The inside of the nose has a delicate lining with many small blood vessels close to the surface. These delicate blood vessels help warm and humidify the air we breathe, but they can also bleed easily when the lining becomes dry, irritated, injured or inflamed. An injured blood vessel near the surface can bleed readily.
Nosebleeds, also called epistaxis, happen when small blood vessels inside the nose break and bleed. Almost everyone has at least one nosebleed at some point, and they are usually harmless.
Most nosebleeds are mild and stop with simple first aid. They often originate from the anterior part of the nose, particularly an area on the nasal septum called Little’s area or Kiesselbach’s plexus. The nasal septum is the wall that separates the two nostrils. Little’s area contains a rich network of small blood vessels, which is why it is a common site of anterior nosebleeds.
A smaller number of nosebleeds come from deeper inside the nose. These are called posterior nosebleeds. Posterior bleeding can be more difficult to control and may cause blood to flow backwards into the throat. This type of bleeding is more common in older adults, those with high blood pressure, and patients taking blood-thinning medication.
In Singapore, nosebleeds may be triggered by nasal allergies, sinus inflammation, nose-picking, air-conditioned rooms, respiratory infections, and irritation from the haze or dry indoor air. Frequent nosebleeds, heavy bleeding, or bleeding that is difficult to stop should be evaluated by an ENT specialist.
Barrie Tan ENT Head & Neck Surgery provides comprehensive care for nosebleeds.
Epistaxis symptoms usually include bleeding from one nostril, but blood may also come from both nostrils or flow down the throat.
A mild nosebleed may appear as a few drops of blood or a small trickle from the nostril. There may be a metallic taste if blood reaches the back of the throat. Some patients feel a tickle, wetness or pressure in the nose before the bleeding starts.
Excessive bleeding may cause blood to drip continuously, run into the mouth, or be coughed or spat out. If blood is swallowed, it may irritate the stomach and cause nausea or vomiting. A large bleed can cause dizziness, weakness, difficulty breathing or fainting, and in rare cases, heavy bleeding can threaten the airway and cause airway compromise. These symptoms need urgent medical attention.
Chronic nosebleeds may occur as repeated small bleeds from the same side of the nose. They may leave crusting, scabbing, blood-stained mucus or recurrent staining on tissues.
Common causes of epistaxis include nose picking, forceful blowing of the nose, facial trauma, nasal injury, dry nasal membranes, colds, sinus infections, and allergic rhinitis. Inflammation makes the lining of the nose more fragile. Once the lining cracks or forms a scab, the small vessels beneath can bleed. Normally, blood clots form quickly to stop the bleeding, but blood thinners will slow this process.
Dryness is a common trigger. Even in humid Singapore, long hours in air-conditioned rooms can dry the nasal passages. Patients with allergic rhinitis may rub or blow their noses repeatedly, which can further irritate Little’s area. Nasal steroid sprays can also cause bleeding if the spray is aimed directly at the septum instead of slightly outwards. Sometimes, spontaneous epistaxis occurs without a clear trigger.
Less common but important causes include a deviated septum, septal perforation, nasal polyps, benign or cancerous tumours of the nose or sinuses, blood-clotting disorders, liver disease, pregnancy-related nasal swelling, and drugs inhaled through the nose. Inherited blood vessel conditions, such as hereditary haemorrhagic telangiectasia, can cause small, widened blood vessels near the surface to bleed repeatedly, especially when they are located in Little’s area.
See a GP for a mild first episode or simple recurrent irritation. See an ENT specialist for frequent, one-sided, heavy or unexplained nosebleeds. Go to the emergency department if bleeding does not stop after 20 minutes of firm pressure, follows significant injury, or causes dizziness, fainting, breathing difficulty or heavy blood loss.
You should arrange an appointment with an ENT specialist if you have recurrent epistaxis from the same nostril, repeated crusting or scabbing, a blocked nose on one side, facial pain, a reduced sense of smell, a visible lump, or blood-stained mucus that keeps returning.
Patients on blood thinners, aspirin, chemotherapy, or medication that affects clotting should seek medical attention if the bleeding is recurrent or hard to control. Do not stop prescribed blood-thinning medication on your own unless advised by your doctor.
Children should be assessed if nosebleeds are frequent, very heavy, linked with easy bruising, or occur together with bleeding from other sites, such as the gums. Adults should be assessed if nosebleeds start suddenly without an obvious trigger, become more frequent, or occur with unexplained weight loss or neck lumps.
Seek medical advice if recurrent bleeding causes tiredness, paleness, shortness of breath, dizziness or weakness, as these may suggest anaemia.
The diagnosis of nosebleeds involves finding the bleeding site, checking for triggers and assessing whether an underlying condition is contributing to the bleeding.
An ENT specialist will ask how often the bleeding occurs, which side bleeds, how long it lasts, how much blood is lost, and whether blood flows out of the nostril or down the throat. The history also includes allergies, sinus symptoms, nasal trauma, previous surgery, high blood pressure, liver disease, clotting problems and medication use.
Tell your doctor if nosebleeds started after aspirin, anti-inflammatory medication, blood thinners, nasal sprays or new supplements, as these can affect bleeding or dry the nasal lining.
The nose is examined carefully, often with a nasal speculum. In many cases, the bleeding point is visible on the anterior aspect of the nasal septum. There may be a scab, a prominent vessel, a raw area, crusting, infection, or telangiectasia in Little’s area.
A nasal endoscopy may be recommended if the bleeding is recurrent, one-sided, heavy, posterior, or not clearly seen at the front of the nose. The endoscopy uses a slim camera to examine deeper parts of the nasal cavity. This helps the ENT specialist look for a posterior bleeding source involving the sphenopalatine or posterior ethmoidal arteries, inflammation, polyps, tumours, septal problems such as a deviated septum, or abnormal blood vessels.
Blood tests may be ordered if there is heavy or recurrent bleeding, easy bruising, suspected anaemia, use of a blood thinner, or concern about clotting. These tests may include a full blood count and clotting profile.
Contact us for more information on epistaxis or to book an appointment.
Epistaxis surgery may be considered when bleeding is recurrent, severe, posterior or not controlled with standard measures.
For many patients with repeated anterior bleeding, a focused procedure may be enough. Electrocautery of Little’s area telangiectasia is used when small abnormal surface blood vessels in Little’s area are causing recurrent bleeding. Electrocautery uses controlled heat to seal the troublesome vessels. It may be performed under local or general anaesthesia, depending on the patient’s age, comfort, bleeding pattern and the extent of the area involved.
The aim is to reduce recurrence by treating the visible abnormal vessels while protecting the surrounding nasal mucosa.
If bleeding comes from deeper in the nose, other procedures may be needed. An endoscopic cautery can be used to identify and seal a bleeding point further back in the nasal cavity. In more severe posterior bleeding, endoscopic sphenopalatine artery ligation may be considered.
In rare or complex cases, embolisation may be considered by an interventional radiologist. This involves blocking the bleeding vessel from inside the blood vessel system. It is usually reserved for selected patients and for severe episodes when other treatments are unsuitable or unsuccessful.
Recovery after cautery or epistaxis surgery is usually straightforward, but the nasal lining needs time to heal.
Possible risks include pain, infection, crusting, recurrent bleeding and irritation of the nasal mucosa. If both sides of the septum are cauterised aggressively, there is a small risk of septal perforation, which is a hole in the septum.
To prevent recurrence, keep the nasal lining moist with saline spray or gel, avoid nose picking, trim children’s fingernails, treat allergic rhinitis, avoid forceful nose blowing and reduce exposure to smoke, haze or strong chemical irritants. After a nosebleed, avoid hot drinks, alcohol, strenuous activity and nose blowing for 24 hours if advised.
Preventing nosebleeds means protecting the nasal membranes and treating the conditions that make them fragile.
Keeping the nasal passages moist can help, especially for patients who sleep in air-conditioned rooms. Saline sprays, humidification and prescribed nasal ointments can reduce dryness and crusting. Drinking enough fluids also supports healthy mucous membranes.
Allergy control is important for patients with sneezing, an itchy nose and congestion. Treating allergic rhinitis reduces rubbing and repeated blowing. If a nasal spray is prescribed, the correct technique helps prevent irritation of the septum.
Protective equipment should be used during contact sports or activities where facial injury is possible. Patients with hypertension, clotting disorders or blood-thinner use should keep regular medical follow-up.
Barrie Tan ENT Head & Neck Surgery can help patients with nosebleeds by identifying the source of the bleeding, treating the immediate problem, and reducing the risk of recurrence.
At Gleneagles Hospital in Singapore, Dr Barrie Tan assesses children and adults with recurrent or chronic nosebleeds, heavy bleeding, bleeding related to blood thinners, suspected posterior nosebleeds, and visible nasal blood vessel abnormalities.
For mild cases, treatment may focus on nasal moisturising, allergy control, a medication review and prevention advice. For a visible bleeding point, Dr Tan may recommend a cautery. For recurrent bleeding from Little’s area telangiectasia, an electrocautery may be considered when appropriate. For more severe or posterior bleeding, he will guide patients through packing, endoscopic treatment, or a further investigation.
If you or your child has frequent nosebleeds, a hard-to-stop nosebleed, or recurrent bleeding from the same side, contact Barrie Tan ENT Head & Neck Surgery for a consultation.
Nosebleeds can be a sign of local irritation, nasal allergy, infection, dryness, injury, medication side effects, high blood pressure, clotting problems, or abnormal blood vessels. Recurrent one-sided bleeding should be assessed to rule out structural growth or other nasal disease.
MBBS, MRCS (Edinburgh), MMed (Otorhinolaryngology), FAMS
Dr Barrie Tan is an ENT specialist at Gleneagles Hospital, Singapore, with more than 20 years of clinical and surgical experience. He previously served as Head of ENT and Director of the Centre for Hearing and Ear Implants at Singapore General Hospital. The information provided is not intended as medical advice. More about our medical experts.
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