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Nosebleeds: Doctor, can I damage my nose by blowing too hard?

Welcome back dear friends to this week's TGIF Dr Euan Blog Post!


During the recent COVID pandemic, many of us were hit and down with a bad cough and cold, and often having to blow our noses and using up lots of Kleenex tissues!


Today's topic is on if blowing your nose too hard can cause damage, or even possibly nosebleeds



Q: Does vigorous nose clearing / blowing out all that mucus cause any damage to my nose?


The main thing with blowing your nose too vigorously is that it can cause it to bleed – too much pressure can cause blood vessels to burst – but it's never usually dramatic. You may just notice some bloodstains on your tissue; this results from some capillary (small blood vessels) rupturing at the front portion of your nose, called "Little's Area".

Try to be gentle when blowing your nose to avoid bursting nose capillaries


Epistaxis (Nose Bleeds):

A study conducted by researchers at the University of Virginia found that forcefully blowing our nose builds up an amount of pressure 10 times greater than that of an involuntary response such as a sneeze or cough (via The Health Site). When we blow too hard, the power of all that added pressure can cause the blood vessels stored within the lining of the mucus membrane to burst, potentially resulting in nosebleeds (via Berkeley Wellness).


Additionally, harsh nose blowing can also cause ear or sinus infections. Should you become sick from a viral or bacterial infection, the germs in your nasal cavity can be transferred into the sinuses or inner ear through nose blowing. This is due to the fact that our ears, nose, and throat all function as one connected system.


Here is a short video clip on what happens if you blow your nose too forcefully:

https://www.healthdigest.com/376445/surprising-side-effects-of-blowing-your-nose-too-hard/?utm_campaign=clip


Sinus infection:

According to recent study conducted at the University of Virginia, cited in The Wall Street Journal, when you blow your nose you generate 10 times more pressure than you do while coughing or sneezing. Sometimes, the pressure generated can be so intense that the accumulated mucus may even propel into the sinus spaces and drainage passageways. This can cause sinus infections, making your condition worse.

An earlier study by Gwaltney JM J revealed that a single nose blow can propel nearly 1 ml of viscous mucus or fluid into the intranasal sinuses. Further, blowing also forces air into the sinus spaces, giving rise to mucus bubbles that increase intranasal pressure. This can cause headaches and inflammation of the sinuses or sinusitis. You can read more about my advice on sinusitis here.

According to Dr Rohit Vishnoi, Senior Consultant, ENT, Delhi-based Sri Balaji Action Medical Institute, when blockage of the sinus ostium (an opening that connects the sinus to the nasal cavity) becomes worse, surgical intervention may be needed to remove the blockage eg. balloon sinuplasty or endoscopic sinus surgery.

Blowing your nose too hard can create mucus accumulation in the sinus space causing infection


Ear Barotrauma:

Blowing your nose incorrectly can cause trauma to your eardrums. Especially in the winter months, with cold and flu season causing a stuffy or runny nose, you need to be careful about blowing your nose too much. It seems a simple thing that we often don’t think about, but this repetitive action can damage your ears. In severe cases, blowing your nose too hard can give you an earache or even rupture your eardrum.


The nose, ear, and mouth are all connected. However, a forceful nose blow can cause a rapid change in pressure behind the eardrum in your middle ear. This sudden/rapid change in pressure can cause pain in your ear, a longer-lasting earache, or a ruptured eardrum.


Here are some simple steps to help prevent damaging your eardrums by correctly clearing your nasal passages when needed:

  1. Keep both nostrils open when blowing your nose.

  2. Blow gently into a tissue through both nostrils.

  3. You can partially close one nostril if you are careful not to close it all the way, but this is not recommended.

  4. Wipe any remaining mucus from your nose, dispose of the tissue, and wash your hands to prevent any cross-infections.

If you blow your nose too hard and hear a pop followed by pain, you may have damaged your eardrum and should consult your GP / ENT Specialist to check and inspect your ear. A small pop might be your eustachian tube equalising the pressure between your middle and outer ear.


Ear infection:

Sometimes, you may even hear a crackling sound in your ear while blowing your nose. This means that the generated intra-nasal pressure has forced the mucus to get pushed back up into the middle ear. This may result in an ear infection and is the reason why you may experience ear pain when you're suffering from a cold. You can read more about my advice on ear infections here.



Here is a useful link to an article in the GUARDIAN from the UK:

https://www.theguardian.com/lifeandstyle/2019/nov/24/how-to-blow-your-nose-properly#:~:text=The%20main%20thing%20with%20blowing,some%20bloodstains%20on%20your%20tissue.


You can blow both nostrils simultaneously, but there may be a deviation in the midline partition – the septum – which may make it difficult to perform this. You may find it easier to blow one nostril, then the other nostril to facilitate nasal clearance.


Blowing your nose is mostly for comfort – most people do it because they have a feeling of some mucus buildup in their nose.


In truth, we all produce a pint and a half of mucus every day, which we swallow without noticing. Most of the time, you blow your nose because you have an excess of mucus production – you have a cold, nasal allergy, hay fever or other conditions. If you work in a polluted environment, blowing your nose is a way of clearing out the mucus that has collected debris and pollutants from the atmosphere.

Nasal douching with a saline solution is a technique doctors recommend for patients with various nasal disorders, such as allergies and people with rhino-sinusitis (nasal inflammation), and an additional way to clear excess mucus. You can get a kit from your pharmacist or supermarket.

Photo of Neilmed nasal wash bottle & saline nasal rinse sashays


Q: What are some tips to clear your nasal congestion with minimal risks:

  • Before blowing the nose, moisten it with a saline spray. Practice this especially when you're blowing your nose early in the morning after the nasal passage has dried out throughout the night. You can also do a nasal wash.

  • Close one nostril using your thumb and gently blow the other. Make sure you're not applying too much pressure on the other nostril that you're blocking.

  • In case, blowing the nose doesn't help you, you could use an over-the-counter nasal decongestant or nasal drops to clear the passage. But don't make it a habit because it might dry out your nasal passage and make you susceptible to respiratory infections.

  • Alternatively, you could inhale steam or sip hot soup to clear your blocked nose.

  • You can read more about my advice on nasal sprays here.

If you would like to consult to check your nose, please contact us at Euan's ENT Surgery & Clinic to book an appointment.


Well, I wish you a SNOT free, clear nose weekend ahead :-)

Here are some useful references if you are keen to delve deeper!


References:


1. Chiu W.-C., Huang T.-Y., Ku W.-C., Lih M., Wang W. Spontaneous orbital subcutaneous emphysema after sneezing. The American Journal of Emergency Medicine. 2008;26(3):381.e1–381.e2. doi: 10.1016/j.ajem.2007.05.021. [PubMed] [CrossRef] [Google Scholar]


2. Shah N. Spontaneous subcutaneous orbital emphysema following forceful nose blowing: treatment options. Indian Journal of Ophthalmology. 2007;55(5):p. 395. [PMC free article] [PubMed] [Google Scholar]


3. Jawaid M. S. Orbital emphysema: nose blowing leading to a blown orbit. BMJ Case Reports. 2015;2015 [PMC free article] [PubMed] [Google Scholar]


4. Rodriguez M. J., Dave S. P., Astor F. C. Periorbital emphysema as a complication of functional endoscopic sinus surgery. Ear, Nose & Throat Journal. 2009;88(4):888–889. doi: 10.1177/014556130908800414. [PubMed] [CrossRef] [Google Scholar]


5. Boggess W. J., Ronan J., Panchal N. Orbital, mediastinal and cervicofacial subcutaneous emphysema after dental rehabilitation in a pediatric patient. Journal of Pediatric Dentistry. 2017;39(7):465–467. [PubMed] [Google Scholar]


6. Fleishman J. A., Beck R. W., Hoffman R. O. Orbital emphysema as an ophthalmologic emergency. Ophthalmology. 1984;91(11):1389–1391. doi: 10.1016/S0161-6420(84)34135-5. [PubMed] [CrossRef] [Google Scholar]


7. Gwaltney J. M., Jr., Hendley J. O., Phillips C. D., Bass C. R., Mygind N., Winther B. Nose blowing propels nasal fluid into the paranasal sinuses. Clinical Infectious Diseases. 2000;30(2):387–391. doi: 10.1086/313661. [PubMed] [CrossRef] [Google Scholar]


8. Shuttleworth G. N., David D. B., Potts M. J., Bell C. N., Guest P. G. Lesson of the week: orbital trauma: do not blow your nose. British Medical Journal. 1999;318(7190):1054–1055. doi: 10.1136/bmj.318.7190.1054. [PMC free article] [PubMed] [CrossRef] [Google Scholar]


9. Shameer A., Pushker N., Lokdarshi G., Basheer S., Bajaj M. S. Emergency decompression of orbital emphysema with elevated intraorbital pressure. The Journal of Emergency Medicine. 2017;53(3):405–407. doi: 10.1016/j.jemermed.2016.10.021. [PubMed] [CrossRef] [Google Scholar]


10. Lin C.-Y., Tsai C.-C., Kao S.-C., Kau H.-C., Lee F.-L. Needle decompression in a patient with vision-threatening orbital emphysema. Taiwan Journal of Ophthalmology. 2016;6(2):93–95. doi: 10.1016/j.tjo.2015.02.003. [PMC free article] [PubMed] [CrossRef] [Google Scholar]


11.W.-C. Chiu, T.-Y. Huang, W.-C. Ku, M. Lih, and W. Wang, “Spontaneous orbital subcutaneous emphysema after sneezing,” The American Journal of Emergency Medicine, vol. 26, no. 3, pp. 381.e1–381.e2, 2008.View at: Publisher Site | Google Scholar


12. N. Shah, “Spontaneous subcutaneous orbital emphysema following forceful nose blowing: treatment options,” Indian Journal of Ophthalmology, vol. 55, no. 5, p. 395, 2007.View at: Google Scholar


13. M. S. Jawaid, “Orbital emphysema: nose blowing leading to a blown orbit,” BMJ Case Reports, vol. 2015, 2015.View at: Google Scholar


14. M. J. Rodriguez, S. P. Dave, and F. C. Astor, “Periorbital emphysema as a complication of functional endoscopic sinus surgery,” Ear, Nose & Throat Journal, vol. 88, no. 4, pp. 888-889, 2009.View at: Publisher Site | Google Scholar


15. W. J. Boggess, J. Ronan, and N. Panchal, “Orbital, mediastinal and cervicofacial subcutaneous emphysema after dental rehabilitation in a pediatric patient,” Journal of Pediatric Dentistry, vol. 39, no. 7, pp. 465–467, 2017.View at: Google Scholar


16. J. A. Fleishman, R. W. Beck, and R. O. Hoffman, “Orbital emphysema as an ophthalmologic emergency,” Ophthalmology, vol. 91, no. 11, pp. 1389–1391, 1984.View at: Publisher Site | Google Scholar


17. J. M. Gwaltney Jr., J. O. Hendley, C. D. Phillips, C. R. Bass, N. Mygind, and B. Winther, “Nose blowing propels nasal fluid into the paranasal sinuses,” Clinical Infectious Diseases, vol. 30, no. 2, pp. 387–391, 2000.View at: Publisher Site | Google Scholar


18. G. N. Shuttleworth, D. B. David, M. J. Potts, C. N. Bell, and P. G. Guest, “Lesson of the week: orbital trauma: do not blow your nose,” British Medical Journal, vol. 318, no. 7190, pp. 1054-1055, 1999.View at: Publisher Site | Google Scholar


19. A. Shameer, N. Pushker, G. Lokdarshi, S. Basheer, and M. S. Bajaj, “Emergency decompression of orbital emphysema with elevated intraorbital pressure,” The Journal of Emergency Medicine, vol. 53, no. 3, pp. 405–407, 2017.View at: Publisher Site | Google Scholar


20. C.-Y. Lin, C.-C. Tsai, S.-C. Kao, H.-C. Kau, and F.-L. Lee, “Needle decompression in a patient with vision-threatening orbital emphysema,” Taiwan Journal of Ophthalmology, vol. 6, no. 2, pp. 93–95, 2016.View at: Publisher Site | Google Scholar


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