Nosebleed

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Nosebleed
Synonymsepistaxis, bloody nose
Young child with nosebleed, smiling cropped.jpg
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.
SpecialtyOtorhinolaryngology

A nosebleed, also known as epistaxis (/ˌɛpɪˈstæksɪs/ EP-ih-STAK-sis), is the common occurrence of bleeding from the nose. It is usually noticed when 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.[1]

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.[2] About 60% of people have a nosebleed at some point in their life.[3] About 10% of nosebleeds are serious.[3] Nosebleeds appear to have a bimodal distribution, most commonly affecting those younger than 10 and older than 50.[4]

Cause[edit]

Two children boxing, the one on the right having a nosebleed due to a punch to the face.

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).[5] Relative humidity (including 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.[5]

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 of recurrent or prolonged epistaxis are categorized and listed below:[6][5][7]

Coagulopathy:

Inflammatory:

Medications/Drugs:

Neoplastic:

Traumatic:

Vascular Malformation:

Pathophysiology[edit]

Drawing demonstrating 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.[8] An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.[9] 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.[10] 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.[8]

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.

Treatment[edit]

Image demonstrating how to apply pressure to stop nosebleed

Most anterior nosebleeds (from Kiesselbach's plexus) can be stopped by applying direct pressure, which helps by promoting blood clots.[5] Those who suffer a nosebleed should first attempt to blow out any blood clots and then apply pressure for at least five minutes and up to 20 minutes.[5] Pressure should be firm and tilting the head forward helps decrease the chance of nausea and airway obstruction as seen in the picture on the right.[8] When attempting to stop a nosebleed at home, do not tilt head back.[4] Swallowing excess blood can irritate the stomach and cause vomiting. Vasoconstrictive medications such as oxymetazoline (Afrin) or phenylephrine are widely available over the counter fro treatment of allergic rhinitis and may also be used to control benign cases of epistaxis.[11] Those with nosebleeds that last longer than 20 minutes (in the setting of direct pressure as seen in the image to the right) should seek medical attention.[5] A summary of initial and alternative treatments are listed below:

Initial Treatment of Nosebleeds[5]

  • Blow out blood clots
  • Use vasoconstrictive medications such as oxymetazoline (Afrin) if available
  • Pinch nostrils tightly and tilt head forward

Alternative (more invasive) Treatment of Nosebleeds:

  • Chemical Cauterization: This method involves applying a chemical such as silver nitrate to the nasal mucosa, which burns and seals off the bleeding.[7] Eventually the nasal tissue to which the chemical is applied will undergo necrosis.[7] This form of treatment is best for mild bleeds, especially in children, that are clearly visible.[7] 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, however this will fade with time.[12]
  • Nasal Packing: If pressure and chemical cauterization can not stop epistaxis, nasal packing is the mainstay of treatment.[13] There are several forms of nasal packing that can be contrasted by anterior nasal packing and posterior nasal packing.[14] 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 products such as Merocel and the Rapid Rhino.[13] 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.[5] 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.[13] Systematic review articles have demonstrated that the efficacy in stopping nosebleeds is similar between the Rapid Rhino and Merocel packs; however, Rapid Rhino has been shown to have greater ease of insertion and reduced patient discomfort.[15] Patients who receive nasal packing need to return to a medical professional in 24-48 hours in order to have packing removed.[5] There are also several dissolvable packing materials that stop bleeding through use of thrombotic agents that promote blood clots, such as surgicel.[5] The thrombogenic foams and gels do not require removal and dissolve after a few days. 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 traction.[14]Complications of nasal packing include abscesses, septal hematomas, sinusitis, and pressure necrosis.[16] In rare cases toxic chock syndrome can occur with prolonged nasal packing. As a result, many forms of nasal packing involve use of topical antistaphylococcal antibiotic ointment.[17]
  • 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.[18] There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive.[19] Continued bleeding may be an indication of more serious underlying conditions.[18]

Other[edit]

The utility of local cooling of the head and neck is controversial.[20] Some state that applying ice to the nose or forehead is not useful.[21][22] Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful.[23]

Prevention[edit]

Patients with uncomplicated nosebleeds can utilize conservative methods to prevent future nosebleeds such as sleeping in a humidified environment or applying petroleum jelly to the nasal nares.[5] Although their efficacy has not been proved, topical antibacterials (such as mupirocin) or bacteriostatic agents (such as bacitracin) can be used to prevent nosebleeds. Mupirocin and bacitracin are commonly found in over the counter products such as Neosporin.

Society and culture[edit]

In the visual language of Japanese manga and anime, a sudden, violent nosebleed indicates that the bleeding person is sexually aroused.[24][25] In Western fiction, nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers.[26][27]

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.

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.[28]

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.[29]

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.[30]

In the Dutch language, "pretending to have a nosebleed" is a saying that means pretending not to know anything about something, when actually being involved somehow.[citation needed]

Etymology[edit]

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]".

References[edit]

  1. ^ Wilson, I. Dodd (1990). Walker, H. Kenneth; Hall, W. Dallas; Hurst, J. Willis, eds. Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). Boston: Butterworths. ISBN 040990077X. PMID 21250251.
  2. ^ Work Table I. Deaths from each cause by 5-year age groups, race and sex: US, 1999 Page 1922. U.S. Centers for Disease Control Published 2001-05-11.
  3. ^ a b Wackym,, James B. Snow,... P. Ashley (2009). Ballenger's otorhinolaryngology : head and neck surgery (17th ed.). Shelton, Conn.: People's Medical Pub. House/B C Decker. p. 551. ISBN 9781550093377.
  4. ^ a b Kucik, Corry J.; Clenney, Timothy (2005-01-15). "Management of epistaxis". American Family Physician. 71 (2): 305–311. ISSN 0002-838X. PMID 15686301.
  5. ^ a b c d e f g h i j k Morgan, Daniel J.; Kellerman, Rick (2014-03). "Epistaxis". Primary Care: Clinics in Office Practice. 41 (1): 63–73. doi:10.1016/j.pop.2013.10.007. ISSN 0095-4543. Check date values in: |date= (help)
  6. ^ Kucik, Corry J.; Clenney, Timothy (2005-01-15). "Management of epistaxis". American Family Physician. 71 (2): 305–311. ISSN 0002-838X. PMID 15686301.
  7. ^ a b c d Svider, Peter; Arianpour, Khashayar; Mutchnick, Sean (2018-06). "Management of Epistaxis in Children and Adolescents". Pediatric Clinics of North America. 65 (3): 607–621. doi:10.1016/j.pcl.2018.02.007. ISSN 0031-3955. Check date values in: |date= (help)
  8. ^ a b c Corry J. Kucik; Timothy Clenney (January 15, 2005). "Management of Epistaxis". American Academy of Family Physicians. Retrieved January 31, 2010.
  9. ^ J. F. Lubianca Neto; F. D. Fuchs; S. R. Facco; M. Gus; L. Fasolo; R. Mafessoni; A. L. Gleissner (1999). "Is epistaxis evidence of end-organ damage in patients with hypertension?". Laryngoscope. 109 (7): 1111–1115. doi:10.1097/00005537-199907000-00019. PMID 10401851.
  10. ^ The Journal of Laryngology & Otology (2008), 122: 1074–1077
  11. ^ Guarisco JL, Graham HD (1989). "Epistaxis in children: causes, diagnosis, and treatment". Ear Nose Throat J. 68 (7): 522, 528–30, 532 passim. PMID 2676467.
  12. ^ Béquignon, E.; Teissier, N.; Gauthier, A.; Brugel, L.; Kermadec, H. De; Coste, A.; Prulière-Escabasse, V. (2017-08-01). "Emergency Department care of childhood epistaxis". Emerg Med J. 34 (8): 543–548. doi:10.1136/emermed-2015-205528. ISSN 1472-0205. PMID 27542804.
  13. ^ a b c Iqbal, I. Z.; Jones, G. H.; Dawe, N.; Mamais, C.; Smith, M. E.; Williams, R. J.; Kuhn, I.; Carrie, S. (2017/12). "Intranasal packs and haemostatic agents for the management of adult epistaxis: systematic review". The Journal of Laryngology & Otology. 131 (12): 1065–1092. doi:10.1017/S0022215117002055. ISSN 0022-2151. Check date values in: |date= (help)
  14. ^ a b Killick, N; Malik, V; Nirmal Kumar, B (Mar 2014). "Nasal packing for epistaxis: an evidence-based review". British journal of hospital medicine (London, England : 2005). 75 (3): 143–7. doi:10.12968/hmed.2014.75.3.143. PMID 24621629.
  15. ^ Iqbal, I. Z.; Jones, G. H.; Dawe, N.; Mamais, C.; Smith, M. E.; Williams, R. J.; Kuhn, I.; Carrie, S. (2017/12). "Intranasal packs and haemostatic agents for the management of adult epistaxis: systematic review". The Journal of Laryngology & Otology. 131 (12): 1065–1092. doi:10.1017/S0022215117002055. ISSN 0022-2151. Check date values in: |date= (help)
  16. ^ Kucik, Corry J.; Clenney, Timothy (2005-01-15). "Management of epistaxis". American Family Physician. 71 (2): 305–311. ISSN 0002-838X. PMID 15686301.
  17. ^ Kucik, Corry J.; Clenney, Timothy (2005-01-15). "Management of epistaxis". American Family Physician. 71 (2): 305–311. ISSN 0002-838X. PMID 15686301.
  18. ^ a b MedlinePlus Medical Encyclopedia: Nosebleed U.S. National Library of Medicine Medline Plus service. Retrieved 2010-03-15.
  19. ^ Villwock, JA; Jones, K (Dec 2013). "Recent trends in epistaxis management in the United States: 2008–2010". JAMA Otolaryngology–Head & Neck Surgery. 139 (12): 1279–84. doi:10.1001/jamaoto.2013.5220. PMID 24136624.
  20. ^ Folz, BJ; Kanne, M; Werner, JA (November 2008). "[Current aspects in epistaxis]". HNO. 56 (11): 1157–65, quiz 1166. doi:10.1007/s00106-008-1838-3. PMID 18936903.
  21. ^ al.], edited by Roger Jones ... [et (2004). Oxford textbook of primary medical care (repr. ed.). Oxford: Oxford University Press. p. 711. ISBN 9780198567820.
  22. ^ Bissonnette, Bruno (2010). Pediatric Anesthesia. New York: McGraw-Hill Medical. p. 1182. ISBN 9781607950936.
  23. ^ al.], A.Y. Elzouki ... [et. Textbook of clinical pediatrics (2nd ed.). Berlin: Springer. p. 3968. ISBN 9783642022012.
  24. ^ "Manga: The Complete Guide, reviewed by Richard von Busack". Metroactive. Retrieved 5 August 2011.
  25. ^ Morgan, Joyce (February 10, 2007). "Superheroes for a complex world". The Sydney Morning Herald. Retrieved 5 August 2011.
  26. ^ Tracey, Liz (30 August 2016). ""Stranger Things" and the Psychic Nosebleed". JSTOR Daily. Retrieved 6 November 2016.
  27. ^ Meehan, Paul. Cinema of the Psychic Realm: A Critical Survey. McFarland. p. 193.
  28. ^ Various (1984). Erdoes, Richard; Ortiz, Alfonso, eds. American Indian Myths and Legends (2 ed.). Toronto, Ontario: Random House of Canada Limited. p. 274.
  29. ^ "Finnish idioms and proverbs". saaressa.blogspot.fr. Retrieved 2017-12-19.
  30. ^ OMG! Nosebleed! Say what?! Retrieved 28 August 2013

External links[edit]

Classification
External resources