The nose is an area of the body that contains many tiny blood vessels or arterioles that can break easily. In the United States, one of every seven people will develop a nosebleed some time in their lifetime. Nosebleeds can occur at any age but are most common in children aged 2-10 years and adults aged 50-80 years. Nosebleeds are divided into two types, depending on whether the bleeding is coming from the front or back of the nose.
What is an anterior nosebleed?
Most nosebleeds or epistaxes begin in the lower part of the septum, the semi-rigid wall that separates the two nostrils of the nose. The septum contains blood vessels that can be broken by a blow to the nose or the edge of a sharp fingernail. Nosebleed coming from the front of the nose or anterior nosebleeds often begin with a flow of blood out one nostril when the patient is sitting or standing.
Anterior nosebleeds are common in dry climates or during the winter months when dry, heated indoor air dehydrates the nasal membranes. Dryness may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of petroleum jelly or an antibiotic ointment on the end of a fingertip and then rub it inside the nose, especially on the middle portion of the nose (the septum).
How to stop an anterior nosebleed?
- Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who’s been reassured and supported.
- Keep head higher than the level of the heart. Sit up.
- Lean slightly forward so the blood won’t drain in the back of the throat.
- Using the thumb and index finger, pinch all the soft parts of the nose or place a cotton ball soaked with Afrin, Neo-Synephrine, or Dura-Vent spray into the nostril and apply preassure. The area where pressure should be applied is located between the end of the nose and the hard, bony ridge that forms the bridge of the nose. Do not pack the inside of the nose with gauze or cotton.
- Apply ice—crushed in a plastic bag or washcloth—to nose and cheeks.
- Hold the position for five minutes. If it’s still bleeding, hold it again for an additional 10 minutes.
What is a posterior nosebleed?
More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat even if the patient is sitting or standing
Obviously, when lying down, even anterior (front of nasal cavity) nosebleeds may seem to flow toward the back of the throat especially if coughing or blowing the nose. It is important to try to make the distinction between the anterior and posterior nosebleed, since posterior nosebleeds are often more severe and almost always require a physician’s care. Posterior nosebleeds are more likely to occur in older people, persons with high blood pressure, and in cases of injury to the nose or face
What are the causes of recurring nosebleeds?
- Allergies, infections, or dryness that cause itching and lead to picking of the nose.
- Vigorous nose blowing that ruptures superficial blood vessels.
- Clotting disorders that run in families or are due to medications.
- Drugs (such as anticoagulants or anti-inflammatories).
- Fractures of the nose or the base of the skull. Head injuries that cause nosebleeds should be regarded seriously.
- Hereditary hemorrhagic telangiectasia, a disorder involving a blood vessel growth similar to a birthmark in the back of the nose.
- Tumors, both malignant and nonmalignant, have to be considered, particularly in the older patient or in smokers.
When should an otolaryngologist be consulted?
If frequent nosebleeds are a problem, it is important to consult an otolaryngologist. An ear, nose, and throat specialist will carefully examine the nose using an endoscope, a tube with a light for seeing inside the nose, prior to making a treatment recommendation. Two of the most common treatments are cautery and packing the nose. Cautery is a technique in which the blood vessel is burned with an electric current, silver nitrate, or a laser. Sometimes, a doctor may just pack the nose with a special gauze or an inflatable latex balloon to put pressure on the blood vessel.
Tips to prevent a nosebleed
- Keep the lining of the nose moist by gently applying a light coating of petroleum jelly or an antibiotic ointment with a cotton swab three times daily, including at bedtime. Commonly used products include Bacitracin, A and D Ointment, Eucerin, Polysporin, and Vaseline.
- Keep children’s fingernails short to discourage nose picking.
- Counteract the effects of dry air by using a humidifier.
- Use a saline nasal spray to moisten dry nasal membranes.
- Quit smoking. Smoking dries out the nose and irritates it. Tips to prevent rebleeding after initial bleeding has stopped.
- Do not pick or blow nose.
- Do not strain or bend down to lift anything heavy.
- Keep head higher than the heart.
If rebleeding occurs:
- Attempt to clear nose of all blood clots.
- nose four times in the bleeding nostril(s) with a decongestant spray such as Afrin or Neo-Synephrine.
- Repeat the steps to stop an anterior nosebleed.
- Call a doctor if bleeding persists after 30 minutes or if nosebleed occurs after an injury to the head.
What Is Post-Nasal Drip?
The glands in your nose and throat continually produce mucus (1 to 2 quarts a day). It moistens and cleans the nasal membranes, humidifies air, traps and clears inhaled foreign matter, and fights infection.
Although mucus normally is swallowed unconsciously, the feeling that it is accumulating in the throat or dripping from the back of your nose is called post-nasal drip.
This feeling can be caused by excessive or thick secretions or by throat muscle and swallowing disorders.
What Caused Abnormal Secretions – Thin & Thick
Increased thin clear secretions can be due to colds and flu, allergies, cold temperatures, bright lights, certain foods/spices, pregnancy, and other hormonal changes. Various drugs (in¬cluding birth control pills and high blood pressure medications), and structural abnormalities can also produce increased secretions. These abnormalities might include a deviated or irregular nasal septum (the cartilage and bony dividing wall that separates the two nostrils).
Increased thick secretions in the winter often result from too little moisture in our heated buildings and homes. They can also result from sinus or nose infections and some allergies, especially to certain foods such as dairy products. If thin secretions become thick and green or yellow, it is likely that a bacterial sinus infection is developing. In children, thick secretions from one side of the nose can mean that something is stuck in the nose (such as a bean, wadded paper, or piece of toy, etc.).
Sinuses are air filled cavities in the skull. They drain into the nose through small openings. Blockages in the openings from swelling due to colds, flu, or allergies may lead to acute sinus infection. A viral “cold” that persists for ten days or more may have become a bacterial sinus infection. With this infection you may notice increased post-nasal drip. If you suspect that you have a sinus infection, you should see your physician for antibiotic treatment.
Chronic sinusitis occurs when sinus blockages persist and the lining of the sinuses swell further. Polyps (growths in the nose) may develop with chronic sinusitis. Patients with polyps tend to have irritating, persistent post-nasal drip. Evaluation by an otolaryngologist may include an exam of the interior of the nose with a fiberoptic scope and CAT scan x-rays. If medication does not relieve the problem, surgery may be necessary.
Vasomotor rhinitis describes a nonallergic “hyperirritable nose” that feels congested, blocked, or wet.
Swallowing problems may result in accumulation of solids or liquids in the throat that may complicate or feel like post nasal drip. When the nerve and muscle interaction in the mouth, throat, and food passage (esophagus) aren’t working properly, overflow secretions can spill into the voice box (larynx) and breathing passages (trachea and bronchi) causing hoarseness, throat clearing, or cough.
Several factors contribute to swallowing problems:
- With age, swallowing muscles often lose strength and coordination. Thus, even normal secretions may not pass smoothly into the stomach.
- During sleep, swallowing occurs much less frequently, and secretions may gather. Coughing and vigorous throat clear¬ing are often needed when awakening.
- When nervous or under stress, throat muscles can trigger spasms that feel like a lump in the throat. Frequent throat clearing, which usually produces little or no mucus, can make the problem worse by increasing irritation.
- Growths or swelling in the food passage can slow or prevent the movement of liquids and/or solids.
- Swallowing problems may be caused also by gastroesophageal reflux disease (GERD). This is a return of stomach contents and acid into the esophagus or throat. Heartburn, in¬digestion, and sore throat are common symp¬toms. GERD may be aggravated by lying down especially following eating. Hiatal her¬nia, a pouch-like tissue mass where the esophagus meets the stomach, often contributes to the reflux.
Chronic Sore Throat
Post-nasal drip often leads to a sore, irritated throat. Although there is usually no infection, the tonsils and other tissues in the throat may swell. This can cause discomfort or a feeling of a lump in the throat. Successful treatment of the post-nasal drip will usually clear up these throat symptoms.
A correct diagnosis requires a detailed ear, nose, and throat exam and possible laboratory, endoscopic, and X-ray studies. Each treatment is different:
Bacterial infection, when present, is treated with an¬tibiotics. These drugs may provide only temporary relief. In cases of chronic sinusitis, surgery to open the blocked sinuses may be required.
Allergy is managed by avoiding the cause if possible. Antihistamines and decongestants, cromolyn and steroid (cor¬tisone type) nasal sprays, and other forms of steroids may offer relief. Immunotherapy (allergy shots) also may be helpful. However, some older, sedating an¬tihistamines may dry and thicken post-nasal secretions even more; newer non-sedating antihistamines, available by prescription only, do not have this effect. Decongestants can aggravate high blood pressure, heart, and thyroid disease. Steroid sprays generally may be used safely under medical supervision. Oral and injectable steroids rarely produce serious complications in short term use. Because significant side effects can occur, steroids must be monitored carefully when used for more than one week.
Gastroesophageal reflux is treated by elevating the head of the bed six to eight in¬ches, avoiding late evening foods and beverages, and cutting alcohol and caffeine from the daily diet. Antacids (e.g., Maalox ®, Mylanta®, Gaviscon ®) and drugs that block stomach acid production (e.g., Zantac®, Tagamet®, Pepcid®) or more powerful medications may be prescribed. A trial treatment may be sug¬gested before x-rays and other diagnostic studies are performed.
General measures for thinning secretions so they can pass more easily may be recommended when it is not possible to determine whether an existing structural abnormality is causing the post-nasal drip or if some other condition is to blame.
Many people, especially older persons, need more fluids to thin secretions. Drinking more water; eliminating caffeine; and avoiding diuretics (fluid pills) will help. Mucus thinning agents such as guaifenesin (Humibid®, Robitussin®) may also thin secretions.
Nasal irrigations may alleviate thickened secretions. These can be performed two to four times a day either with a nasal douche device or a Water Pik® with a nasal irrigation nozzle. Warm water with baking soda or salt (½ to 1 tsp. to the pint) or Alkalol,® a nonprescription irrigating solution (full strength or diluted by half warm water) may be helpful. Finally, use of simple saline (salt) nonprescription nasal sprays (e.g., Ocean®, Ayr®, or Nasal®) to moisten the nose is often very beneficial.
Have you ever had a cold or allergy attack that wouldn’t go away? If so, there’s a good chance you actually had sinusitis. Experts estimate that 37 million people are afflicted with sinusitis each year, making it one of the most common health conditions in America. That number may be significantly higher, since the symptoms of bacterial sinusitis often mimic those of colds or allergies, and many sufferers never see a doctor for proper diagnosis and treatment.
What is sinusitis?
Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.
Normally, mucus collecting in the sinuses drains into the nasal passages. When you have a cold or allergy attack, your sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Diagnosis of acute sinusitis usually is based on a physical examination and a discussion of your symptoms. Your doctor also may use x-rays of your sinuses or obtain a sample of your nasal discharge to test for bacteria.
When does acute sinusitis become chronic?
When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.
What treatments are available?
Antibiotic therapy – Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. In addition to an antibiotic, an oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.
Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.
Intensive antibiotic therapy – If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.
Sinus surgery – Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.
Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.
Before surgery, be sure that you have realistic expectations for the results, recovery, and postoperative care. Good results require not only good surgical techniques, but a cooperative effort between the patient and physician throughout the healing process. It is equally important for patients to follow pre- and postoperative instructions.
When should a doctor be consulted?
Because the symptoms of sinusitis sometimes mimic those of colds and allergies, you may not realize you need to see a doctor. If you suspect you have sinusitis, review these signs and symptoms. If you suffer from three or more, you should see your doctor.
What are the symptoms of sinusitis vs. a cold or allergy?
|Facial Pressure /Pain||Yes||Sometimes||Sometimes|
|Duration of Illness||Over 10-14 days||Varies||Under 10 days|
|Nasal Discharge||Thick, yellow-green||Clear, thin, watery||Thick, whitish or thin|
|Pain in Upper Teeth||Sometimes||No||No|
Can children suffer from sinus infections?
Your child’s sinuses are not fully developed until age 20. However, children can still suffer from sinus infection. Although small, the maxillary (behind the cheek) and ethmoid (between the eyes) sinuses are present at birth. Sinusitis is difficult to diagnose in children because respiratory infections are more frequent, and symptoms can be subtle. Unlike a cold or allergy, bacterial sinusitis requires a physician’s diagnosis and treatment with an antibiotic to prevent future complications.
The following symptoms may indicate a sinus infection in your child:
- a “cold” lasting more than 10 to 14 days, sometimes with low-grade fever
- thick yellow-green nasal drainage
- post-nasal drip, sometimes leading to or exhibited as sore throat, cough, bad breath, nausea and/or vomiting
- headache, usually not before age 6
- irritability or fatigue
- swelling around the eyes
If despite appropriate medical therapy these symptoms persist, care should be taken to seek an underlying cause. The role of allergy and frequent upper respiratory infections should be considered.
Tips to prevent sinusitis
As always, an ounce of prevention is worth a pound of cure. To avoid developing sinusitis during a cold or allergy attack, keep your sinuses clear by:/
- using an oral decongestant or a short course of nasal spray decongestant
- gently blowing your nose, blocking one nostril while blowing through the other
- drinking plenty of fluids to keep nasal discharge thin
- avoiding air travel. If you must fly, use a nasal spray decongestant before take-off to prevent blockage of the sinuses allowing mucus to drain
- If you have allergies, try to avoid contact with things that trigger attacks. If you cannot, use over-the-counter or prescription antihistamines and/or a prescription nasal spray to control allergy attacks
Allergy testing, followed by appropriate allergy treatments, may increase your tolerance of allergy-causing substances. If you believe you may have sinusitis, see our tips for sinusitis sufferers.
Nasal congestion, stuffiness, or obstruction to nasal breathing is one of man’s oldest and most common complaints. While it may be a mere nuisance to some persons, to others it is a source of considerable discomfort, and it detracts from the quality of their lives.
Medical writers have classified the causes of nasal obstruction into four categories, recognizing that overlap exists between these categories and that it is not unusual for a patient to have more than one factor involved in his particular case.
An average adult suffers a common “cold” two to three times per year, more often in childhood and less often the older he gets as he develops more immunity. The common “cold” is caused by any number of different viruses, some of which are transmitted through the air, but most are transmitted from hand-to-nose contact. Once the virus gets established in the nose, it causes release of the body chemical histamine, which dramatically increases the blood flow to the nose, causing swelling and congestion of nasal tissues, and stimulating the nasal membranes to produce excessive amounts of mucus. Antihistamines and decongestants help relieve the symptoms of a “cold,” but time alone cures it.
During a virus infection, the nose has poor resistance against bacterial infections, which explains why bacterial infections of the nose and sinuses so often follow a “cold.” When the nasal mucus turns from clear to yellow or green, it usually means that a bacterial infection has taken over and a physician should be consulted.
Acute sinus infections produce nasal congestion, thick discharge, and pain and tenderness in the cheeks and upper teeth, between and behind the eyes, or above the eyes and in the forehead, depending on which sinuses are involved.
Chronic sinus infections may or may not cause pain, but nasal obstruction and offensive nasal or postnasal discharge is often present. Some persons develop polyps (fleshy growths in the nose) from sinus infections, and the infection can spread down into the lower airways leading to chronic cough, bronchitis, and asthma. Acute sinus infection generally responds to antibiotic treatment; chronic sinusitis usually requires surgery.
Included in this category are deformities of the nose and the nasal septum, which is the thin, flat cartilage and bone that separates the nostrils and nose into its two sides. These deformities are usually due to an injury at some time in one’s life. The injury may have been many years earlier and may even have been in childhood and long since forgotten. It is a fact that 7 percent of newborn babies suffer significant nasal injury just from the birth process; and, of course, it is almost impossible to go through life without getting hit on the nose at least once. Therefore, deformities of the nose and the deviated septum should be fairly common problems — and they are. If they create obstruction to breathing, they can be corrected with surgery.
One of the most common causes for nasal obstruction in children is enlargement of the adenoids: tonsil-like tissues that fill the back of the nose up behind the palate. Children with this problem breath noisily at night and even snore. They also are chronic mouth breathers, and they develop a “sad” long face and sometimes dental deformities. Surgery to remove the adenoids and sometimes the tonsils may be advisable.
Other causes in this category include nasal tumors and foreign bodies. Children are prone to inserting various objects such as peas, beans, cherry pits, beads, buttons, safety pins, and bits of plastic toys into their noses. Beware of one-sided foul smelling discharge, which can be caused by a foreign body. A physician should be consulted
Hay fever, rose fever, grass fever, and “summertime colds” are various names for allergic rhinitis. Allergy is an exaggerated inflammatory response to a foreign substance which, in the case of a stuffy nose, is usually a pollen, mold, animal dander, or some element in house dust. Foods sometime play a role. Pollens cause problems in spring (trees) and summer (grasses) or fall (weeds) whereas house dust allergies and mold may be a year-around problem. Ideally the best treatment is avoidance of these substances, but that is impractical in most cases.
In the allergic patient, the release of histamine and similar substances results in congestion and excess production of watery nasal mucus. Antihistamine Help relieve the sneezing and runny nose of allergy. Many antihistamines are now available without a prescription. The most familiar brands include Chlor-Trimeton®, Benadryl®, Clarinex®, Claritin®, Allegra®, and Zyrtec® (although most are also available in generic forms). Decongestants, such as Sudafed® (also available in generic forms) shrink congested nasal tissues. Combinations of antihistamines with decongestants are also available; for example, Actifed®, Allegra D®, Chlortrimetron D®, Claritin D®. All these preparations have potential side effects, and patients must heed the warnings of the package or prescription insert. This is especially important if the patient suffers from high blood pressure, glaucoma, irregular heart beats, difficulty in urination, or is pregnant.
Allergy shots are the most specific treatment available, and they are highly successful in allergic patients. Skin tests or at times blood tests are used to make up treatment vials of substances to which the patient is allergic. The physician determines the best concentration for initiating the treatment. These treatments are given by injection. They work by forming blocking antibodies in the patient’s blood stream, which then interfere with the allergic reaction. Many patients prefer allergy shots over drugs because of the side effects of the drugs.
Patients with allergies have an increased tendency to develop sinus infections and require treatment as discussed in the previous section.
“Rhinitis” means inflammation of the nose and nasal membranes. “Vasomotor” means blood vessel forces. The membranes of the nose have an abundant supply of arteries, veins, and capillaries, which have a great capacity for both expansion and constriction. Normally these blood vessels are in a half-constricted, half-open state. But when a person exercises vigorously, his/her hormones of stimulation (i.e., adrenaline) increase. The adrenaline causes constriction or squeezing of the nasal membranes so that the air passages open up and the person breathes more freely.
The opposite takes place when an allergic attack or a ”cold” develops: The blood vessels expand, the membranes become congested (full of excess blood), and the nose becomes stuffy, or blocked.
In addition to allergies and infections, other events can also cause nasal blood vessels to expand, leading to vasomotor rhinitis. These include psychological stress, inadequate thyroid function, pregnancy, certain anti-high blood pressure drugs, and overuse or prolonged use of decongesting nasal sprays and irritants such as perfumes and tobacco smoke.
In the early stages of each of these disorders, the nasal stuffiness is temporary and reversible. That is, it will improve if the primary cause is corrected. However, if the condition persists for a long enough period, the blood vessels lose their capacity to constrict. They become somewhat like varicose veins. They fill up when the patient lies down and when he/she lies on one side, the lower side becomes congested. The congestion often interferes with sleep. So it is helpful for stuffy patients to sleep with the head of the bed elevated two to four inches accomplish this by placing a brick or two under each castor of the bedposts at the head of the bed. Surgery may offer dramatic and long time relief.
Stuffy nose is one symptom caused by a remarkable array of different disorders, and the physician with special interest in nasal disorders will offer treatments based on the specific causes. Additional information and suggestions can be found in the AAO-HNS pamphlets “Hayfever, Summer Colds and Allergies” and “Antihistamines.”