|Synonyms||epistaxis, bloody nose|
|A three year old with a minor nosebleed from falling and hitting the floor with his face. Nosebleeds like this one normally resolve within a few minutes.|
|Classification and external resources|
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.
Although the sight of large amounts of blood can be alarming and may warrant medical attention, nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. About 60% of people have a nosebleed at some point in their life. About 10% of nosebleeds are serious.
The causes of nosebleeds can generally be divided into two categories, local and general factors, although a significant number of nosebleeds occur with no obvious cause.
- 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, 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). Evidence to support this however is weak.
- Nasal cannula O2 (tending to dry the nasal mucosa)
- Nasal sprays (particularly prolonged or improper use of nasal steroids)
- Middle ear barotrauma (such as from descent in aircraft or ascent in scuba diving)
- Surgery (e.g. septoplasty and functional endoscopic sinus surgery)
Most common factors
Other possible factors
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- Alcohol (due to vasodilation)
- Blood dyscrasias
- Connective tissue disease
- Drugs—aspirin, fexofenadine, warfarin, clopidogrel, prasugrel, isotretinoin, desmopressin and others
- Envenomation by mambas, taipans, kraits, and death adders
- Chronic liver disease—cirrhosis causes deficiency of factor II, VII, IX,& X
- Heart failure (due to an increase in venous pressure)
- Hematological malignancy (such as leukemia)
- Idiopathic thrombocytopenic purpura
- Pregnancy (rare, due to hypertension and hormonal changes)
- Vascular disorders
- Vitamin C and vitamin K deficiency
- Von Willebrand's disease
- Hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), a rare disease that runs in families
- Mediastinal compression by tumours (raised venous pressure)
- Thrombotic thrombocytopenic purpura
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.
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.
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 helps decrease the chance of nausea and airway obstruction. Swallowing excess blood can irritate the stomach and cause vomiting.
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 they may be used for this purpose.
If these simple measures do not work then medical intervention may be needed to stop bleeding. The use of silver nitrate to cauterize bleeding blood vessels is common but not very useful for those with more than mild bleeding. It is also often painful even when freezing is used.
There are two types of nasal packing, anterior nasal packing and posterior nasal packing. There are a number of different types of anterior nasal packs. Some use gauze and others use balloons. Posterior packing can be achieved by using a Foley catheter, blowing up the balloon when it is in the back of the throat, and applying traction. Ribbon gauze or Merocel packing can also be used. There are also several dissolvable packing materials, such as surgicel that function as a pack but are not removed and dissolve after a few days. Packing is generally left in for two to five days.
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 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. There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive. Continued bleeding may be an indication of more serious underlying conditions.
The utility of local cooling of the head and neck is controversial. Some state that applying ice to the nose or forehead is not useful. Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful.
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 as effective as nasal cautery in the prevention of recurrent epistaxis in people without active bleeding at the time of treatment—both had a success rate of approximately 50 percent.
Society and culture
In the visual language of Japanese comics (manga) and animation (anime), a sudden, violent nosebleed indicates that the bleeding person is sexually aroused. In Western fiction, nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers.
In American and Canadian usage, "nosebleed section" or "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.
In Finnish language, "begging for a nosebleed" is commonly used in abstract meaning to describe self-destructive behaviour, for example ignoring safety procedures or deliberately aggravating stronger parties.
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.
The word epistaxis is from Greek: ἐπιστάζω epistazo, "to bleed from the nose" from ἐπί epi, "above, over" and στάζω stazo, "to drip [from the nostrils]".
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|Wikimedia Commons has media related to Nosebleeds.|
- National Library of Medicine - Describes causes, solutions, and prevention of nosebleeds