Nosebleed

Last updated
Nosebleed
Other namesEpistaxis, bloody nose, nasal hemorrhage [1]
Young child with nosebleed, smiling cropped.jpg
A three-year-old child with a minor nosebleed from falling and hitting his face on the floor
Pronunciation
Specialty Otorhinolaryngology
Symptoms Bleeding from the nose [1]
Usual onsetLess than 10 and over 50 years old [2]
Risk factors Trauma, excessive nose picking, certain infections, blood thinners, high blood pressure, alcoholism, seasonal allergies, dry weather [3]
Diagnostic method Direct observation [1]
Differential diagnosis Bleeding from the lungs, esophageal varices, [1] vomiting blood
Prevention Petroleum jelly in the nose [4]
TreatmentPressure over the lower half of the nose, nasal packing, endoscopy [5]
Medication Tranexamic acid [6]
Frequency60% at some point in time [7]
DeathsRare [3]

A nosebleed, also known as epistaxis, is an instance of bleeding from the nose. [1] Blood can flow down into the stomach, and cause nausea and vomiting. [8] In more severe cases, blood may come out of both nostrils. [9] Rarely, bleeding may be so significant that low blood pressure occurs. [1] Blood may also be forced to flow up and through the nasolacrimal duct and out of the eye, producing bloody tears. [10]

Contents

Risk factors include trauma, including putting the finger in the nose, blood thinners, high blood pressure, alcoholism, seasonal allergies, dry weather, and inhaled corticosteroids. [3] There are two types: anterior, which is more common; and posterior, which is less common but more serious. [3] Anterior nosebleeds generally occur from Kiesselbach's plexus while posterior bleeds generally occur from the sphenopalatine artery or Woodruff's plexus. [3] The diagnosis is by direct observation. [1]

Prevention may include the use of petroleum jelly in the nose. [4] Initially, treatment is generally the application of pressure for at least five minutes over the lower half of the nose. [5] If this is not sufficient, nasal packing may be used. [5] Tranexamic acid may also be helpful. [6] If bleeding episodes continue, endoscopy is recommended. [5]

About 60% of people have a nosebleed at some point in their life. [7] About 10% of nosebleeds are serious. [7] Nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. [11] Nosebleeds most commonly affect those younger than 10 and older than 50. [2]

Cause

Two children boxing, the one on the right having a nosebleed due to a punch to the face, in Vecses, Hungary in November 2006 Boxing children - bloody nose.jpg
Two children boxing, the one on the right having a nosebleed due to a punch to the face, in Vecsés, Hungary in November 2006

Nosebleeds can occur due to a variety of reasons. Some of the most common causes include trauma from nose picking, blunt trauma (such as a motor vehicle accident), or insertion of a foreign object (more likely in children). [4] Low relative humidity (such as in centrally heated buildings), respiratory tract infections, chronic sinusitis, rhinitis or environmental irritants can cause inflammation and thinning of the tissue in the nose, leading to a greater likelihood of bleeding from the nose. [4]

Most causes of nose bleeding are self-limiting and do not require medical attention. However, if nosebleeds are recurrent or do not respond to home therapies, an underlying cause may need to be investigated. Some rarer causes are listed below: [2] [4] [12]

Coagulopathy

Dietary

Inflammatory

Medications/Drugs

Neoplastic

Traumatic

Vascular

Pathophysiology

The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds) Arteries of the Nose.jpg
The arteries that supply Kiesselbach's plexus (responsible for anterior nosebleeds)

The nasal mucosa contains a rich blood supply that can be easily ruptured and cause bleeding. 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 appear to occur in males more than females. [15] An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis. [16] 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 nosebleeds as their blood vessels are less able to constrict and control the bleeding.

The vast majority of nosebleeds occur in the front 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 farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexus, a venous plexus situated in the posterior part of inferior meatus. [17] 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. [15]

Sometimes blood flowing from other sources of bleeding passes through the nasal cavity and exits the nostrils. It is thus blood coming from the nose but is not a true nosebleed, that is, not truly originating from the nasal cavity. Such bleeding is called "pseudoepistaxis" ( pseudo + epistaxis). Examples include blood coughed up through the airway and ending up in the nasal cavity, then dripping out.

Prevention

People with uncomplicated nosebleeds can use conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying petroleum jelly to the nasal nares. [4]

Individuals who suffer from nosebleeds regularly, especially children, are encouraged to use over-the-counter nasal saline sprays and avoid vigorous nose-blowing as preventative measures. [18]

Treatment

Most anterior nosebleeds can be stopped by applying direct pressure, which helps by promoting blood clots. [4] Those who have a nosebleed should first attempt to blow out any blood clots and then apply pressure to the soft anterior part of the nose (by pinching the nasal ala; not the bony nasal bridge) for at least five minutes and up to 30 minutes. [4] Pressure should be firm and tilting the head forward helps decrease the chance of nausea and airway obstruction due to blood dripping into the airway. [15] When attempting to stop a nosebleed at home, the head should not be tilted back. [2] Swallowing excess blood can irritate the stomach and cause vomiting. Vasoconstrictive medications such as oxymetazoline (Afrin) or phenylephrine are widely available over the counter for treatment of allergic rhinitis and may also be used to control benign cases of epistaxis. [19] For example, a few sprays of oxymetazoline may be applied into the bleeding side(s) of the nose followed by application of direct pressure. Those with nosebleeds that last longer than 30 minutes (despite use of direct pressure and vasoconstrictive medications such as oxymetazoline) should seek medical attention. [4]

Chemical Cauterization

This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding. [12] Eventually the nasal tissue to which the chemical is applied will undergo necrosis. [12] This form of treatment is best for mild bleeds, especially in children, that are clearly visible. [12] A topical anesthetic (such as lidocaine) is usually applied prior to cauterization. Silver nitrate can cause blackening of the skin due to silver sulfide deposit, though this will fade with time. [20] Once the silver nitrate is deposited, saline may be used to neutralize any excess silver nitrate via formation of silver chloride precipitate.

Nasal packing

If pressure and chemical cauterization cannot stop bleeding, nasal packing is the mainstay of treatment. [21] Nasal packing is typically categorized into anterior nasal packing and posterior nasal packing. [22] Nasal packing may also be categorized into dissolvable and non-dissolvable types.

Dissolvable nasal packing materials stop bleeding through use of thrombotic agents that promote blood clots, such as surgicel and gelfoam. [4] The thrombogenic foams and gels do not require removal and dissolve after a few days. Typically, dissolvable nasal packing is first attempted; if the bleeding persists, non-dissolvable nasal packing is the next option.

Traditionally, nasal packing was accomplished by packing gauze into the nose, thereby placing pressure on the vessels in the nose and stopping the bleeding. Traditional gauze packing has been replaced with other non-dissolvable nasal packing products such as Merocel and the Rapid Rhino. [21] The Merocel nasal tampon is similar to gauze packing except it is a synthetic foam polymer (made of polyvinyl alcohol and expands in the nose after application of water) that provides a less hospitable medium for bacteria. [4] The Rapid Rhino stops nosebleeds using a balloon catheter, made of carboxymethylcellulose, which has a cuff that is inflated by air to stop bleeding through extra pressure in the nasal cavity. [21] Systematic review articles have demonstrated that the efficacy in stopping nosebleeds is similar between the Rapid Rhino and Merocel packs; however, the Rapid Rhino has been shown to have greater ease of insertion and reduced discomfort. [21] Posterior nasal packing can be achieved by using a Foley catheter, blowing up the balloon when it is in the back of the throat, and applying anterior traction so that the inflated balloon occludes the choanae. [22] Patients who receive non-dissolvable nasal packing need to return to a medical professional in 24–72 hours in order to have packing removed. [4] [3] Complications of non-dissolvable nasal packing include abscesses, septal hematomas, sinusitis, and pressure necrosis. [2] In rare cases toxic shock syndrome can occur with prolonged nasal packing. As a result, any patient who has non-dissolvable nasal packing should be given prophylactic antibiotic medication to be taken as long as the nasal packing remains in the nose. [2]

Surgery

Ongoing bleeding despite good nasal packing is a surgical emergency and can be treated by endoscopic evaluation of the nasal cavity under general anesthesia 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 a branch of the external carotid 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. [23] There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive. [24] Continued bleeding may be an indication of more serious underlying conditions. [23]

Tranexamic acid

Tranexamic acid helps promote blood clotting. [6] For nosebleeds it can be applied to the site of bleeding, taken by mouth, or injected into a vein. [6]

Other

The utility of local cooling of the head and neck is controversial. [25] Some state that applying ice to the nose or forehead is not useful. [26] [27] Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful. [28] In Indonesian traditional medicine, betel leaf is used to stop nosebleeds as it contains tannin which causes blood to coagulate, thus stopping active bleeding. [29]

Society and culture

In the visual language of Japanese manga and anime, nosebleeding often indicates that the bleeding person is sexually aroused. [30] [31] [32] In Western fiction, nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers. [33] [34]

In American and Canadian usage, "nosebleed section" and "nosebleed seats" are common slang for seating at sporting or other spectator events that are the highest up and farthest away from the event. The reference alludes to the propensity for nasal hemorrhage at high altitudes, usually owing to lower barometric pressure.

The oral history of the Native American Sioux tribe includes reference to women who experience nosebleeds as a result of a lover's playing of music, implying sexual arousal. [35]

In the Finnish language, "picking blood from one's nose" and "begging for a nosebleed" are commonly used in abstract meaning to describe self-destructive behaviour, for example ignoring safety procedures or deliberately aggravating stronger parties. [36]

In Filipino slang, to "have a nosebleed" is to have serious difficulty conversing in English with a fluent or native English speaker. It can also refer to anxiety brought on by a stressful event such as an examination or a job interview. [37]

In the Dutch language, "pretending to have a nosebleed" is a saying that means pretending not to know anything about something. [38]

Etymology

The word epistaxis is from Ancient Greek : ἐπιστάζωepistazo, "to bleed from the nose" from ἐπίepi, "above, over" and στάζωstazo, "to drip [from the nostrils]".[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Bleeding</span> Loss of blood escaping from the circulatory system

Bleeding, hemorrhage, haemorrhage or blood loss is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a puncture in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination. Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties. The stopping or controlling of bleeding is called hemostasis and is an important part of both first aid and surgery.

Cauterization is a medical practice or technique of burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undesired growth, or minimize other potential medical harm, such as infections when antibiotics are unavailable.

<span class="mw-page-title-main">Nasal cavity</span> Large, air-filled space above and behind the nose in the middle of the face

The nasal cavity is a large, air-filled space above and behind the nose in the middle of the face. The nasal septum divides the cavity into two cavities, also known as fossae. Each cavity is the continuation of one of the two nostrils. The nasal cavity is the uppermost part of the respiratory system and provides the nasal passage for inhaled air from the nostrils to the nasopharynx and rest of the respiratory tract.

Hematemesis is the vomiting of blood. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

<span class="mw-page-title-main">Internal bleeding</span> Leakage of blood within the body

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Hereditary hemorrhagic telangiectasia</span> Genetic disorder affecting blood vessel development

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease and Osler–Weber–Rendu syndrome, is a rare autosomal dominant genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain.

<span class="mw-page-title-main">Septoplasty</span> Corrective surgical procedure

Septoplasty, or alternatively submucous septal resection and septal reconstruction, is a corrective surgical procedure done to straighten a deviated nasal septum – the nasal septum being the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Deviated nasal septum or “crooked” internal nose can occur at childbirth or as the result of an injury or other trauma. If the wall that functions as a separator of both sides of the nose is tilted towards one side at a degree greater than 50%, it might cause difficulty breathing. Often the inferior turbinate on the opposite side enlarges, which is termed compensatory hypertrophy. Deviations of the septum can lead to nasal obstruction. Most surgeries are completed in 60 minutes or less, while the recovery time could be up to several weeks. Put simply, septoplasty is a surgery that helps repair the passageways in the nose making it easier to breathe. This surgery is usually performed on patients with a deviated septum, recurrent rhinitis, or sinus issues.

<span class="mw-page-title-main">Embolization</span> Passage and lodging of an embolus within the bloodstream

Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin (pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced (therapeutic), as a hemostatic treatment for bleeding or as a treatment for some types of cancer by deliberately blocking blood vessels to starve the tumor cells.

<span class="mw-page-title-main">Nasal septum perforation</span> Medical condition

A nasal septum perforation is a medical condition in which the nasal septum, the bony/cartilaginous wall dividing the nasal cavities, develops a hole or fissure.

<span class="mw-page-title-main">Coagulopathy</span> Condition involving impaired blood clotting ability

Coagulopathy is a condition in which the blood's ability to coagulate is impaired. This condition can cause a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.

<span class="mw-page-title-main">Tranexamic acid</span> Chemical compound

Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken either by mouth, injection into a vein, or by intramuscular injection.

<span class="mw-page-title-main">Kiesselbach's plexus</span> Vascular network in the nose

Kiesselbach's plexus is an anastomotic arterial network (plexus) of four or five arteries in the nose supplying the nasal septum. It lies in the anterior inferior part of the septum known as Little's area, Kiesselbach's area, or Kiesselbach's triangle. It is a common site for anterior nosebleeds.

<span class="mw-page-title-main">Sphenopalatine artery</span> Blood vessel

The sphenopalatine artery is an artery of the head, commonly known as the artery of epistaxis. It passes through the sphenopalatine foramen to reach the nasal cavity. It is the main artery of the nasal cavity.

<span class="mw-page-title-main">Rhinolith</span> Solid mass which forms in the nasal cavity

A rhinolith is a stone present in the nasal cavity. It is an uncommon medical phenomenon, not to be confused with dried nasal mucus. A rhinolith usually forms around the nucleus of a small exogenous foreign body, blood clot or secretion by slow deposition of calcium and magnesium carbonate and phosphate salts. Over time, they grow into large irregular masses that fill the nasal cavity.

<span class="mw-page-title-main">Human nose</span> Feature of the human face

The human nose is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the nasal septum, which separates the nostrils and divides the nasal cavity into two.

<span class="mw-page-title-main">Nasal septal hematoma</span> Medical condition

Nasal septal hematoma is a condition affecting the nasal septum. It can be associated with trauma.

<span class="mw-page-title-main">Nasopharyngeal angiofibroma</span> Benign vascular tumor of the throat (nasopharynx)

Nasopharyngeal angiofibroma is an angiofibroma also known as juvenile nasal angiofibroma, fibromatous hamartoma, and angiofibromatous hamartoma of the nasal cavity. It is a benign but locally aggressive vascular tumor of the nasopharynx that arises from the superior margin of the sphenopalatine foramen and grows in the back of the nasal cavity. It most commonly affects adolescent males. Though it is a benign tumor, it is locally invasive and can invade the nose, cheek, orbit, or brain.

Emergency bleeding control describes actions that control bleeding from a patient who has suffered a traumatic injury or who has a medical condition that has caused bleeding. Many bleeding control techniques are taught as part of first aid throughout the world. Other advanced techniques, such as tourniquets, are taught in advanced first aid courses and are used by health professionals to prevent blood loss by arterial bleeding. To manage bleeding effectively, it is important to be able to readily identify types of wounds and types of bleeding.

<span class="mw-page-title-main">Hemotympanum</span> Presence of blood in the tympanic cavity of the middle ear

Hemotympanum, or hematotympanum, refers to the presence of blood in the tympanic cavity of the middle ear. Hemotympanum is often the result of basilar skull fracture.

Woodruff's plexus was discovered by George H. Woodruff in 1949. The plexus is located below the posterior end of the inferior concha, on the lateral wall of the nasal cavity. He described it as the naso-nasopharyngeal plexus.

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