Nosebleed

Nosebleed

Definition

A nosebleed is bleeding from the nose; the medical term for it is epistaxis.

Description

Unexpected bleeding from anywhere is cause for alarm. Persistent bleeding should always be investigated because it may be the earliest sign of cancer. Fortunately, nosebleeds are rarely a sign of cancer. A much more common cause of nosebleeds is injury from picking or blowing or fisticuffs. People with hay fever have swollen membranes that are fragile and more likely to bleed.

Most nosebleeds (about 90%) come from the front of the septum, that plane of cartilage that separates the nostrils. These are called anterior nosebleeds. The lower front part of the septum has a mass of blood vessels on either side called Kiesselbach's plexus that is easy to injure. Nosebleeds from the more remote reaches of the nose are called posterior nosebleeds. They are less common, are less likely to have a benign cause, and are much harder to manage.

Nosebleeds are most likely to occur in children between the ages of two and 10 years, in part because younger children frequently insert small objects in the nose or pick at the tissues lining the nose. Nosebleeds in adolescents may indicate cocaineabuse. Nosebleeds in older adults may result from arteriosclerosis or high blood pressure.

Causes and symptoms

Nosebleeds may result from a number of different causes:

Treatment

The first treatment is to pinch the patient's nostrils together, have them sit forward, and ask them to stay that way for 5-10 minutes. This method usually stops nosebleeds originating in Kiesselbach's plexus. The patient should not tilt his or her head backward, as this position may cause blood to drip backward into the throat or windpipe. It is best to hold the head upright.

In the case of small children, the doctor may examine the inside of the nose to check for foreign bodies, evidence of scratching or picking, etc. Small foreign bodies (watch batteries, dried peas or beans, buttons, etc.) can be removed by suction if necessary. The doctor may also have to remove clotted blood by suction.

Bleeding that continues originates from the back of the nose in most cases and will flow down the throat. If that happens, emergency intervention is needed.

As an emergency procedure, the nose will be packed front and/or back with cotton gauze and a rubber balloon from a Foley catheter. This treatment is not comfortable. Having no place to flow, the blood should clot, giving the ear, nose and throat specialists (otorhinolaryngologists) a chance to find the source and permanently repair it. If the packing has to remain for any length of time, antibiotics and pain medication will be necessary—antibiotics because the sinuses will be plugged up and prone to infection. Nose packing may so interfere with breathing that the patient will need supplemental oxygen.

Newer options for controlling posterior nosebleeds include the use of Surgicel, Merocel, or other oxidized cellulose products that expand with moisture. These may control the bleeding without the need for bulky nasal packing.

Many bleeds are from small exposed blood vessels with no other disease. They can be destroyed by cautery, usually done by applying silver nitrate to the affected area. Larger vessels may not respond to cautery. The surgeon may have to tie them off, which is known as ligation. Another technique that is sometimes used with larger vessels is embolization, in which the doctor injects a chemical to block or close the blood vessel.

Alternative treatment

Estrogen cream, the same preparation used to revitalize vaginal tissue, can toughen fragile blood vessels in the anterior septum and forestall the need for cauterization. Botanical medicines known as styptics, which slow down and can stop bleeding, may be taken internally or applied topically. Some of the plants used are achillea (yarrow), trillium, geranium, and shepherd's purse (capsella-bursa). Homeopathic remedies can be one of the quickest and most effective treatments for epistaxis.

Prevention

Both before and after a nosebleed, the patient should blow the nose gently and avoid picking or scratching the tissues that line it. Children with recurrent nosebleeds during heating season may benefit from the use of a cool-mist vaporizer to humidify the bedroom at night, or from the application of a small quantity of petroleum jelly to the inside of each nostril. Treatment of hay fever helps reduce the fragility of the tissues.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Epistaxis." Section 7, Chapter 86 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Bhatnagar, R. K., and S. Berry. "Selective Surgicel Packing for the Treatment of Posterior Epistaxis." Ear, Nose, and Throat Journal 83 (September 2004): 633-634.

Gluckman, William, DO, and Robert Baricella, DO. "Epistaxis." eMedicine October 11, 2004. http://emedicine.com/ped/topic1618.htm.

Gurney, T. A., C. F. Dowd, and A. H. Murr. "Embolization for the Treatment of Idiopathic Posterior Epistaxis." American Journal of Rhinology 18 (September-October 2004): 335-339.

Organizations

American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237 or (913) 906-6000. http://www.aafp.org.

American Academy of Otolaryngology—Head and Neck Surgery. One Prince Street, Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org.

Key terms

Cautery — The use of heat, electricity, or chemicals to destroy tissue.

Embolization — A technique for stopping bleeding by introducing a substance into larger blood vessels that blocks or closes them.

Epistaxis — The medical term for nosebleed.

Kiesselbach's plexus — An area on the anterior part of the nasal septum that has a rich supply of blood vessels and is a common site of nosebleeds. It is named for Wilhelm Kiesselbach, a nineteenth-century German otolaryngologist.

Septum — The partition that separates the two nostrils. It consists of membranes, cartilage, and bone.

Styptic — Any remedy with an astringent and hemo-static (stopping bleeding) quality.

nosebleed /nose·bleed/ (noz´bled) epistaxis.

nose·bleed (n