Nosebleed (aka epistaxis, from Greek "epi" meaning "over", and "taxis" meaning "to drip") is hemorrhage from the nose.

• Noticed when blood drains out through the nostrils, common
• Bleeding from both nostrils, associated w/ posterior bleeds
• Flow of blood into the mouth, associated w/ posterior bleeds
• Blood can come out of the eye, up from the nasolacrimal duct, in more severe cases
• Nausea and vomiting, due to blood (fresh and clotted) flowing down into the stomach

• Local factors, including:
  • Blunt trauma, usually a sharp blow to the face e.g. a punch, sometimes accompanying a nasal fracture
  • Foreign bodies, e.g. fingers during nose-picking
  • Inflammatory reactions, e.g. acute RTI's, chronic sinusitis, rhinitis or environmental irritants
  • Less commonly:
    • Anatomical deformities, e.g. septal spurs or hereditary hemorrhagic telangiectasia
    • Insufflated drugs, particularly cocaine
    • Intranasal tumors, e.g. nasopharyngeal carcinoma, nasopharyngeal angiofibroma
    • Low relative humidity of inhaled air, particularly during cold winter seasons
    • Nasal cannula oxygen, tending to dry the olfactory mucosa
    • Nasal sprays, particularly prolonged or improper use of nasal steroids
    • Middle ear barotrauma, e.g. from descent in aircraft or ascent in scuba diving
    • Surgery, e.g. septoplasty and functional endoscopic sinus surgery
• Systemic factors, including:
  • Infectious diseases, e.g. common cold
  • HTN
  • Less commonly:
    • Alcohol, due to vasodilation
    • Anemia
    • Blood dyscrasias
    • Connective tissue disease
    • Drugs, including aspirin, fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidigrel, prasugrel, isotretinoin, desmopressin, ginseng, etc
    • Envenomation, by mambas, taipans, kraits, and death adders
    • Liver disease, including hepatic cirrhosis causing deficiency of factor 2, 7, 9, 10
    • Heart failure, due to increase in venous pressure
    • Hematological malignancy
    • Idiopathic thrombocytopenic purpura
    • Pregnancy, rare, due to HTN and hormonal changes
    • Vascular disorders
    • Vitamin C and K deficiency
    • Von Willebrand's disease
    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
    • Mediastinal compression by tumors (raised enous pressure)
• Idiopathic (no obvious cause)

• Due to rupture of a blood vessel within the richly perfused nasal mucosa
• Rupture may be spontaneous or initiated by trauma
• Vast majority occur in Little's area (i.e. the anterior/front part of the nose from the nasal septum), which is richly endowed w/ blood vessels (Kiesselbach's plexus)
• Bleeding further back in the nose is known as a posterior bleed, and is usually due to bleeding from Woodruff's plexus (ie. venous plexus situated in the posterior part of the inferior meatus)

• Anterior, the most common
• Posterior, less common, but more liekly to require medical attention

• Apply direct pressure by pinching Little's/Kiesselbach's area (i.e. the soft fleshy part of the nose, the source of majority of nose bleeds), to cause blood to clot, and therefore stop blood flow. Pressure should be firm and applied for at least 5 mins, and up to 20 mins. Tilting the head forward helps decrease the chances of nausea and airway obstruction
• The use of local cooling of the head and neck is controversial, some believing ice to the nose/forehead is not useful, and others believing it promotes vasoconstriction of the nasal blood vessels
• Topical abx ointment to the nasal mucosa, can be useful for recurrent epistaxis
• Drugs, including local application of vasoconstrictive agent, including:
  • Oxymetazoine, OTC nasal sprays for allergic rhinitis, which can be used here too
  • Phenylephrine, OTC nasal sprays for allergic rhinitis, which can be used here too
• Cauterize bleeding blood vessels, w/ silver nitrate, is common but not v useful for those w/ more than mild bleeding. It is also often painful even when freezing is used
• Nasal packing, including:
  • Anterior nasal packing, which use gauze or balloons
  • Posterior nasal packing, which uses a Foley catheter, to blow up the balloon when it is in the back of the throat, and apply traction. Ribbon gauze or Merocel packing can also be used
• Surgery, for:
  • Endoscopic evaluation of the nasal cavity under GA to identify an elusive bleeding point, or to directly ligate (tie off) the blood vessels supplying the nose, including the sphenopalatine, anterior and posterior ethmoidal arteries. More rarely, the maxillary or a branch of the external carotid artery can be ligated
  • Intra-arteirial embolization using a catheter placed int he groin and threaded up to the aorta to the bleeding vessel by an interventional radiologist

• Blood flow normally stops when the blood clots
• Although the sight of large amounts of blood can be alarming, nosebleeds are RARELY fatal
• Increase in BP (generally due to HTN) tends to increase duration of spontaneous nosebleeds
• Anticoagulants and disorders of blood clotting, can promote/prolong bleeding
• Elderly are more prone to prolonged nose bleeds, as their blood vessels are less able to constrict to control the bleeding
• Posterior bleeds are often prolonged and difficult to control
• Ongoing bleeding despite good nasal packing is a surgical EMERGENCY

• Swallowing excess blood can irritate the stomach and cause vomiting → tilt head forward

• Nosebleeds only accounted for 4 of the 2.4 million deaths in the USA annually
• Relatively common, reported in up to 60% of the population
• Peak incidence is those <10yo, and >50yo, tending to occur in the elderly as the nasal mucosa (lining) becomes dry and thin, and BP tends to be higher
• Tend to occur in males more than females

• Broken nose