Why is my husband’s nose always bleeding?

Every week Dr Martin Scurr, a top GP, answers your questions

MY HUSBAND is continually getting nosebleeds — he can have up to four or five a day. He’s been like this every day since the start of the year. He is 33, generally healthy, works out a lot and eats well. Name and address withheld.

VIRTUALLY all of us have experienced nosebleeds, and in the vast majority of cases these are nothing to worry about. Apart from trauma such as being hit in the face or nose-picking, which can physically damage the delicate blood vessels inside the nose, the usual cause is dry air (such as that created by central heating), which dries out the lining of the nose, causing the mucus to become crusty and irritating, and if this is scratched, it can bleed easily.

Another cause is infections such as colds, which inflame the nasal lining, increasing blood flow and in turn making the lining more fragile and prone to bleeding.

Nasal sprays containing steroids used for treating an allergy can also irritate the nose and cause recurrent bleeding.

The technical term for a nose bleed is epistaxis, and there are two types: anterior and posterior.

Anterior is the most common — and less serious — and refers to bleeding near the front of the nose. This is due to damage to the Little’s area, a point on the septum (the cartilage that divides the nose) where three blood vessels meet. It is particularly fragile and nosebleeds here are usually caused by one of the factors mentioned above.

Far less frequent are posterior nosebleeds, which originate much further back in the nose. These are more worrying because the bleeding usually comes from arteries that pass through the back of the nasal cavity. If one of these bursts, the blood loss can be rapid and severe.

THIS type of bleeding will require specialist care in a hospital. You can tell the difference as the blood also flows vigorously backwards into the throat.

Nosebleeds are rarely caused by bleeding disorders or cancer, though in patients with other disorders that require medication such as warfarin or low- dose aspirin to prevent blood clots, nosebleeds are more likely and more difficult to stop.

You say your husband is an otherwise healthy man so it is unlikely that he has a serious bleeding disorder as there are no other symptoms. Doctors pre- sented with frequent recurrent nosebleeds in such patients would consider possible causes such as constant exposure to dry or cold air, and recurrent colds, or the use of medication such as nasal sprays, or illicit drug use.

In many people, the problem is simply a more fragile Little’s area.

It is worth a few words at this point about how to stop a nosebleed. First, sit or stand: do not lie down, as blood might run backwards and then be swallowed, which many find unpleasant.

Blow the nose to get rid of any clots, even though this may worsen the bleeding for a moment. Now squeeze the main part of nose — not the bridge, which many people do but which would make no difference — keeping it closed, firmly, for at least ten minutes. Resist the temptation to release the pressure to see how things are going.

If, after this, bleeding continues, repeat the process but on this occasion squeeze for 30 minutes. If bleeding persists then see a doctor as this may indicate that the bleeding is coming from further back.

I advise you to persuade your husband to see his GP for an inspection of the nose. If there is a fragile bleeding point that is causing the bleeding — as is likely — most GPs have the skill and experience to cauterise (seal) the spot using a crystal of silver nitrate, resolving the problem. WHILE on holiday in America 11 years ago, I suffered a seizure and ended up in hospital overnight and being subjected to a battery of tests before being prescribed 300mg of phenytoin and allowed to catch my flight home.

Back in the UK, I saw my GP, who referred me to a specialist. Again I had all the tests (including an MRI), but nothing was found. I personally think I had suffered a heat stroke due to dehydration, but this was never mentioned.

I am still taking phenytoin every night, purely for preventative reasons, but I would really like to come off this drug (I know that you have to be weaned off).

What I would like to know is exactly what phenytoin does to the brain? I am 72.

Eve Gillmon, Salisbury. I UNDERSTAND your predicament: the desire to stop this very long-term medication is tempered by the fear that doing so might allow a further seizure.

But the risk of this happening is rather difficult to calculate.

Phenytoin is mainly used to treat epilepsy. However, epilepsy is only diagnosed if there have been two or more unprovoked seizures, at least 24 hours apart; and so, by definition, you do not have epilepsy.

For the benefit of other readers, a seizure is when there is a moment of abnormal and excessive electrical activity in the brain — this causes changes in awareness and behaviour, including the characteristic convulsions.

Seizures last for, at most, a few minutes. A key point to note is that not everyone who has had a seizure has epilepsy, which is a condition that causes recurrent seizures.

WHEN your seizure occurred 11 years ago, it was concluded that the single event had no other obvious cause, although your own view is that it was caused by dehydration.

It has to be said that if you were seen by a specialist today after just one seizure, it would be unlikely that they would prescribe you a drug such as phenytoin; although that decision has to be made on a case-by- case basis.

Phenytoin was first used for seizure control more than 80 years ago. It acts in a part of the brain called the motor cortex, blocking some of the electrical activity and preventing the nerve cells from firing excessively.

The important point for you is that the drug only targets abnormal nerve cell function and does not cause any form of permanent brain damage.

With regular daily use, there can be side- effects with this drug including nausea, abdominal pain, poor appetite and unwanted hair growth, but it appears that none of those problems affect you.

I agree that it would be reasonable to be gradually weaned off the phenytoin at this point. Your GP can advise on the correct regimen, or a referral to a consultant neurologist may offer further supportive guidance.