EPISTAXIS

The nose is the main gateway to the respiratory (breathing) system. The inside of the nose is covered with mucosa (moist, soft tissues) that has a rich blood supply. This warms and moistens the air we breathe. Air passes to and from the lungs through the nostrils. A thin flexible wall called a nasal septum separates the two nostrils.
Little's Area- it is situated in the anterior inferior part of nasal septum. Four arteries anastomose here to form a vascular plexus called 'Kiesselbach's plexus'. This area is exposed to the drying effect of inspiratory current and to finger trauma and is the usual site for epistaxis in children and young adults.

It is defined as a bleeding from inside nose. It is present in all age groups. It is a sign not a disease and an attempt has to made to find out cause behind it. Epistaxis is often a frightening sight to the patient and the attendants, especially if the patient is a kid.

Etiology:

A. Local Causes:
a. Nose- 1. Trauma- finger nail trauma , injuries to nose, fractures of middle third of the face, violent sneezing.
              2. Infections- Acute- viral rhinitis, nasal diphtheria, and acute sinusitis.
                                  Chronic- Atrophic rhinitis, rhinitis sica, tuberculosis,
                                  granulomatous lesions like rhinosporodiasis, syphilitic
                                  nasal septum perforation.
              3. Foreign bodies- Living and non- living.
              4. Neoplams of nose and paranasal sinuses.
              5. Atmospheric changes- High altitude and sudden compression.
              6. Deviated nasal septum.
b. Nasopharynx- 1. Adenoiditis.
                         2. Juvenile angiofibroma.
                         3. Malignant tumors.

B. General Causes:
a.Cardiavascular- hypertension, mitral stenosis are commonly seen in old age.
b.Allergies.
c.Drugs - Aspirin, Fexofenadine/Allegra/Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin, ginseng and others
d.Alcohol (due to vasodilation)
e.Anemia
f.Connective tissue disease
g.Blood dyscrasias
h.Envenomation by mambas, taipans, kraits, and death adders
i.Heart failure (due to an increase in venous pressure)
j.Hematological malignancy
k.Idiopathic thrombocytopenic purpura
l.Pregnancy
m.Vascular disorders
n.Vitamin C or Vitamin K deficiency
o.von Willebrand's disease

C. Idiopathic- Many times the cause of Epistaxis is not clear.

Classification of Epistaxis:
1.Anterior Epistaxis- when the blood is coming out from the front of nose with the patient in sitting position. Mostly occur in children or young adults. Bleeding is usually mild, and can be controlled by local pressure.
2.Posterior Epistaxis- Many the blood flows back into the throat. Patient may swallow it and later have a "coffee coloured" vomitus. This may erroneously be diagnosed as haematemesis. It commonly present after 40 years of age.

Diagnosis:
1.Clinical history- to detect any injury.
2.Physical examination with the help of nasal speculum.
3.Nasal endoscopy.
4.Blood Test
5.Angiography

Management:
a.Make the patient sit up with a backrest and record any blood loss-taking place through spitting and vomiting.
b.Reassure the patient.
c.Don't panic because most of the time bleeding can be controlled by pinching the nose tightly for about five minutes.
d.Ice compress can be applied in the nose. They cause bleeding blood vessels to constrict & bleeding stops.
e.Keep check on pulse, BP and respiration.
f.Maintain haemodynamics.
g.Investigate and treat the patient for any underlying local and general causes.
h.Nasal Packing
i.Surgeries in emergencies condition.
j.Homoeopathy- the medicine is selected on the basis on the symptoms similarity and underlying cause. The epistaxis can also be treated safely and effectively with homeopathic medicines. Homoeopathic remedies selected after properly studying the patient's case are very effective in stopping epistaxis without any relapse.

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