for: Yarrow

Epistaxis (or a nosebleed in plain English) is the relatively common occurrence of hemorrhage from the nose, usually noticed when the blood drains out through the nostrils. 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 accounted for only 4 deaths in the U.S. in 1999, representing 0.000167% of all death that year. Perhaps the most well-known Epistaxis-related death was that of Attila the Hun. He drank a colossal amount of alcohol on his wedding night after his parley with Pope Leo I, suffered a nosebleed in his sleep and was suffocated by the blood.

Etiology

The cause 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

• Anatomical deformities (e.g. septal spurs or Osler-Weber-Rendu Syndrome)
• Blunt trauma (usually a sharp blow to the face, sometimes accompanying a nasal fracture)
• Foreign bodies (such as fingers during nose-picking)
• Inflammatory reaction (e.g. acute respiratory tract infections, chronic sinusitis, allergic rhinitis or environmental irritants)
• Insufflated drugs (particularly cocaine)
• Intranasal tumors (e.g. Nasopharyngeal carcinoma or nasopharyngeal angiofibroma)
• Low relative humidity of inhaled air (particularly during cold winter seasons)
• Nasal prong O₂ (tending to dry the olfactory mucosa)
• Nasal sprays (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)

Systemic factors

• Drugs – Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin, ginseng and others
• Alcohol (due to vasodilation)
• Allergies
• Anemia
• Connective tissue disease
• Blood dyscrasias
• Envenomation by mambas, taipans, kraits, and death adders
• Heart failure (due to an increase in venous pressure)
• Hematological malignancy
• Hypertension
• Idiopathic thrombocytopenic purpura
• Infectious diseases
• Pregnancy
• 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. An increase in blood pressure (e.g. due to general hypertension) or local blood flow (for example following a cold or infection) will increase the likelihood of a spontaneous nosebleed. 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.