Nosebleed

For other uses, see Nosebleed (disambiguation).
"Epistaxis" redirects here. It is not to be confused with Epitaxis.
Nosebleed
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
Specialty Otorhinolaryngology
ICD-10 R04.0
ICD-9-CM 784.7
DiseasesDB 18327
MedlinePlus 003106
eMedicine emerg/806 ent/701
Patient UK Nosebleed
MeSH C08.460.261

Nosebleed, also known as a epistaxis, is the common occurrence of bleeding from the nose. It is 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.[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]

Cause

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

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.

Local factors

Other possible factors

Systemic factors

Most common factors

Other possible factors

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.[6] An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.[7] 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.[8] 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.[6]

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

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.[6] Swallowing excess blood can irritate the stomach and cause vomiting.

Medications

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.[9]

Procedures

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.[10] It is also often painful even when freezing is used.[11]

There are two types of nasal packing, anterior nasal packing and posterior nasal packing.[12] There are a number of different types of anterior nasal packs. Some use gauze and others use balloons.[12] 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.[12] Ribbon gauze or Merocel packing can also be used.[12] 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.

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.[13] There is no difference in outcomes between embolization and ligation as treatment options, but embolization is considerably more expensive.[14] Continued bleeding may be an indication of more serious underlying conditions.[13]

Other

The utility of local cooling of the head and neck is controversial.[15] Some state that applying ice to the nose or forehead is not useful.[16][17] Others feel that it may promote vasoconstriction of the nasal blood vessels and thus be useful.[18]

Prevention

Application of a topical antibiotic ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.[19] 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.[20]

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.[21][22] Separately in Western fiction, nosebleeds often signify intense mental focus or effort, particularly during the use of psychic powers.[23][24]

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.[25]

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.[26]

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.[27]

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.

Etymology and pronunciation

The word epistaxis (/ˌɛpᵻˈstæksᵻs/) is from Greek: ἐπιστάζω epistazo, "to bleed from the nose" from ἐπί epi, "above, over" and στάζω stazo, "to drip [from the nostrils]".

References

  1. ↑
  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. 1 2 3 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. ↑ Kemal, O; Sen, E (2014). "Does the weather really affect epistaxis?". B-ENT. 10 (3): 199–202. PMID 25675665.
  5. ↑ Comelli, I; Vincenti, V; Benatti, M; Macri, GF; Comelli, D; Lippi, G; Cervellin, G (November 2015). "Influence of air temperature variations on incidence of epistaxis.". American journal of rhinology & allergy. 29 (6): 175–81. doi:10.2500/ajra.2015.29.4239. PMID 26637565.
  6. 1 2 3 Corry J. Kucik; Timothy Clenney (January 15, 2005). "Management of Epistaxis". American Academy of Family Physicians. Retrieved January 31, 2010.
  7. ↑ 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.
  8. ↑ The Journal of Laryngology & Otology (2008), 122: 1074–1077
  9. ↑ 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.
  10. ↑ Stucker, F.J. (2009). Rhinology and facial plastic surgery. Berlin: Springer. p. 145. ISBN 9783540743804.
  11. ↑ Qureishi, A; Burton, MJ (Sep 12, 2012). "Interventions for recurrent idiopathic epistaxis (nosebleeds) in children.". The Cochrane database of systematic reviews. 9: CD004461. doi:10.1002/14651858.CD004461.pub3. PMID 22972071.
  12. 1 2 3 4 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.
  13. 1 2 MedlinePlus Medical Encyclopedia: Nosebleed U.S. National Library of Medicine Medline Plus service. Retrieved 2010-03-15.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ al.], edited by Roger Jones ... [et (2004). Oxford textbook of primary medical care. (repr. ed.). Oxford: Oxford University Press. p. 711. ISBN 9780198567820.
  17. ↑ Bissonnette, Bruno (2010). Pediatric Anesthesia. New York: McGraw-Hill Medical. p. 1182. ISBN 9781607950936.
  18. ↑ al.], A.Y. Elzouki ... [et. Textbook of clinical pediatrics (2nd ed.). Berlin: Springer. p. 3968. ISBN 9783642022012.
  19. ↑ Kubba H, MacAndie C, Botma M, Robison J, O'Donnell M, Robertson G, Geddes N (2001). "A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood". Clin Otolaryngol Allied Sci. 26 (6): 465–8. doi:10.1046/j.1365-2273.2001.00502.x. PMID 11843924.
  20. ↑ Murthy P, Nilssen EL, Rao S, McClymont LG (1999). "A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis". Clin Otolaryngol Allied Sci. 24 (3): 228–31. doi:10.1046/j.1365-2273.1999.00236.x. PMID 10384851.
  21. ↑ "Manga: The Complete Guide, reviewed by Richard von Busack". Metroactive. Retrieved 5 August 2011.
  22. ↑ Morgan, Joyce (February 10, 2007). "Superheroes for a complex world". The Sydney Morning Herald. Retrieved 5 August 2011.
  23. ↑ Tracey, Liz (30 August 2016). ""Stranger Things" and the Psychic Nosebleed". JSTOR Daily. Retrieved 6 November 2016.
  24. ↑ Meehan, Paul. Cinema of the Psychic Realm: A Critical Survey. McFarland. p. 193.
  25. ↑ Various (1984). Erdoes, Richard; Ortiz, Alfonso, eds. American Indian Myths and Legends (2 ed.). Toronto, Ontario: Random House of Canada Limited. p. 274.
  26. ↑ http://saaressa.blogspot.fr/2011/01/finnsh-idioms.html
  27. ↑ OMG! Nosebleed! Say what?! Retrieved 28 August 2013
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