My husband has been having nosebleeds every night for about two weeks. It seems to happen only at night. Should I be concerned? He doesn't seem to be.

B.L.

When people ask questions like this, what they are really asking is, "Could this problem lead to the development of significant disability? Could it lead to my/his/her death?"
Sometimes the answer is obvious. If the question is, "I have this lump on the side of my neck that's, oh, about the size of my fist. Is this serious?" the answer is inevitably YES. If the question is, "Whenever I vacuum my house and dust under the beds, my nose gets stuffed and my eyes water. Is this serious?" the answer is, of course, NO.

Unfortunately, the answer to most questions is MAYBE. It is almost impossible, based on a thumbnail description, to answer otherwise. In order to give a reliable answer, a good doctor will gather an enormous amount of information during the course of the history and physical examination. Even then, the doctor will be able to provide you only with a list of possibilities or likelihoods -- a list that is known in the biz as a differential diagnosis.

The differential diagnosis for your husband's nosebleeds is quite lengthy, and includes problems both trivial and lethal. Fortunately, the trivial problems are common and the lethal problems are rare, so the odds are in your husband's favor.

The most common explanations for recurrent nosebleeds are (1) digital endonasal covert extractions (nose picking) and (2) adverse microclimatologic fluctuations (a dry nose). That portion of the nasal septum that is within reach of a wandering fingernail happens to have a very rich blood supply. This blood supply has the ungainly name Kisselbach's plexus, but the region has a somewhat more user-friendly name, Little's area. Because of its location, Little's area also tends to chap easily. Thus, nasal dryness can lead to spontaneous rupture of one of the many tiny capillaries in Little's area ... and oh boy, can those little capillaries bleed like all get-out.

What are some of the more worrisome causes of nosebleeds? Here are some of the scarier possibilities:

• Coagulopathy, or an impairment in one's blood-clotting system. This problem has an incredibly long differential diagnosis, too, but most of the possibilities are quite grim. For example, liver failure, kidney failure and leukemia are each associated with coagulopathy. On the other hand, many medications cause a temporary coagulopathy. (Aspirin is the best example, but ibuprofen, excessive amounts of vitamin E and even ginger can impair clotting.) Stop the offending medication, and the clotting problem should resolve.
  
• Tumors (malignant or benign) of the sinuses or nasal cavities can make themselves known with episodic bleeding.
  
• Granulomatous diseases can cause severe tissue destruction. Granulomatous refers to a particular type of scar tissue (granuloma) that is found in such diseases. Some of these illnesses are due to infection (such as tuberculosis or leprosy), while others are more mysterious (such as sarcoidosis or Wegener's granulomatosis).
  

What should you do? Ultimately, the answer is simple. If the nosebleeds have already stopped by the time you receive this response, then it is unlikely (yet still not impossible) that your husband has one of these dread diseases. If the nosebleeds have NOT stopped, it is STILL unlikely that your husband has one of these dread diseases, but he should nevertheless see an ear, nose and throat doctor. Why? Because we can usually fix this problem with one office visit. Why fuss with nightly nosebleeds when you can get the problem fixed?