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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 the nose. It can present in any age group. It is a sign not a disease and an attempt has to be made to find out the cause behind it. Epistaxis is often a frightening sight to the patient and the attendants, especially if the patient is a child.

Etiology:
A. Local Causes:
Nose-	Trauma	finger nail trauma, injuries to nose, fractures of middle third of the face, violent sneezing.
	Infections	Acute- Viral rhinitis, nasal diphtheria, and acute sinusitis. Chronic- Rhinitis atrophica, rhinitis sica, TB, syphilitic nasal septum perforation, granuloma like lesions like rhino-sporodiasis
	Foreign bodies	Living and non-living.
	Neoplams of nose and paranasal sinuses
	Atmospheric changes- High altitude and sudden compression
	Deviated nasal septum
Nasopharynx	Adenoiditis Juvenile angiofibroma Malignant tumors.

B. General Causes:
Cardiovascular-	Hypertension, mitral stenosis are commonly seen in old age
Allergies
Drugs-	Aspirin, Fexofenadine / Allegra / Telfast, warfarin, ibuprofen, clopidogrel, isotretinoin, desmopressin, ginseng and others
Alcohol (due to vasodilation)
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
Idiopathic thrombocytopenic purpura
Pregnancy
Vascular disorders
Vitamin C or Vitamin K deficiency
von Willebrand's disease
Idiopathic-	Many times, the cause of Epistaxis is not clear

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

Diagnosis

Clinical history- to detect any injury.
Physical examination with the help of nasal speculum.
Nasal endoscopy.
Blood Test
Angiography

Management

Make the patient sit up with a backrest and record any blood loss taking place through spitting and vomiting.
Reassure the patient.
Don't panic because most of the time bleeding can be controlled by pinching the nose tightly for about five minutes.
Ice compress can be applied in the nose. They cause bleeding blood vessels to constrict & bleeding stops.
Keep check on pulse, BP and respiration.
Maintain haemodynamics.
Investigate and treat the patient for any underlying local and general causes.
Nasal Packing
Surgeries in emergencies.

Role of Homoeopathy

Homeopathy- 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.

Please E-mail dr_ramanand@rediffmail.com for any questions/treatment

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