Nosebleed
Encyclopedia
Epistaxis or a nosebleed is the relatively common occurrence of hemorrhage from the nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

, usually noticed when the blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....

 drains out through the nostril
Nostril
A nostril is one of the two channels of the nose, from the point where they bifurcate to the external opening. In birds and mammals, they contain branched bones or cartilages called turbinates, whose function is to warm air on inhalation and remove moisture on exhalation...

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
Nasolacrimal duct
The nasolacrimal duct carries tears from the lacrimal sac into the nasal cavity. Excess tears flow through nasolacrimal duct which drains into the inferior nasal meatus...

 and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 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
    Blunt trauma
    In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

     (usually a sharp blow to the face such as a punch, sometimes accompanying a nasal fracture
    Nasal fracture
    Broken Nose' redirects here, for the Song by Catherine Wheel, please see Adam and EveA nasal fracture, commonly referred to as a broken nose, is a fracture of the bone or cartilage of the nose...

    )
  • Foreign bodies
    Foreign body
    A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....

     (such as fingers during nose-picking
    Nose-picking
    Nose-picking is the act of extracting dried nasal mucus or foreign bodies from the nose with a finger. Despite being a very common habit, it is a mildly taboo activity in most cultures, and the observation of the activity in another person may provoke mixed feelings of disgust and amusement...

    )
  • Inflammatory reaction
    Inflammation
    Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

     (e.g. acute respiratory tract infection
    Respiratory tract infection
    Respiratory tract infection refers to any of a number of infectious diseases involving the respiratory tract. An infection of this type is normally further classified as an upper respiratory tract infection or a lower respiratory tract infection...

    s, chronic sinusitis, allergic rhinitis
    Allergic rhinitis
    Allergic rhinitis, also known as pollenosis or hay fever, is an allergic inflammation of the nasal airways.It occurs when an allergen, such as pollen, dust or animal dander is inhaled by an individual with a sensitized immune system...

     or environmental irritants)

Other possible factors

  • Anatomical deformities
    Deformity
    A deformity, dysmorphism, or dysmorphic feature is a major difference in the shape of body part or organ compared to the average shape of that part.Deformity may arise from numerous causes:*A Genetic mutation*Damage to the fetus or uterus...

     (e.g. septal spurs or Hereditary hemorrhagic telangiectasia
    Hereditary hemorrhagic telangiectasia
    Hereditary hemorrhagic telangiectasia , also known as Osler-Weber-Rendu disease and Osler-Weber-Rendu syndrome, is a genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver and brain.It may lead to nosebleeds, acute...

    )
  • Insufflated
    Insufflation (medicine)
    Insufflation is the practice of inhaling a substance. Insufflation has limited medical use, but is a common route of administration with many respiratory drugs used to treat conditions in the lungs and paranasal sinus .The technique is common for many recreational drugs and is also used for some...

     drugs (particularly cocaine
    Cocaine
    Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...

    )
  • Intranasal tumor
    Tumor
    A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...

    s (e.g. Nasopharyngeal carcinoma
    Nasopharyngeal carcinoma
    Nasopharyngeal carcinoma is the most common cancer originating in the nasopharynx, the uppermost region of the pharynx , behind the nose where the nasal passages and auditory tubes join the remainder of the upper respiratory tract. NPC differs significantly from other cancers of the head and neck...

     or nasopharyngeal angiofibroma
    Nasopharyngeal angiofibroma
    Nasopharyngeal angiofibroma is a histologically benign but locally aggressive vascular tumor that grows in the back of the nasal cavity. It most commonly affects adolescent males...

    )
  • Low relative humidity
    Relative humidity
    Relative humidity is a term used to describe the amount of water vapor in a mixture of air and water vapor. It is defined as the partial pressure of water vapor in the air-water mixture, given as a percentage of the saturated vapor pressure under those conditions...

     of inhaled air (particularly during cold winter seasons)
  • Nasal cannula
    Nasal cannula
    The nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help. This device consists of a plastic tube which fits behind the ears, and a set of two prongs which are placed in the nostrils. Oxygen flows from these prongs...

     O2 (tending to dry the olfactory mucosa
    Olfactory mucosa
    The olfactory mucosa is located in the upper region of the nasal cavity and is made up of the olfactory epithelium and the underlying lamina propria, connective tissue containing fibroblasts, blood vessels, Bowman's glands and bundles of fine axons from the olfactory neurons.The mucus protects the...

    )
  • Nasal spray
    Nasal spray
    Nasal sprays come in a variety of forms. Medicated such as Astelin, Afrin and Nasonex and natural such as Sinusoothe and Sterimar. Although delivery methods vary, most nasal sprays function by instilling a fine mist into the nostril by action of a hand-operated pump mechanism.-Antihistamine nasal...

    s (particularly prolonged or improper use of nasal steroids)
  • Otic barotrauma
    Barotrauma
    Barotrauma is physical damage to body tissues caused by a difference in pressure between an air space inside or beside the body and the surrounding fluid...

     (such as from descent in aircraft or ascent in scuba diving)
  • Surgery (e.g. septoplasty
    Septoplasty
    Septoplasty is a corrective surgical procedure done fix to straighten the nasal septum, the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Often the...

     and Functional Endoscopic Sinus Surgery
    Functional Endoscopic Sinus Surgery
    Functional endoscopic sinus surgery is the mainstay in the surgical treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent acute, and chronic sinus problems. Ample research supports its record of safety and success...

    )
  • Leech
    Leech
    Leeches are segmented worms that belong to the phylum Annelida and comprise the subclass Hirudinea. Like other oligochaetes such as earthworms, leeches share a clitellum and are hermaphrodites. Nevertheless, they differ from other oligochaetes in significant ways...

     infestation

Most common factors

  • Allergies
  • Infectious diseases (e.g. common cold)
  • Hypertension
    Hypertension
    Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...


Other possible factors

  • Drugs — Aspirin
    Aspirin
    Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...

    , Fexofenadine
    Fexofenadine
    Fexofenadine is an antihistamine drug used in the treatment of hayfever and similar allergy symptoms...

    /Allegra/Telfast, warfarin
    Warfarin
    Warfarin is an anticoagulant. It is most likely to be the drug popularly referred to as a "blood thinner," yet this is a misnomer, since it does not affect the thickness or viscosity of blood...

    , ibuprofen
    Ibuprofen
    Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....

    , clopidogrel
    Clopidogrel
    Clopidogrel is an oral, thienopyridine class antiplatelet agent used to inhibit blood clots in coronary artery disease, peripheral vascular disease, and cerebrovascular disease. It is marketed by Bristol-Myers Squibb and Sanofi-Aventis under the trade name Plavix. The drug works by irreversibly...

    , prasugrel
    Prasugrel
    Prasugrel is a novel platelet inhibitor developed by Daiichi Sankyo Co. and produced by Ube and currently marketed in the United States in cooperation with Eli Lilly and Company for acute coronary syndromes planned for percutaneous coronary intervention...

    , isotretinoin
    Isotretinoin
    Isotretinoin, INN, is a medication used mostly for cystic acne. It was first developed for brain, pancreatic and other cancers. It is used to treat harlequin-type ichthyosis, a usually lethal skin disease, and lamellar ichthyosis. Its effects are systemic and nonselective...

    , desmopressin
    Desmopressin
    Desmopressin is a synthetic replacement for vasopressin, the hormone that reduces urine production. It may be taken nasally, intravenously, or as a tablet...

    , ginseng
    Ginseng
    Ginseng is any one of eleven species of slow-growing perennial plants with fleshy roots, belonging to the genus Panax of the family Araliaceae....

     and others
  • Alcohol (due to vasodilation
    Vasodilation
    Vasodilation refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When...

    )
  • Anemia
    Anemia
    Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...

  • Connective tissue disease
    Connective tissue disease
    A connective tissue disease is any disease that has the connective tissues of the body as a target of pathology. Connective tissue is any type of biological tissue with an extensive extracellular matrix that supports, binds together, and protects organs...

  • Blood dyscrasias
    Dyscrasia
    Dyscrasia is a concept from ancient Greek medicine with the word "dyskrasia", meaning bad mixture.The concept of dyscrasia was developed by the ancient Greek physician Galen , who elaborated a model of health and disease as a structure of elements, qualities, humors, organs, and temperaments...

  • Envenomation
    Envenomation
    Envenomation is the process by which venom is injected into some animal by the bite of a venomous animal. Many kinds of animals, including mammals , reptiles , spiders , insects , employ venom for hunting and for self defense...

     by mamba
    Mamba
    Mambas, of the genus Dendroaspis , are a group of highly venomous, fast-moving land-dwelling snakes of Africa. They belong to the family of Elapidae which includes cobras, coral snakes, taipans, brown snakes, tiger snakes, death adders, kraits and, debatably, sea snakes...

    s, taipan
    Taipan
    The taipans are a genus of large, fast, highly venomous Australasian snakes of the elapid family.-Overview:The taipan was named by Donald Thomson after the word used by the Wik-Mungkan Aboriginal people of central Cape York Peninsula, Queensland, Australia.There are three known species: the coastal...

    s, kraits
    Bungarus
    Bungarus, commonly referred to as kraits , is a genus of venomous elapid snakes found in South and South-East Asia. There are 12 species and 5 subspecies recognized.- Distribution :...

    , and death adders
  • Heart failure (due to an increase in venous pressure)
  • Hematological malignancy
    Hematological malignancy
    Hematological malignancies are the types of cancer that affect blood, bone marrow, and lymph nodes. As the three are intimately connected through the immune system, a disease affecting one of the three will often affect the others as well: although lymphoma is technically a disease of the lymph...

  • Idiopathic thrombocytopenic purpura
    Idiopathic thrombocytopenic purpura
    Idiopathic thrombocytopenic purpura is the condition of having an abnormally low platelet count of no known cause . As most incidents of ITP appear to be related to the production of antibodies against platelets, immune thrombocytopenic purpura or immune thrombocytopenia are terms also used to...

  • Pregnancy
    Pregnancy
    Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

     (rare)
  • Vascular disorders
  • Vitamin C
    Vitamin C
    Vitamin C or L-ascorbic acid or L-ascorbate is an essential nutrient for humans and certain other animal species. In living organisms ascorbate acts as an antioxidant by protecting the body against oxidative stress...

     or Vitamin K
    Vitamin K
    Vitamin K is a group of structurally similar, fat soluble vitamins that are needed for the posttranslational modification of certain proteins required for blood coagulation and in metabolic pathways in bone and other tissue. They are 2-methyl-1,4-naphthoquinone derivatives...

     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
Anticoagulant
An anticoagulant is a substance that prevents coagulation of blood. A group of pharmaceuticals called anticoagulants can be used in vivo as a medication for thrombotic disorders. Some anticoagulants are used in medical equipment, such as test tubes, blood transfusion bags, and renal dialysis...

 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
Kiesselbach's plexus
Kiesselbach's area, also Kiesselbach's plexus, Kiesselbach's triangle, and Little's area, is a region in the anteroinferior part of the nasal septum, where four arteries anastomose to form a vascular plexus called 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
Coagulation
Coagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel...

, which may be encouraged by direct pressure
Emergency bleeding control
Emergency bleeding control describes the steps or actions taken to control bleeding from a patient who has suffered a traumatic injury or who has a medical condition which has led to bleeding...

  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
Oxymetazoline
Oxymetazoline is a selective alpha-1 agonist and partial alpha-2 agonist topical decongestant, used in the form of Oxymetazoline hydrochloride, in products such as Afrin, Dristan, Nasivin, Logicin, Vicks Sinex, Visine L.R., Sudafed OM, and Zicam. It was developed from Xylometazoline at E.Merck...

 or phenylephrine
Phenylephrine
Phenylephrine is a selective α1-adrenergic receptor agonist used primarily as a decongestant, as an agent to dilate the pupil, and to increase blood pressure...

 are widely available in over-the-counter nasal sprays for the treatment of allergic rhinitis
Allergic rhinitis
Allergic rhinitis, also known as pollenosis or hay fever, is an allergic inflammation of the nasal airways.It occurs when an allergen, such as pollen, dust or animal dander is inhaled by an individual with a sensitized immune system...

, 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)
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....

. In the first instance this can take the form of chemical cautery
Cauterization
The medical practice or technique of cauterization is the burning of part of a body to remove or close off a part of it in a process called cautery, which destroys some tissue, in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities...

 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
Silver nitrate
Silver nitrate is an inorganic compound with chemical formula . This compound is a versatile precursor to many other silver compounds, such as those used in photography. It is far less sensitive to light than the halides...

 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
Sphenopalatine artery
The sphenopalatine artery is an artery of the head, commonly known as the artery of epistaxis.-Course:The sphenopalatine artery is a branch of the maxillary artery which passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus...

, anterior and posterior ethmoidal arteries. More rarely the maxillary or a branch of the external carotid artery
Common carotid artery
In human anatomy, the common carotid artery is an artery that supplies the head and neck with oxygenated blood; it divides in the neck to form the external and internal carotid arteries. - Structure :...

 can be ligated. The bleeding can also be stopped by intra-arterial embolization
Embolization
Embolization is a non-surgical, minimally-invasive procedure performed by an interventional radiologist and interventional neuroradiologists. It involves the selective occlusion of blood vessels by purposely introducing emboli.-Therapeutic applications:...

 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
Saline (medicine)
In medicine, saline is a general term referring to a sterile solution of sodium chloride in water but is only sterile when it is to be placed intravenously, otherwise, a saline solution is a salt water solution...

 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
Lipid pneumonia
Lipid pneumonia or lipoid pneumonia is a specific form of lung inflammation that develops when lipids enter the bronchial tree. The disorder is sometimes called Cholesterol pneumonia in cases where the lipid is a factor.-Causes:...

.

Application of a topical antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...

 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
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...

 due to iron deficiency
Iron deficiency (medicine)
Iron deficiency is one of the most common of the nutritional deficiencies. Iron is present in all cells in the human body, and has several vital functions...

.

In popular culture

In the visual language of Japanese comics (manga
Manga
Manga is the Japanese word for "comics" and consists of comics and print cartoons . In the West, the term "manga" has been appropriated to refer specifically to comics created in Japan, or by Japanese authors, in the Japanese language and conforming to the style developed in Japan in the late 19th...

) and animation (anime
Anime
is the Japanese abbreviated pronunciation of "animation". The definition sometimes changes depending on the context. In English-speaking countries, the term most commonly refers to Japanese animated cartoons....

), 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. (Interestingly, the nose is now known to contain erectile tissue which may become engorged during sexual arousal: honeymoon rhinitis
Honeymoon rhinitis
Honeymoon rhinitis is a condition in which the sufferer experiences nasal congestion during sexual intercourse.The condition appears to be genetically determined, and caused by the presence in the nose of erectile tissue which may become engorged during sexual arousal as a side effect of the...

is a condition in which nasal stuffiness or sneezing accompanies sexual thoughts or activities.)

External links

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