Well, in my world we call nosebleeds epistaxis, from the Greek words epi, meaning “in addition,” and stazein, meaning “to drip.” And yes, altitude can cause nosebleeds as can many other things, so let’s explore what’s in this part of the auditorium!
Importantly, most nosebleeds are totally benign, self-limiting, and need little more than a bit of pressure to treat them—more of that to follow—but they can be indicative of a serious underlying disease, especially if incessant or repetitive. Garden-variety nosebleeds can affect anyone, although they are more common in the very young and older folks, the former because they get more colds, the latter for disparate reasons like hardened blood vessels.
The blood may originate from the front of the nose, or anterior as we like to say, and often flows out of one nostril due to a damaged, delicate vessel in Kiesselbach’s plexus, also known as Little’s area, situated just inside the nose on the septum, the wall dividing the nostrils. This explains the best way to stop a nosebleed; apply pressure across the bottom of the nose, pinching both nostrils against the central wall. And don’t put your head down below your knees—that actually increases the flow of blood—just sit back calmly in a chair, your head tilted ever so slightly forward to stop blood flowing back, breathe through your mouth, wait 10–20 minutes, and then do not blow your nose for as long as possible to give the clot time to mature and harden.
Bleeding that either comes from both sides, or does not stop with the above maneuver, is possibly from further back (the nose goes “backward” more than it goes “up”) or posterior in medispeak, and likely emanates from Woodruff’s plexus. Because of its position, the blood may unpleasantly flow back into the throat and be coughed back up, a symptom called hemoptysis. Blood has a strong flavor, and a patient once commented after a nosebleed it was funny that blood tastes metallic. The doctor responded, “Yes, it’s pretty iron-ic.”
As for causes, far and away the most common is an upper respiratory tract infection like the common cold, or seasonal allergies which, like viruses, cause nasal inflammation. This induces blood vessels to swell and excess mucus to be produced, sneezing follows, and, together with nose-blowing, vessels are traumatized, leak, and hey presto, nosebleed! Some nasal sprays to treat these symptoms can themselves cause nosebleeds by drying out the membranes. We all know that coughs and colds are more common in winter, when air is cold and dry and homes are heated, possibly without humidification, all of which predispose to nosebleeds. If you are prone to a stuffy and runny nose, make sure you humidify your dwelling. And while it is soothing to bathe when unwell, you don’t want to take a shower with a nosebleed—it would be a bloodbath!
Chronic inflammation from nasal infections, asthma, or allergies can manifest as a polyp, a cauliflower-like appendage that may bleed and block the air passages but can be removed by an ENT surgeon. Exposure to tobacco smoke or cocaine can also cause nasal polyps and bleeding among many other problems.
The next most common is nasal trauma, which in children may be due to them inserting a foreign body; my family doctor friend regaled me with stories of items he has retrieved in his career, enough toy soldiers to start a regiment! In adults, trauma might be from the socially questionable habit of picking one’s nose (which, I believe, is induced by being stuck in a traffic jam—at least my observations lead me to that conclusion) or walking into a leading edge or hangar door or criticizing another pilot’s technique in the FBO.
Repetitive nosebleeds might indicate a nasal tumor, so if bleeds recur, please get checked out. As higher forms of life, pilots might use oxygen, and cannulae can rub against the nasal lining causing bleeding; spend extra money for ones with soft tips and add a saline nasal spray to your flight bag for frequent insertion. Remember, air is dry at altitude, aviation oxygen is devoid of humidity and at high flow very efficiently desiccates delicate tissues. Do not be tempted to add a smear of petroleum jelly (Vaseline) to the tips to prevent chafing. Although this is done in hospitals when gaseous oxygen is delivered, liquid aviators breathing oxygen are volatile in contact with petroleum products; not a good combination in an aircraft!
General causes for nosebleeds include high blood pressure or anything that affects the blood’s ability to clot. This includes drugs like aspirin or ibuprofen or medications like clopidogrel or coumadin to prevent blood clots. Blood diseases like leukemia or ITP, a disease where platelets are lacking, and more obscure disorders like hemophilia and von Willebrand’s disease, can also do this. Many will know about Rasputin, a shadowy Russian historical figure who helped the young Tsarevich Alexei “control” his hemophilia, although most of these stories are as fanciful as Daedalus and Icarus’ first controlled flight!
A rare condition called Osler-Weber-Rendu syndrome, where various aberrant blood vessels have a bleeding tendency, also appears in any list of causes. More commonly, and worthy of note, excessive alcohol use damages one’s ability to make clotting factors in the liver and can present with epistaxis.
For a continuous or recalcitrant nosebleed, stemming the flow may involve spraying a vessel-constricting medicine, sealing the leak with an energy source, or packing the nose with a long bandage or nasal tampon to apply pressure to the posterior area. One should not do this at home as there are possible long-term infectious complications such as rhinosinusitis or even toxic shock syndrome, which can have dire consequences. Once things have settled down, the source can be identified either by peeking inside with a flexible scope or, in certain cases, doing a special X-ray where contrast is injected into an arm vein, thereby allowing doctors to identify and block the leaking vessel from inside.
I was once on board a transatlantic flight and heard the dreaded announcement, “Is there a doctor on board?” I duly responded and found a 9-year-old boy in the mid-cabin galley, a worried dad and compassionate airline employees at hand. He had traveled with his father from their home in Liberia to visit London and were now off to see relatives in New York and the poor little fellow had an impressive nosebleed. The flight attendants had tried to control it to no avail and while I was doing the squeeze trick, the captain appeared and said that he heard we had a possible case of Ebola on board. While that dreaded virus can cause bleeding, including from the nose, this lad’s nosebleed was from a simple cold and soon responded to my administrations. Our esteemed pilot did say he was willing to divert to Newfoundland where he claimed to know a fine establishment where we might enjoy a libation, but when I told him that declaring a possible case of Ebola would put us all in isolation, he retreated to the cockpit!
Finally, a question for you: why did the shark keep swimming in circles? It had a nosebleed! With that performance of Jaws, shell out for decent seats and keep out of the nosebleed section! Fly well!
Please consider taking up your free subscription at Spotify or Apple Podcasts for my—hopefully—fun and inspiring podcast “Join the Docs!” You can also check out the website
And watch all sorts of entertaining videos on
YouTube: @JoinTheDocs
Instagram:@JoinTheDocs
TikTok: @JoinTheDocs
Facebook: @JoinTheDocs
Twitter: @JoinTheDocs
And you can send your questions and comments to me via email: [email protected]
