Epistaxis

Epistaxis (from Greek 🇬🇷 (epistazo) to bleed from the nose: 🇬🇷 (epi) - "above", "over" + 🇬🇷 (stazo) - "to drip" [from the nostrils]) 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.

Cause
The causes 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

 * Blunt trauma (usually a sharp blow to the face such as a punch, sometimes accompanying a nasal fracture)
 * Foreign bodies (such as fingers during nose-picking)
 * Inflammatory reaction (e.g. acute respiratory tract infections, chronic sinusitis, allergic rhinitis or environmental irritants)

Other possible factors

 * Anatomical deformities (e.g. septal spurs or Hereditary hemorrhagic telangiectasia)
 * Insufflated drugs (particularly cocaine)
 * Intranasal tumors (e.g. Nasopharyngeal carcinoma or nasopharyngeal angiofibroma)
 * Low relative humidity of inhaled air (particularly during cold winter seasons)
 * Nasal cannula O2 (tending to dry the olfactory mucosa)
 * Nasal sprays (particularly prolonged or improper use of nasal steroids)
 * Otic barotrauma (such as from descent in aircraft or ascent in scuba diving)
 * Surgery (e.g. septoplasty and Functional Endoscopic Sinus Surgery)
 * Leech infestation

Most common factors

 * Allergies
 * Infectious diseases (e.g. common cold)
 * Hypertension

Other possible factors

 * Drugs — Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, prasugrel, isotretinoin, desmopressin, ginseng and others
 * Alcohol (due to vasodilation)
 * Anemia
 * Connective tissue disease
 * Blood dyscrasias
 * Envenomation by mambas, taipans, kraits, and death adders
 * Heart failure (due to an increase in venous pressure)
 * Hematological malignancy
 * Gunfire
 * Nose-picking
 * Idiopathic thrombocytopenic purpura
 * Pregnancy (rare)
 * Vascular disorders
 * Vitamin C or Vitamin K deficiency
 * von Willebrand's disease
 * Recurrent epistaxis is a feature of Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome)

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 appear to occur in males more than females. An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous 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 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. 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 (Kiesselbach'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 (France), Stop Hemo (Sweden, Italy, Switzerland ) and NasalCEASE (US and Australia ). These are calcium alginate meshes or swabs that are inserted in the nasal cavity to accelerate coagulation. QuikClot nosebleed is also available in the U.S. (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 a branch of the 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 Vaseline, and installing a humidifier in the bedroom. Intranasal application of petroleum based products like Vaseline should be avoided due to the risk of Lipid pneumonia.

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. Particularly in posterior bleeds, though, a great deal of blood may be swallowed and thus blood loss underestimated. Recurrent nosebleeds may cause anemia due to iron deficiency.

In popular culture
In the visual language of Japanese comics (manga) and animation (anime), a sudden, violent nosebleed indicates that the bleeding person is sexually aroused. This is based on a Japanese folk belief according to which nosebleeds are signs of sexual excitement.