When a Nosebleed May be Dangerous

May 1, 2022 Return

Words Lim Teck Choon

Dato’ Paduka Dr Balwant Singh Gendeh
Consultant Ear, Nose & Throat Surgeon

Attila the Hun, the much-feared fifth century king, managed to carve an empire from the Black Sea to the Mediterranean, and his name sent jolts of fear down the spines of even the most daring generals of the Roman Empire. Alas, the mighty leader eventually died… of a nosebleed. Okay, many historians still debate to this very day over the actual cause of that man’s death, but we do wonder: can a nosebleed really be that dangerous? We decide to ask Dato’ Paduka Dr Balwant Singh Gendeh for the pesky details.

Usually, nosebleeds are not so serious in children.

A nosebleed isn’t usually serious in children, says Dr Balwant. It is sometimes seen in children with allergies who also suffer from infections – such as during a bout of allergic rhinitis or when the child inserts a germ-filled finger or two up a nostril. And with children being children, they may also get a little rough while playing and sustain a nosebleed as a result. However, these cases are usually self-limiting, as the bleeding often goes away on its own after a short while.

However, if nosebleeds are frequent, or if the amount of blood is worrisome, parents may want to bring the child to see a doctor. Even if the nosebleed turns out to be not-so-serious, the parents will at least get some peace of mind knowing that their child is alright!

But be careful if it occurs in teenagers.

Teenagers, especially males, who also suffer from nasal obstruction on top of nosebleed should consult a ear, nose and throat (ENT) specialist, as the presence of both the bleeding and the obstruction could be a sign that they have angiofibroma.

Angiofibroma is a benign tumour formed in the nasal cavity. It almost exclusively affects males, and commonly shows up in teenagers between seven and 19 years of age.

While the tumour is benign (not cancerous), it can grow in size and eventually protrude into the surrounding tissues (such as the sinuses, eye cavity or orbit, and the space in the skull occupied by the brain or cranial vault). As a result, the affected person may experience any or some of the following:

Appearance changes such as swollen cheeks, bulging eyes and drooping eyelids.
Cranial nerve palsy, which happens when the tumour presses into and damages nerves linked to the brain, causing difficulties in controlling facial muscles and/or eye movements.
Hearing loss when the tumour obstructs the Eustachian tube.
When the tumour grows into the eye cavity and presses onto the optic nerves, double vision or blindness may occur over time as a result of damage to these nerves.
While not common, some affected people may lose their sense of smell.

Dr Balwant explains that angiofibroma can be removed via the endoscopic endonasal approach (EEA) surgery, which he had kindly detailed in the August 2017 issue of HealthToday. This is a relatively straightforward procedure that involves the removal of the tumour while guided by an endoscope through the nostril. If the tumour is removed completely, there is usually no recurrence.

Dr Balwant advises to see a doctor quickly if the nosebleed is severe or torrential. Otherwise, we may be at risk of hypovolemic shock – a condition in which the heart is unable to pump enough blood to keep up with the blood loss, causing body organs to malfunction or even stop functioning altogether.

The elderly must be especially careful of nosebleeds.

Members of the elderly age group that experience both nosebleeds and nasal obstruction must see an ENT specialist to ensure that they do not have health conditions that cause these issues.

Can it be cancer?

Dr Balwant explains that nasopharyngeal carcinoma (NPC) is one of the conditions that can be responsible for both the nasal bleeding and obstruction. Like its name suggests, NPC originates in the nasopharynx, which is the area that encompasses the upper part of our throat, behind our nose. (When we inhale, air flows from the nostrils through the nasopharynx into the lungs.) NPC is especially common among the Chinese in Malaysia, and it mainly affects adults aged 40 to 60.

Like most cancers, NPC has a better treatment outcome if it is detected early. Therefore, while nosebleed and nasal obstruction may not necessarily be a sign that one has NPC, it doesn’t hurt to consult an ENT specialist to be certain!

It may be a sign of high blood pressure

Dr Balwant explains that, in the absence of other causes of nosebleed (such as injuries or lesions in the nose), moderate to severe (torrential) nosebleed can be a result of high blood pressure or hypertension.

If we experience such nosebleeds, especially on a frequent basis, we need to see an ENT specialist as soon as possible.

Hereditary haemorrhagic telangiectasia

Frequent nosebleed is one of the symptoms of a rare genetic condition called hereditary haemorrhagic telangiectasia (HHT), or Osler–Weber–Rendu disease.

People born with HHT have abnormally formed blood vessels (such as fragile vessels, lack of capillaries, etc) and experience frequent internal bleeding as a result.
Aside from frequent nosebleeds, they also experience lesions on the skin and in the mouth.
In the long run, the frequent internal bleeding will likely lead to health complications in the brain, lungs, liver and other organs.
Because of its rarity, HHT is sometimes confused for haemophilia and other blood conditions. It can be diagnosed by gene testing.
As of now, there is no cure, and management involves treating complications as they arise. However, several experimental drugs are currently being tested to help minimize the rate of internal bleeding.

Medications that prevent the formation of blood clots, such as anti-coagulants like warfarin or anti-platelet drugs such as aspirin, can cause nosebleeds as a side effect. These medications are commonly prescribed to treat health conditions related to our cardiovascular system. We should let our doctor know if we experience frequent nosebleeds while taking these medications.

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