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Published: Monday, 4/4/2011

Nosebleeds affect young and old; have many causes

BY JANE E. BRODY
NEW YORK TIMES NEWS SERVICE

Nosebleeds, like noses, come in varied forms, and the number of sufferers is growing as the population ages. Millions of them rejoice at this time of year, when the most frequent cause — winter's dry, heated indoor air — begins to yield to the warm, moist air of spring.

Four years ago Charles Kingson, a New Yorker in his 70s, experienced a frightening series of nosebleeds that initially proved hard to control. Eventually Mr. Kingson found a doctor who stopped the bleeding, and he has since learned how to prevent it from recurring.

But Mr. Kingson also found that several of his friends also were similarly plagued, and none knew why — or what to do about it.

Nosebleeds most often afflict older adults and young children. Among the young, Dr. Alan Lipkin, an otolaryngologist in Denver, said, "digital and other manipulation" is the usual cause. Translation: nose-picking or putting foreign objects in the nose, behaviors that most parents are eager to discourage.

Of course, some adults also engage in "digital manipulation," especially when winter dryness turns nasal mucus into irritating crusts that can impair breathing. And nosebleeds in young children might be caused by nasal dryness, as they often are in older adults.

Among adults and children, however, there are many other causes worth knowing about. And while most nosebleeds can be self-treated or prevented with simple home remedies, frequent nosebleeds should never be taken lightly. They can be a sign of a more serious problem, like leukemia, a nasal tumor, or a blood clotting disorder, and should be brought to a doctor's attention.

Two major types
Most often, nosebleeds originate in the front of the nose, where many small blood vessels near the surface of the nasal septum (the tissue that divides the two nostrils) warm the air you inhale. These so-called anterior nosebleeds are annoying, and they can be frequent and frightening, on occasion producing several ounces of blood.

But anterior nosebleeds are rarely dangerous. Of greater concern are the severe, potentially dangerous nosebleeds that originate in larger blood vessels far back in the nose. So-called posterior nosebleeds are relatively uncommon, and home remedies are ineffective. They require prompt medical attention and more involved treatment, perhaps under anesthesia in a hospital.

Here are some common causes:

•Medications that “thin” the blood, like warfarin (Coumadin); clopidogral bisulfate (Plavix); nonsteroidal anti-inflammatory drugs, or Nsaids, like ibuprofen, and naproxen; and aspirin, including “baby” aspirin that many older adults take to help prevent heart disease and colon cancer.

•Topical medications that irritate the nasal passages, like corticosteroid and antihistamine sprays, and overuse of decongestant nasal sprays.

•Allergies and their consequences — frequent sneezing and overly aggressive nose blowing.

• Upper qrespiratory infections involving the nose or sinuses.

•Nasal trauma from a direct or indirect blow to the nose, including a broken nose.

•A deviated septum, which can impede breathing through one nostril and overwork the other.

•Abrupt changes in air pressure.

•High blood pressure and atherosclerosis, which are more common with age, can be a contributing factor in adults.

•Other disorders, like liver or kidney disease, chronic abuse of alcohol and sniffing cocaine, also can result in nosebleeds.

In most cases, nosebleeds affect only one nostril, although if the problem is severe, blood can sometimes come from both nostrils (or even from an eye). Seek medical care if you experience repeated nosebleeds, bleed heavily or bruise easily; if you take medication or have an underlying disease that can interfere with blood clotting; if you vomit blood, become dizzy or faint; if you have trouble breathing or your heart races; or if your nosebleed is accompanied by a rash or fever.

Prevention, treatment
Moistening the air you breathe and staying well hydrated, especially during the winter months, is a good place to start.

Mr. Kingson’s otolaryngologist suggested that he use a cold-mist vaporizer in the bedroom, take hot showers and drink lots of water, as often as every 15 minutes.

Nosebleed sufferers also might consider using absorbent cotton or gauze to coat the interior of the nostrils with a gel or petroleum jelly, Lipkin said. Nasal saline sprays are also helpful.

Avoid forceful nose blowing, and do not try to clear the nose with an object like a Q-tip. To keep undue pressure from building up in nasal vessels, children and adults should be taught to sneeze with their mouths open. To control nose-picking in children, keep their fingernails cut short.

If you must take a medication that can cause bleeding, ask your doctor whether a lower dose or different drug might be used. For pain control, try acetaminophen (Tylenol and many generics) instead of an Nsaid, but be sure not to exceed the recommended daily dose.

Most minor nosebleeds can be controlled easily at home. Do not lie down. Sit upright, and bend forward slightly from the hips to keep blood from running down the back of the throat. Swallowing blood can cause vomiting.

Placing your thumb and index finger on the soft part of the nose, just below the bony bridge, pinch the nostrils closed for 10 minutes without interruption, Dr. Lipkin recommended. Do not stuff anything into the nostril, but short-term use of a decongestant nasal spray may help constrict the culprit vessel, he said.

To keep the bleeding from restarting, do not blow your nose soon afterward. Do not bend over, and avoid strenuous activity and heavy lifting for a few hours.

If self-treatment is not effective and bleeding continues for more than 20 minutes, or if a nosebleed resulted from an injury to the face, see a doctor. Something else might be wrong, perhaps a fracture.

Medical treatment of challenging nosebleeds might require cauterizing the bleeding vessel with a chemical like silver nitrate or with a laser beam. Nasal packing, which is what ultimately stopped Mr. Kingson’s nosebleeds, might be used to apply pressure to the bleeding vessel and promote clotting.

If the problem involves a posterior vessel, hospitalization and sedation or anesthesia might be necessary. Posterior nasal packings are left in for two or three days, and should be removed only by a professional.

If that procedure doesn’t work, surgery or arterial blockage might be needed.



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