Recurrent Nosebleeds in Adults

Recurrent nosebleeds are very common, and in many people they come from a fragile area at the front of the nose. They can still be very distressing, particularly if they happen without warning or start affecting confidence, sleep, work, or travel. The good news is that most recurrent nosebleeds are treatable, but the right treatment depends on where the bleeding is coming from and why it is happening.

In my practice, the aim is to work out whether the bleeding is from the front of the nose, deeper in the nose, or part of a wider underlying problem such as infection, inflammation, blood thinning medication, poorly controlled blood pressure, or more rarely a tumour or systemic condition. A careful examination is important, because not all recurrent bleeding is the same problem.

What is the difference between anterior and posterior nosebleeds?

Most recurrent nosebleeds are anterior nosebleeds, meaning they come from the front part of the nose, usually from small fragile blood vessels on the nasal septum. These are the bleeds most likely to show as blood from the nostril and are often the easiest to treat in clinic.

Posterior nosebleeds come from further back in the nose. They tend to be heavier, may run backwards into the throat, and are more likely to need hospital treatment. In practice, a posterior bleed is often coming from the region of the sphenopalatine artery, which is one of the main blood supplies to the inside of the nose.

What can cause recurrent nosebleeds?

Common causes include:

• fragile surface blood vessels

• dryness and crusting

• nose picking or repeated irritation

• infection

• inflammation

• nasal sprays

• blood thinning medication

• trauma

• structural issues inside the nose

• poorly controlled blood pressure

Blood pressure management is important. High blood pressure does not usually directly cause the first small fragile vessel to break, but it can make bleeding more difficult to control and may contribute to more significant or persistent episodes. Good blood pressure control is therefore an important part of managing recurrent epistaxis.

Sometimes crusting or irritation is part of a simple infection or irritation pattern. In other people it may be related to allergy or inflammatory rhinitis. More rarely, crusting and bleeding can be part of an autoimmune condition. This means a condition where the immune system mistakenly attacks the body’s own tissues and causes inflammation. That matters because those cases need a different type of assessment and treatment rather than simple cautery alone.

When is bleeding more concerning?

Repeated small bleeds from the front of the nose are common and often benign. However, blood-stained discharge, especially if it is mainly on one side and associated with nasal obstruction, can be more concerning and deserves proper assessment. That is because the combination of unilateral bleeding, discharge, and blockage can occasionally point to a more significant structural problem inside the nose or sinus.

What should I do if I get a nosebleed?

Basic first aid is important and often helps stop the bleeding.

If a nosebleed starts:

• sit upright and lean slightly forward

• pinch the soft part of the nose firmly, just below the bony bridge. Applying pressure on the solid bony bridge will not compress the bleeding point

• keep steady pressure on for at least 10 to 15 minutes without letting go

• spit out any blood that runs into the mouth rather than swallowing it

• avoid lying flat or tilting the head back

After the bleeding stops, it is sensible to avoid heavy exercise, hot drinks, hot baths, nose blowing, or picking at the nose for a short period, as this can trigger the bleeding again.

A helpful first-aid video is here:

• How to treat a nosebleed | NHS

What examination is needed?

A careful history and nasal examination are the starting point. I usually want to know:

• how often the bleeding happens

• whether it is one-sided or both-sided

• whether it feels like it comes from the front or runs backwards

• whether there is obstruction, crusting, pain, or blood-stained discharge

• whether you use nasal sprays

• whether you take blood thinners

• whether there are symptoms suggesting allergy, infection, or inflammation

In many patients, examination in clinic is enough to identify an obvious bleeding point. In others, especially if the bleeding seems deeper, one-sided, or associated with more worrying symptoms, a more detailed endoscopic nasal examination is needed.

Endoscopic means using a fine camera passed gently into the nose to look properly inside the nasal cavity. This gives a much clearer view than simply looking with a light at the front of the nose.

What investigations might be needed?

Not everyone needs scans or blood tests. Investigation depends on the pattern.

Sometimes the key step is simply identifying the exact bleeding point in clinic. In other cases, further tests may be helpful, such as:

• blood tests if bleeding is heavy, frequent, or there is concern about anaemia or clotting

• endoscopic examination of the nose

• scans if there is concern about deeper disease, unilateral symptoms, or a structural cause

• further medical assessment if an autoimmune or inflammatory condition is suspected

The important thing is that recurrent bleeding with crusting, unilateral symptoms, or obstruction should not just be assumed to be dryness.

How is recurrent epistaxis treated?

Treatment depends on the cause and the site of bleeding.

First-line measures

For simple anterior bleeding, treatment may include nasal moisturising measures, avoidance of irritation, and treatment of crusting or infection. Naseptin ointment is commonly used in selected patients, particularly when the problem is recurrent anterior bleeding related to crusting or bacterial colonisation, provided there is no peanut allergy or other reason not to use it.

Naseptin can help by softening crusting, reducing local irritation, and treating low-grade bacterial colonisation at the front of the nose, which in turn can reduce repeated bleeding from fragile surface vessels.

Silver nitrate cautery

If I can see a clear bleeding point at the front of the nose, silver nitrate cautery is often a very effective treatment. This is done under local anaesthetic in clinic. The local anaesthetic numbs the lining of the nose, and the silver nitrate is then applied to seal the small blood vessel.

Silver nitrate is a form of chemical cautery. In simple terms, it works by applying a chemical to the surface of the bleeding point to seal it.

Bipolar cautery under local anaesthetic

Some patients are better treated with bipolar cautery under local anaesthetic, particularly if the bleeding point is more substantial or silver nitrate is not the best option.

Bipolar cautery is a form of electrical cautery. In simple terms, it uses a controlled electrical current to generate heat at the tip of the instrument, which seals the blood vessel more precisely. This can be especially helpful when a more targeted or controlled treatment is needed.

What if clinic treatment is not enough?

If the bleeding is recurrent, heavy, difficult to localise, or coming from further back in the nose, it may not be suitable for simple clinic cautery.

Sometimes that means an examination under anaesthetic, where I can assess the nose more thoroughly and treat any bleeding points more precisely. This is especially useful when the source is not easily seen in clinic, when the patient cannot tolerate adequate examination awake, or when there is concern about a deeper cause.

Packing may also be needed. In some cases I may use dissolvable packing, which stays in place and gradually breaks down. If the bleeding is heavier, a firmer pack that needs to be removed later may be required, such as a Rapid Rhino. If a Rapid Rhino is used, admission to hospital is usually required.

How are posterior nosebleeds treated?

Posterior bleeds are more serious and are more likely to need admission, nasal packing, or surgery. This is because they are often coming from the sphenopalatine artery region, one of the most effective treatments is sphenopalatine artery ligation.

This is an operation done through the nostril using an endoscope, which means a fine camera passed into the nose. The aim is to identify and seal off the sphenopalatine artery, which is one of the main blood supplies to the inside of the nose. In simple terms, it treats the problem much closer to its source by blocking the vessel that is feeding the recurrent bleed. It is done from inside the nose, so there are no cuts on the outside.

Very occasionally, if bleeding remains difficult to control or the situation is more complex, interventional radiology may be needed, but this is uncommon.

When should urgent assessment be sought?

Urgent assessment is important if:

• the bleeding is heavy or does not stop

• blood is running backwards into the throat

• there is dizziness, faintness, or concern about blood loss

• the bleeding keeps recurring over a short period

• you are on blood thinners

• the bleed feels like it is coming from deeper in the nose rather than the front

Posterior bleeds and uncontrolled recurrent bleeds should not be managed casually at home.

Useful link

• ENT UK: Nosebleeds (Epistaxis)

Disclaimer

This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice.