- Nosebleed treatment
- Managing nosebleeds
- Are you sure your patient has epistaxis? What are the typical findings for this disease?
- What caused this disease to develop at this time?
- What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
- Would imaging studies be helpful? If so, which ones?
- If you are able to confirm that the patient has epistaxis, what treatment should be initiated?
- What causes this disease and how frequent is it?
- What complications might you expect from the disease or treatment of the disease?
- How can epistaxis be prevented?
- What is the evidence?
- When a Nosebleed is More than a Nosebleed: Understanding HHT with Sara Palmer
- Cerebrovascular Center
- Severe Nosebleed (Epistaxis)
- Treatment Options
- Lung Cancer Symptoms
- General lung cancer symptoms
- Lung cancer symptoms – coughing up blood
- Less common lung cancer symptoms
- Lung cancer symptoms – hormone symptoms
- Lung cancer symptoms – Pancoast syndrome
- When Is a Nosebleed a Sign of Nasal Cancer?
What should I do when I get a nosebleed?
A nosebleed can be scary to get — or see — but try to stay calm. Most nosebleeds look much worse than they really are. Almost all nosebleeds can be treated at home.
If you get a nosebleed, sit down and lean slightly forward. Keeping your head above your heart will slow the bleeding. Lean forward so the blood will drain out of your nose instead of down the back of your throat. If you lean back, you may swallow the blood. This can irritate your stomach.
Use your thumb and index finger to squeeze together the soft portion of your nose. This area is located between the end of your nose and the hard, bony ridge that forms the bridge of your nose. Keep holding your nose until the bleeding stops. Don’t let go for at least 5 minutes. If it’s still bleeding, hold it again for another 5 to 10 minutes.
Once the bleeding stops, don’t do anything that may make it start again, such as bending over or blowing your nose.
See your doctor if:
- The bleeding goes on for more than 20 minutes
- The bleeding was caused by an injury, such as a fall or something hitting your face
- You get nosebleeds often
What will my doctor do for a nosebleed?
Your doctor will try to find out where the bleeding is coming from in your nose. He or she will probably ask you some questions and examine your nose. If the bleeding doesn’t stop on its own or when pressure is applied, your doctor may cauterize the bleeding vessel or pack your nose to stop the bleeding.
Cauterization involves using a special solution called silver nitrate or an electrical or heating device to burn the vessel so that it stops bleeding. Your doctor will numb your nose before the procedure.
Packing the nose involves putting special gauze or an inflatable latex balloon into the nose so that enough pressure is placed on the vessel to make it stop bleeding.
Nosebleeds can be a common side effect of certain breast cancer treatments that lower your platelet count. A type of blood cell, platelets collect at the site of a cut or injury and make the blood clot. If your platelet count is lower than usual because of treatment, it may be hard for your body to stop bleeding, especially in your nose. Nosebleeds can happen fairly easily from lightly bumping your nose or even blowing it.
Breast cancer treatments that can cause nosebleeds are:
- Avastin (chemical name: bevacizumab), a targeted therapy
Some pain medications such aspirin also can increase your risk of nosebleeds.
Severe nosebleeds may contribute to anemia or fatigue.
If you’re having frequent, severe nosebleeds, talk to your doctor. You may be able to change medications.
To stop a nosebleed:
- Don’t lie down. Sitting up prevents you from coughing or choking on any blood that may be running down the back of your throat.
- Don’t tilt your head back; this will cause you to swallow blood. Lean your head forward.
- Pinch your nostrils together for 10 minutes with your index finger and thumb. Look at a clock when you do this so you know that you’ve compressed your nose long enough to stop the bleeding.
- Spit out any blood that may be in your mouth to avoid swallowing the blood, which may cause you to vomit.
- Call your doctor if the bleeding doesn’t stop after 15 or 20 minutes.
To prevent future nosebleeds:
- Try to avoid itching or blowing your nose for 24 hours after the initial nosebleed.
- Place a humidifier or vaporizer in your house to add moisture to the air. Dry nasal passages can increase your risk of nosebleeds.
- Avoid non-steroidal anti-inflammatory medications (NSAIDs) such as aspirin and ibuprofen. They can increase your risk of nosebleeds.
Was this article helpful? /
Last modified on April 26, 2019 at 11:14 AM
Leer esta página en español
Are you sure your patient has epistaxis? What are the typical findings for this disease?
Epistaxis is a common complaint. More often than not, bleeding is evident from the front of the nose and may be unilateral or bilateral. It is possible to have posterior nasal bleeding, which may present as blood in the patient’s mouth (spitting up blood or vomiting blood) rather than blood from the nose, but this is much less common.
The most common symptoms of epistaxis are obvious fresh blood from the nose and/or mouth. The next most common symptoms are nausea and vomiting (if blood has been swallowed).
Remember your ABCs. Epistaxis can be a life-threatening event or a harbinger of other life-threatening conditions. Bleeding in the nose can interfere with the patient’s ability to adequately protect his or her airway. If the patient is neurologically altered at baseline or is incapacitated, bleeding and subsequent loss of airway protection can be life-threatening. Even neurologically intact patients can be overwhelmed and lose airway control if bleeding is brisk.
Ask yourself, is this patient protecting his or herself adequately or is the bleeding sufficient to cause aspiration and difficulty breathing. If so, call for a medical response team. This is also an appropriate time for an emergent consultation with an otolaryngologist.
Again remember your ABCs. Check the patient’s vital signs. Hypertension may exacerbate epistaxis. Hypotension may indicate rapid volume loss and the need for fluid resuscitation (volume expanders and/or blood). If you find yourself in this type of situation, again ask for assistance, ensure that there is large-bore intravenous access and working suction in the room and begin efforts to stabilize the patient. Again, the otolaryngologic service should be called as well. Laboratory studies should be obtained to assess hemoglobin level, platelet level, and coagulation profile.
Far more commonly, epistaxis presents as a troublesome occurtence rather than a life-threatening emergency. In this situation, you will be afforded the time to both manage the problem and investigate its cause.
Epistaxis should first be classified as anterior, posterior, or cannot be determined. The vast majority of epistaxis is occurring from the anterior portion of the nose rather than posteriorly. Anterior bleeding tends to present with blood from the nose, whereas posterior bleeding often presents with blood from the nose as well as a significant amount of blood from the mouth as well. Posterior bleeding is more often a major significant bleeding event. Determining where the bleeding is coming from, or determining that you cannot tell where the bleeding is coming from, is an early part of epistaxis management.
Epistaxis should next be determined to be primary or secondary. Those nosebleeds that are determined to be secondary to an underlying condition will have, as a part of their management, care of the underlying condition.
Vascular Anatomy of the Nose
The majority of the blood supply comes from the external carotid artery, with a small amount from the internal carotid artery.The anterior and posterior ethmoid arteries, which supply the superior nasal cavity and superior septum, are branches of the ophthalmic artery, itself a branch of the internal carotid artery. The facial artery and internal maxillary artery are branches of the external carotid artery. The sphenopalatine artery, a branch of the internal maxillary artery, provides the majority of blood supply to the nose.
What caused this disease to develop at this time?
Environmental factors: mucosal drying
Inflammatory diseases: Wegener granulomatosis, relapsing polychondritis
Trauma: evident by physical examination, ranging from facial trauma (accidents, nonaccidental trauma), digital trauma (nose picking), foreign bodies, nasal cannulas or continuous positive airway pressure masks, iatrogenic (recent nasal or sinus surgery)
Genetic diseases: von Willebrand factor deficiency, hemophilia, hereditary hemorrhagic telangiectasia to name a few—inquire after family history or patient history of bleeding with previous procedures
Congenital lesions: vascular malformations
Aquired coagulopathy: medication use (see below), liver disease (leads to deficiency in clotting factors), renal failure, chemotherapy, hematologic malignancies
Malnutrition: evident by history and physical examination
Drugs: aspirin, clopidogrel, warfarin, cocaine use, topical nasal steroid sprays, nonprescription medications associated with bleeding.
Neoplastic causes: benign and malignant neoplasms of nasal cavity and sinuses—in the male adolescent pediatric population a bleeding intranasal mass represents juvenile nasal angiofibroma until proved otherwise
Hypertension: a common systemic condition associated with epistaxis, although a cause-and-effect relationship has not been proved
What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?
Laboratory studies that may be helpful depend on the setting in which the epistaxis has occurred. For the healthy patient who presents with epistaxis that is easily controlled and does not recur, no studies are necessary. This is the vast majority of patients, both pediatric and adult.
For patients in whom there is a positive family or personal history of a particular bleeding disorder or of easy bruising or bleeding, a coagulation profile and complete blood count as well as platelet function assay may reveal a particular coagulopathy. Tests for von Willebrand factor deficiencies are now widely available and may also be considered.
In the hospitalized, critically ill patient, it is reasonable consider ordering coagulation studies and a complete blood count, particularly in the setting of known disruptions from baseline. For example, compromised hepatic or renal function and chemotherapeutic treatment will both affect the body’s ability stop epistaxis once it has started. These patients may need factor replacement, platelets, or blood to replenish stocks and prevent further bleeding.
Would imaging studies be helpful? If so, which ones?
In certain settings, radiologic studies are useful both for diagnosis and treatment of epistaxis. Depending on local experience and expertise, epistaxis refractory to medical care may be treated surgically or with interventional radiologic techniques. See the section on treatment.
If you are able to confirm that the patient has epistaxis, what treatment should be initiated?
Elements of immediate management of airway compromise and life-threatening blood loss is covered above. For epistaxis that is not life threatening, have the patient gently blow his or her nose to evacuate clots and then remain leaning forward to allow the blood to drip from the nose. Begin inspecting the nose for a source, using a nasal speculum, suction, and a headlight. If available, a rigid endoscope is an excellent alternative. Protective equipment should be worn.
In the setting of anterior nasal bleeding, topical therapy should be attempted. In escalating order of intervention: pressure (squeezing the cartilaginous portion of the nose for 20 minutes), topical vasoconstrictor spray (e.g., oxymetazoline spray) on a cotton ball placed in the nose, cauterization (topical silver nitrate), and anterior packing (unilateral or bilateral). There are commercially available packing materials specifically for epistaxis and the otolaryngologic and/or emergency medicine services will be familiar with their use. These often contain inflatable balloons that exert pressure and can be left in place for days and slowly deflated.
In the pediatric population, most bleeding is from the anterior septum, called Little area or Kiesselbach plexus, an area of vascular anastomoses. Little area/Kiesselbach plexus can be treated with pressure with or without topical vasoconstrictor spray. For prominent vessels seen on the septum or floor of the nose, antiseptic or barrier creams may be applied in an effort to reduce the chance of bleeding. These vessels may also be cauterized with silver nitrate or electrocautery in the setting of an active nosebleed or as a measure directed at preventing recurent bleeding. Evidence supporting these measures is somewhat controversial.
In the setting of posterior bleeding, topical therapy may be attempted first (topical vasoconstrictor sprayed into nasal cavity). If the site of bleeding is discrete and accessible, cautery may be performed. Commercially available packing materials exist that are long enough to reach the posterior nasal cavity and nasopharynx and can apply pressure and act as carriers for hemostatic agents to the likely area of bleeding.
If these devices do not control the hemorrhage, other devices exist that contain balloons and can be inflated to exert pressure in the posterior nose and nasopharynx. Posterior packing warrants admission to a monitored setting because pressure within the posterior nose and nasopharynx may lead to activation of the nasopulmonary reflex with resultant suppression of the respiratory drive, apnea, hypoxia, and cardiac arrhythmias.
If the nose requires packing, the next step in management varies with local expertise and preference. Packing may be left in place for hours to several days. If there is a balloon within the device, it can be deflated in steps until it is empty, and the packing device may removed some time later. While packing material is in place, antibiotics directed against Staphylococcus aureus and upper respiratory flora are prescribed. The patient is observed for a period packing removal. Alternatively, the patient requiring packing and whose medical condition permits it can proceed to surgical or interventional radiologic interevention without a waiting period.
Bleeding refractory to medical management (including packing) may require interventional radiologic procedures and/or surgical intervention, depending on available experience and expertise.
Neuroendovascular interventional radiologic services offer potential embolization of the arterial blood supply most likely responsible for the epistaxis. These therapies can be directed at the branches of the external carotid artery. The risk of stroke precludes embolization of the anterior and posterior ethmoid arteries, since these are branches of the ophthalmic artery (itself a branch of the internal carotid artery).
Embolization is often carried out bilaterally, treating the internal maxillary arteries (and thereby its branches, including the sphenopalatine artery) and one of the facial arteries (usually the side ipsilateral to the bleeding). Abruzzo and Heran recently published a report describing the safe use of neuroendovascular therapies in the pediatric population. This therapy offers excellent long-term success, demonstrated by a growing body of supportive literature.
Surgical therapies include ethmoid artery ligation, endoscopic sphenopalatine artery ligation, transantral ligation of the maxillary artery and ligation of the external carotid artery. Anterior ethmoid artery ligation is most commonly perfomed through an external approach with an incision in the medial canthal region. The artery is ligated, clipped or cauterized.
The posterior ethmoid artery may also be approached in this fashion. This procedure is usually used to address bleeding in the superior nasal cavity. Endoscopic sphenopalatine artery ligation is used for posterior nasal cavity bleeding and has demonstrated excellent efficacy. Transantral maxillary artery ligation has given way to endoscopic sphenopalatine artery ligation.
Medical work-up can proceed simultaneously with neuroendovascular interventional or surgical management for serious bleeding. This includes laboratory studies and medical therapy directed at correcting any underlying conditions predisposing the patient to epistaxis (e.g., platelet count for thrombocytopenia).
What causes this disease and how frequent is it?
Epistaxis is a common complaint (about 10% of the population experiences epistaxis per year). It is more common in male individuals and frequent in the dry winter months. In children, epistaxis is uncommon in those younger than 2 years of age. Thirty percent of all children 0-5 years old, 56% of those 6-10 years old, and 64% of those 11-15 years old have experienced at least one episode of epistaxis.
What complications might you expect from the disease or treatment of the disease?
Topical vasconstrictors: there is one case report of oxymetazoline overuse causing stimulant psychosis in an adult patient. Oxymetazoline, like several other nasal topical decongestants, is a sympathomimetic drug. It can cross the blood-brain barrier and cause central noradrenergic effects. A study of the effects of xylometazoline did not reveal systemic side effects such as tachycardia, anxiety, restlessness, or insomnia, although patients did experience epistaxis and blood-tinged mucus.
Silver nitrate cautery can be painful and can cause recurrent epistaxis. In addition, crusting, septal perforation, and tattooing of the mucosa may occur. Chemical cautery or electrocautery when performed on the septum bilaterally can cause a septal perforation, although Felek and colleagues noted no perforations in 38 children treated with bilateral silver nitrate application.
Nasal packing requires antibiotic prophylaxis against S. aureus and can cause damage to the external nose if the material exerts pressure on the ala. Bilateral packing can cause ischemia and necrosis of the nasal septum. Posterior packing with or without balloon use can cause respiratory suppression and apnea or hypoxia as well as cardiac arrhythmias.
Embolization has been associated with serious complications including stroke, vision loss, facial paralysis, and necrosis of skin and/or mucous membranes. Pain is not an uncommon symptom of the treatment itself.
Surgical complications are associated with the particular surgical intervention performed. Each particular operation has its own attendant sequelae and risks, from external scar formation to surgical failure, infection, sensory changes to the face, vision loss, and leakage of cerebrospinal fluid. Discussion of the risks, benefits, and alternatives for each particular operation is beyond the scope of this chapter.
How can epistaxis be prevented?
Preventive measures to reduce the risk of anterior epistaxis include antiseptic and barrier ointments. Antiseptics are thought to reduce inflammation and prevent excessive drying. Barrier ointments prevent drying as well.
If digital trauma is thought to contribute, attempting to curtail this behavior will be beneficial.
If there are known hereditary diseases that are predisposing to epistaxis, disease management (or at the least awareness) will be beneficial.
What is the evidence?
Wormald, PJ, Bailey, BJ, Johnson, JT. “Epistaxis”. Otolaryngology Head and Neck Surgery. 2006.
Kubba, H, MacAndie, C, Botma, M. “A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood”. Clin Otolaryngol. vol. 26. 2001. pp. 465-8. (Children in the group randomized to cream therapy experienced less epistaxis than did those who received no treatment.)
Glynn, F, Amin, M, Sheahan, P. “Prospective double blind randomized clinical trial comparing 75% versus 95% silver nitrate cauterization in the management of idiopathic childhood epistaxis”. Int J Pediatr Otorhinolaryngol. vol. 75. 2011. pp. 81-4. (Authors compared different concentrations of silver nitrate. Overall success for chemical cautery was greater than 90% at 8 weeks.)
Burton, MJ, Doree, CJ. “Interventions for recurrent idiopathic epistaxis (nosebleeds) in children”. Cochrane Database Syst Rev. 2007. (A 2004 Cochrane review of treatment options for idiopathic recurrent epistaxis in the pediatric population failed to reveal a difference in frequency of recurrence comparing antiseptic cream to no therapy, petroleum jelly to no therapy, and antiseptic cream to silver nitrate cautery. This review concluded that the best treatment for this particular condition is unkown.)
Murthy, P, Nilssen, ELK, Rao, S. “A randomized clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis”. Clin Otolaryngol. vol. 24. 1999. pp. 228-31. (Fifty patients, both children and adults, randomized to chlorhexidine and bacitracin cream with or without silver nitrate cautery. No difference in control rates of epistaxis between these groups.)
Calder, N, Kang, S, Fraser, L. “A double-blind randomized controlled trial of management of recurrent nosebleeds in children”. Otolaryngol Head Neck Surg. vol. 140. 2009. pp. 670-4. (Adding silver nitrate cautery to 4 weeks of antibiotic ointment offered a small advantage in decreasing recurrent epistaxis versus antibiotic ointment alone.)
Strach, K, Schröck, A, Wilhelm, K. “Endovascular treatment of epistaxis: indications, management and outcome”. Cardiovasc Intervent Radiol. vol. 34. 2011. pp. 1190-8. (This is a review of 48 patients, age range 14-87 years. The primary success rate for their intervention was 93.8% and their patients experienced two major complications—necrosis of the nasal tip requiring surgery and transient unilateral hemiparesis.)
Wormald, PJ, Wee, DTH, van Hasselt, CA. “Endoscopic ligation of the sphenopalatine artery for refractory posterior epistaxis”. Am J Rhinol. vol. 14. 2000. pp. 261-4. (Review of 13 patients demonstrating 92% epistaxis control over a mean follow-up of 13 months. No complications were encountered.)
Petruson, B. “Epistaxis in childhood”. Rhinology. vol. 17. 1979. pp. 83-90.
Ticoll, B, Shugar, G. “Paranoid psychosis induced by oxymetazoline nasal spray”. CMAJ. vol. 150. 1994. pp. 375-6.
Felek, SA, Celik, H, Islam, A. “Bilateral simultaneous nasal septal cauterization in children with recurrent epistaxis”. Int J Pediatr Otorhinolaryngol. vol. 73. 2009. pp. 1390-3. (Thirty-eight pediatric patients underwent bilateral simultaneous cauterization using silver nitrate, nine of whom underwent a second cauterization procedure. No patients experienced septal perforation. It is not clear whether or not second cauterization procedures were performed bilaterally.)
When a Nosebleed is More than a Nosebleed: Understanding HHT with Sara Palmer
Few people are familiar with HHT, an uncommon blood vessel disorder affecting about 1 in 5000 people around the world. So today I’ll introduce you to HHT—what it is and when to get tested for it.
What is HHT? HHT stands for Hereditary Hemorrhagic Telangiectasia—a mouthful of medical terminology! Here’s what it means:
Hereditary (genetic; inherited)
Hemorrhagic (causes bleeding)
Telangiectasia (abnormal blood vessel)
In other words, HHT is inherited; it causes bleeding; and the bleeding comes from abnormal blood vessels. HHT is caused by a mutation in one of several genes related to blood vessel development. If you have HHT, each of your children has a 50% chance of inheriting the disease. Only some blood vessels in people with HHT are abnormal or malformed. In these malformations, there is a direct connection between an artery and a vein, while normal capillaries (the smallest blood vessels) are missing. These malformations commonly occur in nose, gastrointestinal tract (gut), or on the skin (where they are called telangiectasias) and in the lungs, brain, or liver (where they are called arteriovenous malformations (AVMs)). The location, size and number of these abnormal vessels are different in each person with HHT, even within the same family. Some people with undiagnosed lung or brain AVMs will have serious medical complications, while others remain symptom-free. And many medical problems associated with HHT can be caused by other illnesses. All of these factors make it difficult to know if you or your family has HHT.
When to Get Tested for HHT? A variety of symptoms and medical complications result from HHT. Nosebleeds (caused by bleeding from telangiectasias in the nose) are the most common symptom of HHT, affecting about 95% of people with HHT by the time they reach middle age. Anemia can result from telangiectasias bleeding in the gut (or from frequent nosebleeds). Anemia causes fatigue, shortness of breath and weakness. Multiple small red spots (telangiectasias) on the lips, tongue, fingertips or face, while not harmful, are important in diagnosing HHT. Heart failure can result from AVMs in the liver, though this is uncommon. Stroke, brain abscess (infection) and lung or brain hemorrhage (bleeding)—most of the serious complications in HHT—come from AVMs in the lungs and brain that have not been diagnosed or treated.
HHT should be suspected if a pattern of these symptoms and complications exists in one person or in multiple family members. If you have frequent nosebleeds and you had a stroke or brain abscess with no known cause, then you might have HHT. If you have nosebleeds and your father has many red spots on his face and lips, then you and your family might have HHT. Nosebleeds alone may be a reason to suspect HHT, especially if they are frequent, persist into adulthood and/or are present in multiple generations of your family.
The best way to get tested for HHT is to visit one of the many HHT Centers of Excellence in the US, Canada and other countries (a list of Centers can be found in Living with HHT or at www.curehht.org). The diagnosis of HHT is made by a physician using established criteria including symptoms, family history, and screening tests, or by genetic testing.
What happens after I’m tested? If you’ve been diagnosed with HHT, there are two essential steps you should take: 1) get screening tests to find out whether you have AVMs in your lungs or brain. Strokes, brain abscesses and brain hemorrhages due to lung and brain AVMs are almost all preventable—but only if the AVMs are discovered and treated. 2) Tell your parents, siblings and children that they are also at risk for HHT. They should be tested, either with genetic testing or by clinical examination and screening for AVMs in the lungs and brain. If it turns out you don’t have HHT, then you cannot pass it on to your children; but if your family has the symptom pattern described above, then one of your parents and one or more of your siblings could have HHT, and they need to be tested.
When you know you have HHT, you can get the tests and treatments you need to stay healthy, learn to manage your symptoms and prevent many serious complications. Most people with HHT can live full lives, and researchers are developing new treatments for those who are limited by HHT related illness and disability. So if you think you have HHT, get tested, get screened and get treated! Tell your family and encourage them to do the same.
Want to know more about HHT? In Living with HHT, you will find in-depth discussions of symptoms, diagnosis and screening tests; treatments, procedures and preventive measures; research advances; and how to cope with the emotional and social stress of having HHT. Stay tuned for a future blog post on treatment options. And for more information, visit www.curehht.org .
Sara Palmer, PhD, is a psychologist and an assistant professor in the Department of Physical Medicine and Rehabilitation at Johns Hopkins University School of Medicine. She is the coauthor of Spinal Cord Injury: A Guide for Living; When Your Spouse Has a Stroke: Caring for Your Partner, Yourself, and Your Relationship; and Just One of the Kids: Raising a Resilient Family When One of Your Children Has a Physical Disability. Her latest book, Living with HHT: Understanding and Managing Your Hereditary Hemorrhagic Telangiectasia, deals with managing this little known disease.
Severe Nosebleed (Epistaxis)
Nosebleeds, also known as epistaxis, are common issues that usually resolve on their own or are easily treated in a medical environment. For some patients, nosebleeds can be severe enough that further treatments are needed. At Mount Sinai, we have experience handling these cases of epistaxis.
Severe episodes of nosebleeds can be caused by:
- Hereditary hemorrhagic telangiectasia (HHT), also known as Osler Weber Rendu syndrome, is a genetically inherited condition. People with HHT have small blood vessel malformations, known as telangiectasias, which affect the skin and mucosal membranes. Nosebleeds are the most common symptom; between 50 percent and 80 percent have recurrent bleeds.
- Spontaneous epistaxis usually occurs in the fifth decade of life, and may be associated with hypertension or liver insufficiency. This type of nosebleed resolves without medical treatment; however, in some patients, the intensity or repetition of hemorrhages in a short period of time may require more invasive nosebleed treatment such as embolization.
- Tumors Occasionally bleeding from the nasal or oral cavities may be related to the presence of a tumor. If there is concern for this, further imaging such as computer tomography scan or magnetic resonance imaging to evaluate what is happening.
- Vascular Malformations
The first step in managing a severe nosebleed involves “packing” the nose, which should be performed by an appropriately trained physician. If this does not stop the bleeding, a procedure called embolization is performed by which the blood vessel supplying the inner lining of the nose is blocked.
If you experience severe blood loss from a nosebleed, it can cause serious anemia or cardiac dysfunction and reduced quality of life. At Mount Sinai, we can use embolization to treat severe, recurring nosebleeds that cannot be controlled by traditional means.
We may investigate the source of the bleeding via angiography. After we identify the vessels responsible for the bleeding, we can go back in through a catheter and block the vessels to stop the bleeding (embolization). In some cases, this technique can be lifesaving.
Lung Cancer Symptoms
Sadly the majority of people have no symptoms in the early stages of lung cancer and lung cancer symptoms will vary depending on how far advanced the cancer is and its position within the chest. The type of lung cancer has little impact. This page will give you a guide to the most common lung cancer symptoms but also discuss some symptoms that are less common. If you are concerned about any symptoms you may have, please contact us or your GP immediately.
General lung cancer symptoms
The most common lung cancer symptoms include:
- Appetite loss
- Weight loss
- A persistent cough
- A change in a long standing cough
- Breathlessness or shortness of breath
- Coughing up blood (phlegm with blood in it)
- Aches or pains when breathing or coughing
- Persistent chest infections that don’t respond
to medical treatment
Lung cancer symptoms – coughing up blood
It should be noted that whilst coughing up blood (haemoptysis) usually presenting as phlegm with blood in it, is perceived as being a sure sign of lung cancer, this is not always the case. There are many reasons why people cough up blood that have nothing to do with lung cancer. The most common reason is chest infection. Additional causes include nosebleeds, occasionally bleeding in the throat, irritation in the airways (tracheobronchitis) or inflammation of the stomach or oesophagus. Whatever the cause, if you are coughing up blood you should consult your GP immediately to find out the cause.
Less common lung cancer symptoms
The following symptoms are less common and are usually associated with the more advanced stages of lung cancer. They include:
- Difficulty when swallowing
- A hoarse voice
- Finger clubbing – changes to the shape of the fingers and fingernails
- Swelling of the face and neck which may be due to obstruction of the venous drainage
- Persistent pain in the chest and/or shoulder
Lung cancer symptoms – hormone symptoms
Paraneoplastic symptoms or paraneoplastic syndrome can occur with some lung cancers that release hormones into the bloodstream. This results in symptoms and signs that may appear to have little to do with the lungs and can include:
- Numbness or pins and needles in the fingers and toes
- Swelling of the breasts in men
- Blood clots causing swelling in the legs (Thrombosis)
- Muscle weakness
- Dizziness or confusion
- General weakness
Lung cancer symptoms – Pancoast syndrome
Lung tumours that arise in the upper part of either lung can invade the uppermost ribs and the nerves that run over them to reach the arms. This can produce severe and unremitting pain in the shoulder arm and neck. By invasion of the sympathetic chain of nerves in the upper chest they can also cause drooping of the eyelid and dilatation of the pupil with blurred vision (Known as Horner’s syndrome). This collection of symptoms is called Pancoast syndrome after the surgeon that first described it. This is a serious condition that will usually need a combination of surgery and radiotherapy to treat it. Often surgery is not possible. Therefore the early reporting of any of these symptoms is essential to maximise the chance of successful treatment.
Lung cancer diagnosis and advice
If you are worried about lung cancer then LungHealth UK can help. Our Lungcheck Lung Cancer Screening service is a simple blood test and risk assessment that can put your mind at rest and highlight any risk associated behaviour. If you would like to book an appointment, please contact us and we will be happy to help. You can find the nearest clinic on our clinics page.
Please also see our risk factors page where you can read more about what can increase your risk of getting lung cancer.
When Is a Nosebleed a Sign of Nasal Cancer?
Q2. My dad had nasal polyps. Is he at increased risk for cancer in the nasal cavity? Should he be getting any kind of regular screening tests?
Nasal polyps are usually associated with chronic inflammation of the nose caused by allergies or chronic sinusitis. Most nasal polyps are benign, and treatment can consist of steroids and other medications, with surgery reserved for non-responsive or advanced disease.
Polyps that occur in only one side of the nose (unilateral) are more suspicious and should always be biopsied. The specimen should be carefully evaluated to rule out other diseases that can mimic nasal polyps such as an inverting papilloma (IP). IP is a locally aggressive tumor and although benign, can progress to a malignancy in a small percentage of cases. The treatment for IP is surgical resection.
Bleeding and pain associated with unilateral polyps are even more suspicious and should be a warning sign of a possible underlying cancer. But if your dad did not have these symptoms and his other findings were consistent with nasal polyps, there is very little risk of developing nasal cancer. He should follow his doctor’s recommendation regarding treating any underlying causes of the polyps such as nasal allergies.
Q3. My father has a peripheral nerve sheath tumor and the biopsy result is anaplastic type. The CT scan said that the growth is at maxillary and frontal sinus eroded to sphenoidal bone. There is no other lymph node involvement or metastasis. I’d like to know the staging and treatment options. If there will be radiation and chemo, how many cycles can he expect?
Most nerve sheath tumors are benign growths that occur on sensory nerves of the face or neck. A very small percentage of these tumors are cancerous. These malignancies can be aggressive and require a combination of treatments (known as multimodal therapy) including surgery, radiation and, in some cases, chemotherapy.
Surgery in this area typically involves the removal of involved sinuses, an operation called a maxillectomy. The surgeon has to follow the nerve back to the point of origin at the brain in order to obtain cancer-free margins. Whether or not a cancer is amenable to this type of surgery depends on what other surrounding structures are involved (eye, brain or carotid artery, for example). Since these surgeries can be extensive and can lead to functional and cosmetic changes, individual treatment decisions have to be made between the patient and doctor.
If treatment involves radiation and/or chemotherapy either before or after surgery, the radiation oncologist will determine the total dose of radiation needed and then divide the total dose into more manageable daily doses. The duration of treatment, therefore, will depend on the total dose recommended, but generally is between five and seven weeks of daily treatment.
Q4. I underwent treatment for nasal cavity cancer last year. I heard that vitamin A can help prevent the tumor from coming back. Is that true? How much should I take?
There are studies that suggest vitamin A and related compounds called retinoids can reverse the early changes seen in cancer cells. This has led to studies looking at chemo prevention of new cancers and recurrent cancers in patients at risk. Unfortunately, the data is still very mixed, with some studies suggesting a benefit to taking vitamin A, and others showing no benefit or even a harmful effect of taking vitamin A. Other new studies are looking at the benefits of vitamin A in certain thyroid cancers.
So until more studies are done, I would not recommend taking vitamin A or any other vitamins in high doses. Mega doses of vitamin A can seriously damage your liver as well as your skin. Quitting smoking and eating a balanced diet are still the best ways to minimize your risk of head and neck cancer.
Learn more in the Everyday Health Oral, Head, and Neck Cancer Center.