Epistaxis (or a
nosebleed ) is the relatively common occurrence of
hemorrhage from the
nose, usually noticed when the
blood 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 is rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. Perhaps the most well-known Epistaxis-related death was that of
Attila the Hun. He drank a colossal amount of
alcohol on his wedding night after his parley with
Pope Leo I, suffered a nosebleed in his sleep and was suffocated by the blood.
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
Most common factors
*
Blunt trauma (usually a sharp blow to the face, sometimes accompanying a
Other possible factors
*
Nasal sprays (particularly prolonged or improper use of nasal steroids)
*
Otic barotrauma (such as from descent in aircraft or ascent in scuba diving)
Systemic factors
Most common factors
Other possible factors
* 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. Nosebleeds are reported in up to 60% of the population with peak incidences in those under the age of ten and over the age of 50 and appears to occur in males more than females. An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaenous epistaxis. .
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 (
Kiesselbach's plexus). This region is also known as
Little's 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 its branches. Posterior bleeds are often prolonged and difficult to control. They can be 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
Little's area, the source of the majority of nose bleeds and promotes clotting. Pressure should be firm and be applied for at least five minutes and up to 20 minutes; tilting the head forward will help decrease the chance of nausea and airway obstruction. Swallowing excess blood can irritate the stomach and cause vomiting. Local application of an ice pack to the forehead or back of the neck or sucking an ice cube has seen widespread practice, but has been shown to not have any statistically significant effects on nasal mucosal blood flow. There are conflicting opinions in the use of ice or nasal packing in the treatment of nose bleeds. Most suggest there is no detriment to using ice or nasal packing when initial efforts to pinch the nose fail, while others advise against it.
The local application of a vasoconstrictive agent has been shown to reduce the bleeding time in benign cases of epistaxis. The drugs
oxymetazoline or
phenylephrine are widely available in over-the-counter nasal sprays for the treatment of
allergic rhinitis, and may be used for this purpose.
Other products available to promote coagulation include Coalgan (in Europe) or NasalCEASE (in the US). These are a calcium alginate mesh or swabs that is inserted in the nasal cavity to accelerate coagulation. Also there is QuikClot nosebleed available in the U.S. that is a hemostatic OTC formula.
If these simple measures do not work then medical intervention may be needed to stop bleeding, possibly by an
otolaryngologist (ENT doctor). 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 absorbent dressing (called anterior nasal packing). 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 can be treated by endoscopic evaluation of the nasal cavity under general anaesthesia to identify an elusive bleeding point or to directly ligate (tie off) the blood vessels supplying the nose. These blood vessels include the
sphenopalatine, anterior and posterior
ethmoidal arteries. More rarely the maxillary or external
cartoid artery can be ligated. The bleeding can also be stopped by intra-arterial
embolization using a catheter placed in the groin and threaded up the aorta to the bleeding vessel by an interventional radiologist. Continued bleeding may be an indication of more serious underlying conditions.
Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying
saline in the nose three times per day, lubricating the nose with ointments or creams, such as vasoline, and installing a humidifier in the bedroom.
Application of a topical
antibiotic ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.
One study found it to be as effective as nasal cautery in the prevention of recurrent epistaxis in patients without active bleeding at the time of treatment - both had a success rate of approximately 50 percent.
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.
Recurrent nosebleeds may cause
anemia due to
iron deficiency.
See also
