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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Medical Myths Medical Myths
 

Nosebleeds -- Separating Fact From Fiction


October 10, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Recently, I heard a friend complain that the only tickets he could get to see the Boston Celtics were in the "nosebleed seats." His comment got me thinking:

  • Why do some people get nosebleeds frequently while others never do?
  • Does altitude really cause nosebleeds? How high up do you have to be?
  • What's the best way to treat a nosebleed?
  • When should you worry that a nosebleed is a sign of disease? Should people with nosebleeds see their doctors right away?

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Causes of Nosebleeds

The medical term for nosebleed is epistaxis. It comes from the Greek "to drip upon." It's a fitting name as most people notice a nosebleed when they sense a runny nose, but blood comes out.

Nosebleeds often occur after a trauma, such as a sports injury, or from rubbing or picking the inside of the nose. But when there's no obvious cause, doctors consider nosebleeds "idiopathic."

While there are lots of medical conditions associated with nosebleeds, they're not why most people have nosebleeds. The likely causes of nosebleeds include:

  • Dry air – Nosebleeds are common during the winter where the home or workplace has forced-air heat. Changes in climate or atmospheric pressure, including travel to high altitude, may trigger nosebleeds, too. 
  • Abnormal structure of the nose – A deviated septum, for example, can increase the likelihood of a nosebleed.
     
  • Nasal congestion – Colds and allergies cause dilation of blood vessels inside the nose; sneezing and frequent nose-blowing can cause irritation and trigger bleeding.
     
  • Chemical irritants – The primary culprit is cigarette smoke, even secondhand cigarette smoke. Workers also may develop nosebleeds from on-the-job exposure to sulfuric acid, ammonia, gasoline or other chemical irritants.
     
  • A tendency to bleed – Kidney failure, blood disorders (such as hemophilia), and use of blood-thinning medications (such as aspirin, ibuprofen, or warfarin) increase the likelihood of nosebleeds.
     
  • Alcohol and drug abuse – Because alcohol dilates blood vessels and also inhibits the activity of platelets (blood cells responsible for forming blood clots), heavy alcohol use can contribute to nosebleeds. Snorting cocaine can damage the lining of the nose and cause bleeding.
     
  • Hypertension (high blood pressure) – Elevated blood pressure can increase the risk of nosebleeds although the reason is uncertain.

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Why Are Nosebleeds So Common?

About one out of every seven people will have a nosebleed at some point. The reason that nosebleeds are common is due to the anatomy of the nose. There is a high concentration of blood vessels just beneath the lining of the nose, which is quite thin. It's easy to dry out, crack, irritate or cut the thin tissue that lines the inside of our noses. Perhaps the real mystery is why nosebleeds aren't even more common.

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Nosebleeds and Altitude

Whether it's a myth or just a figure of speech, nosebleed seats don't cause nosebleeds. Atmospheric pressure, humidity and other climate conditions are fairly similar throughout a stadium. So a nosebleed at the game probably has little to do with how high up the seats are.

People get nosebleeds at high altitude because the air is colder and dryer than at sea level. It's not clear how high up you have to be before nosebleeds become more likely but my guess is that the temperature and humidity of the air are more important than the actual altitude. The connection between nose bleeds and high altitudes is probably where the expression "nosebleed seats" came from. It refers to seats that are high up and far from the action.

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How To Stop a Nosebleed

The bleeding usually stops soon after it starts. Sit up straight, lean forward a bit, pinch the nostrils together, apply ice (if it's available), and wait 5 minutes. Then, release the pinch to see if the bleeding has stopped. It may take another 10 to 20 minutes or so of pinching the nostrils to stop the bleeding. If that doesn't work, seek medical attention. If the nosebleed occurred after significant trauma, or if your nose appears misshapen, see your doctor.

When I was a kid and had a nose bleed, I was told to tilt my head back. That's actually not such a good idea. Blood from the nose can trickle back into the throat and into the stomach or the lungs. This can cause nausea and vomiting, or coughing and shortness of breath. Fortunately, none of this happened to me.

Doctors have other options that usually work well. Applying silver nitrate or electrical current into the lining of the nose will often block off the bleeding blood vessel. Placing gauze in the nose can compress the area more effectively to stop the bleeding. For more severe cases, freezing, laser treatment or even surgery may be recommended.

See your doctor is your nosebleeds are frequent or don't stop quickly. He or she will look for any blood clotting abnormalities and for abnormalities in the nose or sinuses.

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How To Prevent the Next One

It may be possible to prevent further nosebleeds by taking these simple steps:

  • Increase the humidity of the air you're breathing – consider investing in a humidifier.
  • Don't scratch or pick at the inside of your nose.
  • Be gentle with your nose when rubbing or blowing it.
  • Don't smoke; wear protective equipment if you're exposed to other chemical irritants.
  • Use petroleum jelly or saline spray to keep the inside of your nose moist.
  • Wear protective gear during activities where trauma is common (such as lacrosse); always wear a seatbelt.
  • Don't abuse alcohol or use recreational drugs.
  • Get your blood pressure monitored and treated if it's high.
  • Talk to your doctor about whether the medicines you're taking (including supplements and herbal remedies) could be contributing to the problem.

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The Bottom Line

The next time someone gives you grief about your "nosebleed" seats, you'll know the truth: They don't mean you're sick, they aren't caused by sitting in the "cheap seats," and leaning your head back when you have one isn't helpful. The good news is that as alarming as all the blood is, most of the time a nosebleed is nothing to worry about.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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