Nosebleed
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Epistaxis is the relatively common occurrence of hemorrhage (bleeding) from the nose, usually noticed when it drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, more likely to require medical attention). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting. It accounts for only 0.001% of all deaths in the U.S.
Etiology
The cause of nosebleeds can generally be divided into two categories, local and systemic factors, although it should be remembered that a significant number of nosebleeds occur with no obvious cause.
Local Factors
- Anatomical deformities, such as septal spurs or Osler Weber Rendu Syndrome
- Chemical inhalant
- Inflammatory reaction (eg. acute respiratory tract infections, chronic sinusitis, allergic rhinitis and environmental irritants)
- Foreign bodies
- Intranasal tumors (Nasopharyngeal carcinoma in adult, and nasopharyngeal angiofibroma in adolescent males)
- Nasal prong O2 which tends to dry the nasal mucosa
- Nasal sprays, particularly prolonged or improper use of nasal steroids
- Surgery (such as septoplasty and endoscopic sinus surgery)
- Trauma (usually a sharp blow to the face)
- Nose-picking
Systemic factors
- Drugs - Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin and others
- Alcohol (due to vasodilation)
- Allergies
- Blood dyscrasias
- Heart failure (due to an increase in venous pressure)
- Hematological malignancy
- Hypertension
- Infectious diseases
- Narcotics, particularly inhaled cocaine
- Pregnancy
- Vascular disorders
Pathophysiology
Nosebleeds are due to the rupture of a blood vessel within the richly perfused nasal mucosa . Rupture may be spontaneous or initiated by trauma. An increase in blood pressure (eg due to general hypertension) or local blood flow (for example following a cold or infection) will increase the liklehood of a spontaneous nosebleed. Anticoagulant medication and disorders of blood clotting can promote and prolong bleeding. Spontaneous epistaxis is more common in the elderly as the nasal mucosa (lining) becomes dry and thin and blood pressure tends to be higher. The elderly are also more prone to prolonged nose bleeds as their blood vessels are less able to constrict and control the bleeding. The vast majority of nose bleeds occur in the anterior (front) part of the nose from the nasal septum. This area is richly endowed with blood vessels (Keisselbach's plexus). This region is known as littles area. Bleeding further back in the nose is known as a posterior bleed and is usually due to rupture of the sphenopalatine artery or one of it's tributaries. Posterior bleeds are often prolonged and difficult to control. They are usually associated with bleeding from both nostrils and with a greater flow of blood into the mouth.
Treatment
The flow of blood normally stops when the blood clots, which may be encouraged by direct pressure applied by pinching the soft fleshy part of the nose. This applies pressure to littles area, the source of the majority of nose bleeds and promotes clotting. Pressure should be firm and be applied for at least 10 minutes whilst leaning forward and spitting out any blood which flows into the mouth. There is no benefit to pinching the bridge of the nose or to tilting the head back. Local application of an ice pack to the forehead or back of the neck or sucking an ice cube can also help by promoting constriction of local blood vessels and thus reducing blood flow. If these simple measures do not work then medical intervention may be needed to stop bleeding. In the first instance this can take the form of chemical cautery of any bleeding vessels or packing of the nose with ribbon gauze or an absorbant dressing. Such procedures are best carried out by a medical professional. Chemical cauterisation is most commonly conducted using local application of silver nitrate compound to any visible bleeding vessel. This is a painful procedure and the nasal mucosa should be anaesthetised first, preferably with the addition of topical adrenaline to further reduce bleeding. If bleeding is still uncontrolled or no focal bleeding point is visible then the nasal cavity should be packed with a sterile dressing, which by applying pressure to the nasal mucosa will tamponade the bleeding point. Ongoing bleeding despite good nasal packing is a surgical emergency and is best treated by endoscopic evaluation of the nasal cavity under anaesthesia to identify an elusive bleeding point or by an operation to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the exterior carotid, maxillary, sphenopalatine and anterior ethmoidal. Continued bleeding may be an indication of more serious underlying conditions.[1]
Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying saline in the nose up to three times per day. Application of petroleum jelly or Naseptin (a topical antimicrobial ointment) to the nasal mucosa can also prevent drying of the nose and is especially important following nasal cautery. Another alternative is to use K-Y Jelly or another simple emollient.
Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be swallowed and thus blood loss underestimated. The elderly and those with co-existing morbidities, particularly of blood clotting should be closely monitored for signs of shock.
A famous person who is reported to have died from a nosebleed was Attila the Hun.
Recurrent nosebleeds may cause anemia due to iron deficiency.
References
See also
External links
- National Library of Medicine - Describes causes, solutions, and prevention of nosebleeds
- stop-nosebleeds.org - describes the Thumbs Up alternate method of stopping nose bleeds
- drtbalu otolaryngology online
- Natural Remedies for Nosebleeds