Epistaxis

An 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, and more severe). 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.

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Etiology

The cause of nosebleeds can generally be divided into two categories, local and systemic factors.

Local Factors

• Anatomic deformities
• 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
• Nasal spray
• 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
• Malnutrition (especially anemia)
• Narcotics
• Pregnancy
• Vascular disorders
• Nose-picking (especially in children)
• Muscle tightness as caused by scoliosis (the tightened muscles cause blood vessels to become constricted, resulting in nosebleeds from the same side as the tightened muscles).

Pathophysiology

All nosebleeds are due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause the tears, while inflammation, coagulation problems and other disorders may make the injury harder to repair.

Treatment

The flow of blood normally stops when the blood clots, which may be encouraged by direct pressure and reducing the blood pressure in the head by sitting upright with the head tilted forward for about 10 minutes. Tilting the head back can help allievate external bleeding, but the blood will then drain down the throat into the stomach, causing stomach pain and nausea. Petroleum jelly is sometimes applied to stop the blood from seeping out of and prohibit the loss of moisture in the nasal cavity. However, the jelly can drain into the lungs producing a buildup that leads to lipid pneumonia. ^[1] Another alternative to using petroleum jelly, and to avoid the risk further drying the nose due to the use of a petroleum based treatment, is to use K-Y Jelly. This can be applied about 0.5 inches into the nose using a cotton swab to prevent further nosebleeds. ^[2]

If other techniques do not work, an anterior packing is a possible remedy. An anterior pack works by applying pressure from the inside of the cavity, thus stopping the bleeding. This procedure can be performed at home for minor nosebleeds by gently packing tissue or gauze into the nasal cavity. Nasal sponges^[3] are readily available at most drugstores and supermarkets.

If bleeding continues, seeking emergency medical attention is important. Continued bleeding is an indication of more serious underlying conditions.^[4]

Chronic epistaxis resulting from a dry nasal mucosa is often treated by spraying saline in the nose up to three times per day. There are also non-petroleum based gels that can be used.

Persistent epistaxis is an indication for urgent medical consultation. Nasal packing, cryosurgery, electrocautery or application of trichloroacetic acid are options that may be used in severe epistaxis.

It is uncommon to die from bleeding through nosebleeds. A famous person who is reported to have died from a nosebleed was Attila the Hun. However, damage to the maxillary artery can lead to rapid blood loss via the nose and presents difficulty in treatment; pressure, vasoconstrictor and rhinocort occasionally proving ineffective. Embolization or ligation of the artery, risking damage to the facial nerves, may be the only solution.

Another technique to stop nose bleeds is to by taking a small ball of cotton, place under a tap of running water, squeeze the water out and place the ball in the nostril that is bleeding. The cotton ball helps the blood to clot faster.

Severe protracted nosebleeds may cause anemia due to iron deficiency.

References

See also

• Kiesselbach's plexus
• Nosebleed section