Nosebleed

Nosebleed (Epistaxis)

Epistaxis, or a nosebleed, is when you lose blood from the tissue that lines the inside of your nose. A combination of dry air and tiny blood vessels that line the inner surface of your nose often cause nosebleeds.

Overview

What is epistaxis?

“Epistaxis” is the medical term for a nosebleed. A nosebleed, meaning a loss of blood from the tissue that lines the inside of your nose, can occur in one or both nostrils. Usually, it only affects one.

Types

• Anterior Epistaxis: Blood flows out of the nose with the patient in a sitting position.
• Posterior Epistaxis: Mainly the blood flows back into the throat. The patient may swallow it and later have coffee-colored vomitus.

Symptoms

What are the symptoms of a nosebleed?

Most often, you won’t have any symptoms other than blood coming from your nose. If you have a posterior nosebleed, some blood may drain down the back of your throat into your stomach. This can cause a bad taste in the back of your throat and make you feel nauseated.

If you have additional symptoms, it may be a sign of a medical condition.

What causes a nosebleed in one nostril?

Most nosebleeds only affect one nostril, but they can affect both at the same time. Epistaxis has many causes. Fortunately, most aren’t serious.

Causes:

Local causes:

In the nose:

• Trauma: Fingernail injury, intranasal surgery, fractures of the middle third of the face and base of the skull, hard blowing of the nose, violent sneeze
• Infections:
  • Acute: Viral rhinitis, nasal diphtheria, acute sinusitis
  • Chronic: Atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis, septal perforation
• Granulomatous lesion of the nose, e.g., Rhinosporidiosis
• Foreign bodies
• Neoplasms of the nose and paranasal sinuses (PNSs):
  • Benign: Hemangioma, papilloma
  • Malignant: Carcinoma/sarcoma
• Atmospheric changes: High altitudes
• Deviated nasal septum (DNS)

In the nasopharynx:

• Adenoiditis
• Juvenile angiofibroma
• Malignant tumors

General Causes:

• Cardiovascular system: Hypertension, arteriosclerosis, mitral stenosis, pregnancy
• Disorders of blood & blood vessels: Aplastic anemia, leukemia, hemophilia, scurvy, Vitamin K deficiency
• Liver diseases: Hepatic cirrhosis
• Kidney diseases: Chronic nephritis
• Acute general infections: Influenza, measles, chickenpox, whooping cough, rheumatic fever, typhoid, pneumonia, malaria, dengue fever
• Drugs: Excessive use of salicylates and other analgesics (as for joint pains), anticoagulant therapy (for heart disease)
• Mediastinal compression: Tumors of the mediastinum

Other nosebleed causes may include:

• Infections: Colds (upper respiratory infections) and sinusitis, especially episodes that cause repeated sneezing, coughing, and nose blowing.
• Allergies: Allergic and non-allergic rhinitis (inflammation of your nasal lining).
• Blood-thinning medications: Drugs such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, and others.
• Recreational drugs
• Chemical irritants
• High altitudes
• Deviated septum
• Nasal sprays
• Other less common causes of nosebleeds include: Alcohol use. Bleeding disorders, such as hemophilia or von Willebrand disease. High blood pressure. Atherosclerosis. Facial and nasal surgery. Nasal tumors. Nasal polyps. Immune thrombocytopenia. Leukemia. Hereditary hemorrhagic telangiectasia. Pregnancy.

Common Sites:

1. Nasal septum: Little’s area accounts for almost 90% of cases.
2. Above the middle turbinate: Anterior ethmoidal vessels may bleed due to hypertension.
3. Below the level of the middle turbinate: Branches of the sphenopalatine artery.

Diagnosis and Tests

• Length (in minutes) of your nosebleed.
• Approximate amount of blood that was lost.
• How often you get them.
• If the bleed involved one or both nostrils.

Investigations:

• Blood pressure
• Hemogram (complete blood count)
• Tests of coagulation: To detect bleeding disorders
• Radiography: Acute sinusitis, fracture, or malignancy of PNS may be detected
• CT scan
• Endoscopy of the nose and PNS

Management and Treatment

Nosebleed treatment depends on the cause of the bleeding. Epistaxis treatment may include:

• Nasal packing: Your healthcare provider will insert gauze, special nasal sponges or foam, or an inflatable latex balloon into your nose to create pressure at the site of the bleed. Your provider may want to leave the material in place for 24 to 48 hours before removing it.
• Cauterization: This procedure involves applying a chemical substance (silver nitrate) or heat energy (electrocautery) to seal the bleeding blood vessel. Your provider will spray a local anesthetic in your nostril first to numb the inside of your nose.
• Medication adjustments/new prescriptions: Reducing or stopping the amount of blood-thinning medications can be helpful. In addition, medications for controlling blood pressure may be necessary.
• Foreign body removal: If the cause of the nosebleed is a foreign object, your provider will remove it.
• Surgery: Surgical repair of a broken nose or correction of a deviated septum (septoplasty) if this is the cause of the nosebleed.
• Ligation: In this procedure, your provider will tie off the culprit blood vessel to stop the bleeding.

Treatment:

• First aid: Pinching the nose with thumb and index finger for about 5 minutes. A cold compress should be applied to the nose to cause reflex vasoconstriction.
• Cauterization: When the bleeding point has been located.
• Anterior nasal packing: The whole nasal cavity is packed by layering the gauze from floor to roof and from before backward.
• Posterior nasal packing: Required for patients bleeding posteriorly into the throat.
• Ligation of vessels

Treatment of Nasagata Raktapitta

Nasagata Raktapitta can be treated following the below-mentioned strategies:

Samanya Raktapitta Chikitsa –

Raktapitta should be treated along the general lines of treatment of Raktapitta.

Specific treatment of nasal bleeding

Just like the general principle of Raktapitta treatment, even in Nasagata Raktapitta, the bleeding should not be stopped in the initial stages because the bleeding comprises contaminated blood, i.e., blood contaminated by vitiated Pitta.

After the elimination of contaminated blood, the kwatha or decoctions of Vasa, etc., which are mentioned in Shamshamani Kriya (formulations to pacify Raktapitta) in the general line of treatment of Raktapitta, shall be used as avapeedana or nasal drops to prevent the bleeding in Nasagata Raktapitta. Alternatively, the juice extracted from individual herbs used in the preparation of kwathas should be used for avapeedana.