A nosebleed, also known medically as epistaxis, is bleeding from the nasal cavity caused by rupture of small blood vessels in the nasal mucosa. Most cases are minor and stop spontaneously with simple first-aid or medical care. In some cases, blood may flow down into the stomach, and cause nausea and vomiting. In more severe cases, blood may come out of both nostrils. Rarely, bleeding may be so significant that low blood pressure occurs. Blood may also be forced to flow up and through the nasolacrimal duct and out of the eye, producing bloody tears. Risk factors include trauma; especially from nosepicking, blood thinners, high blood pressure, alcoholism, seasonal allergies, dry weather, and inhaled corticosteroids. There are two types: anterior, which is more common; and posterior, which is less common but more serious. Anterior nosebleeds generally occur from Kiesselbach's plexus while posterior bleeds generally occur from the sphenopalatine artery or Woodruff's plexus. The diagnosis is by direct observation. Although nosebleeds can appear dramatic, they are rarely life-threatening; most resolve without medical intervention, but posterior or severe bleeds may require urgent care. Prevention may include the use of petroleum jelly in the nose. Initially, treatment is generally the application of pressure for at least thirty minutes over the lower half of the nose. If this is not sufficient, nasal packing may be used. Tranexamic acid may also be helpful. If bleeding episodes continue, endoscopy is recommended. About 60% of people have a nosebleed at some point in their life. About 10% of nosebleeds are serious. Approximately 6% of patients will seek medical attention for epistaxis. Nosebleeds are rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999. Nosebleeds most commonly affect those younger than 10 and older than 50.
Cause
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). Low relative humidity (such as in 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. 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 are listed below: Coagulopathy
Thrombocytopenia (thrombotic thrombocytopenic purpura, idiopathic thrombocytopenic purpura) Von Willebrand's disease Hemophilia Leukemia HIV Chronic liver disease—cirrhosis causes deficiency of factor II, VII, IX,& X Dietary
Sulfur dioxide (sulphur dioxide) E220 (as a food preservative used particularly in wines and dried fruits) Sulphites as food preservatives Salicylates naturally occurring in some fruits and vegetables Inflammatory
Granulomatosis with polyangiitis Systemic lupus erythematosus Medications/Drugs
Anticoagulation (warfarin, heparin, aspirin, etc.) Insufflated drugs (particularly cocaine) Nasal sprays (particularly prolonged or improper use of nasal steroids) Neoplastic
Squamous cell carcinoma Adenoid cystic carcinoma Melanoma Nasopharyngeal carcinoma Nasopharyngeal angiofibroma Nosebleeds can be a sign of cancer in the sinus area, which is rare, or tumors starting at the base of the brain, such as meningioma. Due to the sensitive location, nosebleeds caused by tumors are typically associated with other symptoms, such as hearing or vision problems. Traumatic
Anatomical deformities (e.g. septal spurs) 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) Digital trauma (nose picking) Middle ear barotrauma (such as from descent in aircraft or ascent in scuba diving) Nasal bone fracture Septal fracture/perforation Intranasal tumors (e.g. Nasopharyngeal carcinoma or nasopharyngeal angiofibroma) Nasal cannula O2 (tending to dry the olfactory mucosa) Nasal sprays (particularly prolonged or improper use of nasal steroids) Surgery (e.g. septoplasty and functional endoscopic sinus surgery) Leech infestation Nasal bleeds may be due to fracture of facial bones, namely maxilla and zygoma. Vascular
Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease) Angioma Aneurysm of the carotid artery
Pathophysiology
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