The Nose: Bleeds, Breaks, and Obstructions

Responding to a call for a female stablehand who had been kicked in the face by a horse, EMS providers found the patient awake, lying supine, in obvious pain and crying.


Responding to a call for a female stablehand who had been kicked in the face by a horse, EMS providers found the patient awake, lying supine, in obvious pain and crying. Her nose had been crushed, and she had large bruises under her eyes, other facial deformity and blood oozing from her nose and around her eyes. In the next few minutes, both eyes swelled shut.

You may think it’s a waste of time to call EMS for a nosebleed; however, a nosebleed, break or obstruction can be or become a serious medical problem. Patients with nose problems may call EMS instead of self-transporting for a number of reasons: They have repeated nosebleeds; they are on blood-thinning medications or have an underlying disease process that affects blood clotting; friends and family notice the worrisome signs of hypovolemia; the patient begins to cough or vomit blood; or they are simply unable to drive to the hospital.

Anatomy of the Nose

The nose is a gateway to the airway and assists in critical functions related to breathing. It is a combination of tissue, bone and cartilage that is centered in the face superior to the mouth and between the eyes. The visible external structure of the nose consists of the nares or nostrils; the bridge, which is the bony upper third; and a cartilaginous structure that is covered by muscle and skin and makes up the bottom third. The strong outer structures of the nose protect the delicate internal structures of the nasal cavity.1

The underlying skeletal structure of the nose is a combination of bones and cartilage. The maxillary bone is the upper jaw and the lower border of the orbits, just above which are the nasal bones. Ethmoid and sphenoid bones are internal bones that help form the sinuses. It is the combination of maxillary, frontal, nasal, ethmoid and sphenoid bones that creates the lateral and superior walls of the nasal cavity. The mouth’s hard and soft palate is the base of the nasal cavity.2

Air enters the nose via the nostrils. The nasal septum divides the inner nose into two cavities. The septum, with the turbinates, regulates the flow of air and creates resistance.1 The septum is a combination of bone in the posterior portion and cartilage in the superior portion.

The lateral wall of the nasal cavity supports the inferior, middle and superior turbinates. The nasopharynx is the posterior portion of the nose where the right and left nasal cavities rejoin. The sinuses, eustachian tubes and nasolacrimal (tear) ducts connect with the nasal cavity. Connecting structures assist with nasal functions of filtration and air warming, elimination of irritant particles and pressure equalization.2

The nasal cavity is highly vascular. Small vessels bring blood to the external nose, nasal septum, nasal cavity and sinuses. One of these networks of vessels, called Kiesselbach’s plexus, perfuses the anterior nasal septum, which is where most nosebleeds occur.1 A thin nasal mucosa covers nasal septum vessels, making the nose susceptible to bleeding from trauma and medical causes. When the mucosa dries, scabs or falls off, the vessels are vulnerable to bleeding.

Nasal cavity tissues help protect the airway from microorganisms and allergens. Coarse hairs, sebaceous glands and sweat glands are in the anterior third of the nose.1 The nasal cavity is enclosed and protected by a membranous cellular tissue called epithelium, which produces the mucous covering for the nasal cavity. It also has a high concentration of ciliated cells, which have a short hair-like process that helps trap and move particulates out of the upper airway.1

Nose Function

The nose performs a complex set of ventilation and odor sensation functions. It filters, warms and humidifies air, and also helps protect the lower airway by triggering immunologic and inflammatory responses to allergens, pollutants and other particles.1

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