View source for Epistaxis

{{for|the plant referred to as "nosebleed plant"|Yarrow}}

{{Infobox_Disease |
 Name = Nosebleed |
 Image = Epistaxis1.jpg |
 DiseasesDB = 18327 |
 ICD10 = {{ICD10|R|04|0|r|00}} |
 ICD9 = {{ICD9|784.7}} |
 ICDO = |  
 OMIM = |
 MedlinePlus = |
 eMedicineSubj = emerg |
 eMedicineTopic = 806 |
 eMedicine_mult = {{eMedicine2|ent|701}}, {{eMedicine2|ped|1618}} |
 MeshName = Epistaxis |
 MeshNumber = C08.460.261 |
}}

'''Epistaxis''' (or a '''nosebleed''') is the relatively common occurrence of [[hemorrhage]] from the [[nose]], usually noticed when the [[blood]] drains out through the [[nostril]]s. 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.<ref>[http://www.cdc.gov/nchs/data/statab/vs00199wktbli.pdf  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.</ref> Perhaps the most well-known Epistaxis-related death was that of [[Attila the Hun]]. He drank an extremely  large quantity of [[Alcoholic beverage|alcohol]] on his wedding night after his [[parley]] with [[Pope Leo I]], suffered a nosebleed in his sleep, and was suffocated by the blood.

== Cause ==
The cause of nosebleeds can generally be divided into two categories, local and [[:wikt:systemic|systemic]] factors, although it should be remembered that a significant number of nosebleeds occur with no obvious cause.

=== Local factors ===
===== Most common factors =====
:* [[Blunt trauma]] (usually a sharp blow to the face, sometimes accompanying a [[nasal fracture]])
:* [[Foreign body|Foreign bodies]] (such as fingers during [[nose-picking]])
:* [[Inflammation|Inflammatory reaction]] (''e.g.'' acute [[respiratory tract infection]]s, [[chronic sinusitis]], [[allergic rhinitis]] or environmental [[Irritant (biology)|irritant]]s)

===== Other possible factors =====
:* [[Deformity|Anatomical deformities]] (''e.g.'' septal spurs or [[Hereditary hemorrhagic telangiectasia]])
:* [[Insufflation (medicine)|Insufflated]] drugs (particularly [[cocaine]])
:* Intranasal [[tumor]]s (''e.g.'' [[Nasopharyngeal carcinoma]] or [[nasopharyngeal angiofibroma]])
:* Low [[relative humidity]] of inhaled air (particularly during cold winter seasons)
:* [[Nasal cannula]] O<sub>2</sub> (tending to dry the [[olfactory mucosa]])
:* [[Nasal spray]]s (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 <ref>{{cite journal |author=Yueng-Hsiang Chu & Jih-Chin Lee |url=http://content.nejm.org/cgi/content/full/361/9/e14 |title=Unilateral Epistaxis |journal=[[New England Journal of Medicine]] |year=2009 |volume=361 |pages=e14 |pmid=19710479 |doi=10.1056/NEJMicm0807268 |issue=9}}</ref>

=== Systemic factors ===
===== Most common factors =====
:* [[Allergies]]
:* [[Infectious diseases]] (''e.g.'' common cold)
:* [[Hypertension]] also allergic to aspirin

===== Other possible factors =====
:* Drugs — [[Aspirin]], [[Fexofenadine]]/[[Allegra (drug)|Allegra]]/[[Telfast]], [[warfarin]], [[ibuprofen]], [[clopidogrel]], [[isotretinoin]], [[desmopressin]], [[ginseng]] and others
:* [[Alcohol intoxication|Alcohol]] (due to [[vasodilation]])
:* [[Anaemia]]
:* [[Connective tissue disease]]
:* [[Dyscrasia|Blood dyscrasias]]
:* [[Envenomation]] by [[Mamba|mambas]], [[Taipan|taipans]], [[Bungarus|kraits]], and [[Acanthopis|death adders]]
:* [[Heart failure]] (due to an increase in [[blood pressure#Venous pressure|venous pressure]])
:* [[Hematological malignancy]]
:* [[Idiopathic thrombocytopenic purpura]]
:* [[Pregnancy]] (rare)
:* Vascular disorders
:* [[Vitamin C]] or [[Vitamin K]] deficiency
:* [[von Willebrand's disease]]

== 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 appears to occur in males more than females.<ref name="AAFP">{{cite web |url=http://www.aafp.org/afp/20050115/305.html |title=Management of Epistaxis |author=Corry J. Kucik & Timothy Clenney |date=January 15, 2005 |accessdate=January 31, 2010 |publisher=[[American Academy of Family Physicians]]}}</ref> An increase in blood pressure (e.g. due to general hypertension) tends to increase the duration of spontaneous epistaxis.<ref>{{cite journal |doi=10.1097/00005537-199907000-00019 |author=J. F. Lubianca Neto, F. D. Fuchs, S. R. Facco, M. Gus, L. Fasolo, R. Mafessoni & A. L. Gleissner |title=Is epistaxis evidence of end-organ damage in patients with hypertension? |journal=Laryngoscope |year=1999 |volume=109 |issue=7 |pages=1111–1115 |pmid=10401851}}</ref> [[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 rupture of the [[sphenopalatine artery]] or one of its branches. 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.<ref name="AAFP"/>

== Treatment ==
The flow of blood normally stops when the blood [[coagulation|clots]], which may be encouraged by [[Emergency bleeding control|direct pressure]]  applied by pinching the soft fleshy part of the nose. This applies pressure to [[Little'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.<ref name="AAFP"/> 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.<ref>{{cite journal |url=http://www.ingentaconnect.com/content/bsc/cot/2003/00000028/00000006/art00013 |title=Efficacy of ice packs in the management of epistaxis |author=A. Teymoortash, A. Sesterhenn, R. Kress, N. Sapundzhiev & J. A. Werner |journal=Clinical Otolaryngology & Allied Sciences |volume=28 |issue=6 |year=2003 |pages=545–547 |doi=10.1046/j.1365-2273.2003.00773.x}}</ref> 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,<ref>[http://www.medindia.net/patients/patientinfo/nosebleed_treatment.htm Nose Bleed / Epistaxis Treatment] MedIndia Online.net.   Retrieved 2010-03-15.</ref><ref name="AAFP"/> while others advise against it.<ref>{{cite web|url=http://www.rush.edu/rumc/page-1098987337863.html|publisher=[[Rush University Medical Center]] |accessdate=March 5, 2008 |title=Nosebleeds}}</ref>

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.<ref name="pmid2676467">{{cite journal |author=Guarisco JL, Graham HD |title=Epistaxis in children: causes, diagnosis, and treatment |journal=Ear Nose Throat J |volume=68 |issue=7 |pages=522, 528–30, 532 passim |year=1989 |pmid=2676467 |doi=}}</ref>

Other products available to promote coagulation include Coalgan<ref>Coalgan ,[http://saignementdenez.com/ “le saignement de nez”] Retrieved 2010-07-16</ref>(France), Stop Hemo(Sweden<ref>Stop Hemo, [http://www.nasblod.nu/ “Stop Hemo Information Page”] Retrieved 2010-07-16</ref>, Italy, Switzerland<ref>Stop hemo Switzerland[http://www.uhlmann.ch/index.php?page=catalog.product_details&flypage=catalog.flypage.tpl&product_id=25&category_id=33&option=com_virtuemart&Itemid=2&lang=fr “Stop hemo information”] Retrieved 2010-07-16</ref>) and NasalCEASE(US<ref> NasalCEASE [http://www.nasalcease.com/ “NasalCease Information Page”] Retrieved 2010-03-15</ref> and Australia<ref>NasalCEASE Australia[http://www.scintera.com.au/nasallanding.aspx “Nasalease information”] Retrieved 2010-07-16</ref>). 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 [[otolaryngology|otolaryngologist (ENT doctor)]]. In the first instance this can take the form of chemical [[cauterization|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 [[Common carotid artery|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.<ref>[http://www.nlm.nih.gov/medlineplus/ency/article/003106.htm MedlinePlus Medical Encyclopedia: Nosebleed] [[U.S.]] [[National Library of Medicine]] [[Medline Plus]] service.  Retrieved 2010-03-15.</ref>

Chronic epistaxis resulting from a dry nasal mucosa can be treated by spraying [[Saline (medicine)|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.

Application of a topical [[antibiotic]] ointment to the nasal mucosa has been shown to be an effective treatment for recurrent epistaxis.<ref name="pmid11843924">{{cite journal |author=Kubba H, MacAndie C, Botma M, Robison J, O'Donnell M, Robertson G, Geddes N |title=A prospective, single-blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood |journal=Clin Otolaryngol Allied Sci |volume=26 |issue=6 |pages=465–8 |year=2001 |pmid= 11843924|doi=10.1046/j.1365-2273.2001.00502.x}}</ref>  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.<ref name="pmid10384851">{{cite journal |author=Murthy P, Nilssen EL, Rao S, McClymont LG |title=A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis |journal=Clin Otolaryngol Allied Sci |volume=24 |issue=3 |pages=228–31 |year=1999 |pmid= 10384851|doi=10.1046/j.1365-2273.1999.00236.x}}</ref>

Nosebleeds are rarely dangerous unless prolonged and heavy. Nevertheless they should not be underestimated by medical staff. Particularly in posterior bleeds a great deal of blood may be swallowed and thus blood loss underestimated. The elderly and those with co-existing morbidities, particularly of blood clotting should be closely monitored for signs of shock.

Recurrent nosebleeds may cause [[anemia]] due to [[iron deficiency (medicine)|iron deficiency]].

== See also ==
* [[Kiesselbach's plexus]]
* [[Nosebleed section]]

== References ==
{{reflist|2}}

== External links ==
{{commons}}
* [http://www.nlm.nih.gov/medlineplus/ency/article/003106.htm National Library of Medicine] - Describes causes, solutions, and prevention of nosebleeds


{{Circulatory and respiratory system symptoms and signs}}
{{Speech and voice symptoms and signs}}
[[Category:Rhinology]]
[[Category:First aid]]
[[Category:Injuries]]
[[Category:Symptoms and signs: Circulatory and respiratory systems]]

[[ar:رعاف]]
[[bg:Епистаксис]]
[[ca:Epistaxi]]
[[cs:Epistaxe]]
[[de:Epistaxis]]
[[dv:ނޭފަތުން ލޭއައުން]]
[[es:Epistaxis]]
[[eo:Epistakso]]
[[fa:خون‌دماغ]]
[[fr:Épistaxis]]
[[ko:코피]]
[[hi:नकसीर फूटना]]
[[hr:Epistaksa]]
[[id:Hidung berdarah]]
[[it:Epistassi]]
[[he:דימום מהאף]]
[[hu:Orrvérzés]]
[[ms:Hidung berdarah]]
[[nl:Bloedneus]]
[[ja:鼻血]]
[[no:Neseblod]]
[[nn:Naseblødning]]
[[pl:Krwawienie z nosa]]
[[pt:Epistaxe]]
[[ru:Носовое кровотечение]]
[[simple:Epistaxis]]
[[fi:Nenäverenvuoto]]
[[sv:Näsblod]]
[[vi:Chảy máu cam]]
[[zh:流鼻血]]
[[Category:2Fix]]