after a nosebleed; try to keep your head above the level of your heart during this time

If your child gets regular nosebleeds from persistent crusting of the inside of their nostrils, you can try using ointment, such as petroleum jelly (Vaseline), to soften the inside of the nose.

Go to the nearest accident and emergency department (A&E) as soon as possible,  if the bleeding doesn't stop after you've maintained pressure for 30 minutes.

You should also see your GP if you:

• often have more than one nosebleed a week (it may be due to an undiagnosed underlying condition)
• have had an injury to your head, such as a blow or a fall (you may have broken your nose)
• are taking a blood-thinning medicine (anticoagulant), such as warfarin, and the bleeding doesn't stop or it occurs regularly

Nasal packing

If you seek medical help, your nose may be packed with ribbon gauze or a special nasal sponge. The aim is to apply pressure to the source of the bleeding to stop the flow of blood.

Your GP, or the healthcare professional treating you, will explain the process and tell you how long you need to keep the pack in place. You should also be given an appointment to have it removed. After the bleeding has stopped, and your nose is unpacked, it will be examined.

Avoid any over-exertion while your nose is packed and for one to two weeks afterwards. 

Further tests

Your GP may check your blood pressure and pulse rate to determine what caused the nosebleed.

Frequent or heavy nosebleeds can be a symptom of a blood disorder, such as haemophilia. The doctor may arrange for you to have a blood test to check whether your blood is clotting properly.

If your nosebleeds are found to be caused by medication that you're taking, such as blood-thinning medicines (anticoagulants) like aspirin, warfarin or heparin, or an anti-inflammatory medicine, your GP may need to change or adjust the dose.

If your nosebleed is caused by an infection, such as sinusitis, you may be prescribed antibiotics.

In severe cases, you may need surgery to prevent the nosebleeds happening again (see below). In this case, your GP will refer you to an ear, nose and throat (ENT) specialist.

Nasal fractures

Nasal fractures (cracks or breaks in the bones of the nose) account for nearly 50% of all facial fractures. Most are simple and won't need an X-ray. However, if you have a more serious injury, an X-ray of your entire face and skull may be taken.

Fractures can cause a considerable amount of swelling around the nose. It may take five to seven days for the swelling to go down enough to allow a full examination. Once the swelling has settled, there's often little change to the shape of your nose, and it can be left to heal.

Surgery for recurring nosebleeds

Your ENT specialist may recommend surgery if you have frequent nosebleeds and the cause can be identified. There are a number of possible procedures, which are outlined below.

Septal surgery

Your septum (the wall between the two nose channels) can be crooked from birth or become crooked following injury. If it causes nosebleeds, you can have septal surgery to straighten it.

The surgery is carried out under local anaesthetic or general anaesthetic. It should take less than an hour.

As the surgery is inside your nose, it shouldn't leave any external scars. During the operation, some of the bone and cartilage inside your nose is removed and the septum moved back into the middle of your nose.

Afterwards, a dressing is placed on your nose for a day or two to keep it in place and prevent bleeding. You'll need to rest for one week, or for two weeks if your job involves heavy lifting or carrying.

After the operation, you may experience:

• bleeding for up to 10 days
• a blocked nose for two weeks, although it can take up to three months for your breathing to clear completely
• an infection in your nose (although this is rare)

Your ENT specialist will explain the procedure to you in more detail.

Cautery

Cautery is a minor procedure that cauterises (burns) the blood vessel where the bleeding is coming from. It can be an effective method of stopping recurring nosebleeds.

Cautery is carried out either using:

• an electric current running through a wire, such as platinum (electrocautery)
• a chemical, such as silver nitrate, on the end of a wool swab (chemical cautery)

The bleeding area is touched for around 10 seconds to burn and seal it.

Cautery has some associated problems. For example:

• silver nitrate cautery can be painful, particularly for children, even with the use of a local anaesthetic
• it's not always effective as bleeding can occur around the cauterised area
• it can only be used if a specific bleeding point can be identified

Ligation

If other treatments don't work, ligation may be recommended. This involves endoscopic surgery using fine instruments to tie off the ruptured blood vessel. In rare cases, the main artery from which the bleeding blood vessel branches off may need to be tied off.

If the bleeding blood vessel is far back in the nose, or difficult to compress, further surgery may be required.

Possible side effects of ligation include:

• re-bleeding (the blood vessel still causes nosebleeds)
• swelling, numbing or bruising of the face
• a dry or runny nose