2. EPISTAXIS GENERAL CONSIDERATION
     The most common sites of nasal bleeding are the mucosal vessels over the
cartilaginous nasal septum and the anterior tip of the inferior turbinate. Bleeding is usually due to external trauma, nose picking, nasal infection, or drying of the nasal mucosa. Over 5% of nosebleeds originate posteriorly in the nose, where the bleeding site cannot be seen; these can cause great problems in management. If the blood drains into the pharynx and is swallowed, nosebleed may escape diagnosis. In these cases, bloody vomitus may be the first clue.
     Underlying causes of nosebleed such as blood dyscrasias, hypertension, hemorrhagic disease, nasal tumors, and certain infectious diseases (measles or rheumatic fever) must be considered in any case of recurrent or profuse nosebleed without obvious causes.
     In traditional Chinese medicine, the condition is termed "Bi Niu," which simply
means epistaxis, and is thought to be caused by dry lungs.
CLINICAL MANIFESTATIONS
     Bleeding of the nasal cavity. It chiefly occurs in infants and is manifested as redness, itchiness, pain and ulceration of the nares, or drying of the nasal mucosa.
DIAGNOSIS
     ? Must rule out blood dyscrasias, hypertension, hemorrhagic disease, nasal
tumor and certain infectious diseases.
     ? The Patient should be adequately examined for any contributing systemic
disease.
TREATMENT
I. Management in Western medicine.
     Local measures:
     A. For anterior epistaxis, pressure over the area for 5 minutes is often sufficient to stop bleeding. This may be combined with packing the bleeding nostril with 0.25% phenyleohrine or 1:1000 epinephrine solution.
     After active bleeding has stopped, a cotton pledget moistened with a topical
anesthetic applied to the bleeding area will provide anesthesia for cauterization with a chronic acid bead, trichloroacetic acid, or an eletrocautery. After cauterization, lubrication with petrolatum helps prevent crusting. A second cauterization is infrequently necessary.
     If the source of bleeding is not accessible to cauterization or is not controlled by cauterization, the nasal cavity must be packed. After maximum shrinkage of the mucosa has been achieved with a suitable decongestant and typical anesthesia, the nasal cavity can be tightly packed with help--an inch gauze lubricated with petrolatum or cod liver oil. Pack the gauze into the nose in layers, starting either in the vault or on the floor of the nasal cavity. The packing may be left in place as long as 5 to 6 days if necessary. The patient should be given analgesics for pain and antibiotic medications for suppurative otitis media and sinusitis as needed.
     B. For posterior epistaxis, posterior bleeding can sometimes be controlled only
by means of a posterior nasal pack. This accomplishes 2 things: it compresses and
controls bleeding sites in the nasopharynx or posterior choana, and it prevents very
firm anterior packing from being dislodged into the pharynx.
II. Management in traditional Chinese medicine.
     In traditional Chinese medicine, the nose is understood as the opening of the
lungs. Hence, the nosebleed is usually thought to be caused by the pulmonic heat.
The general rule of treatment is to dissipate the heat and to cool blood.
     1. Herb therapy
     A. Xi Jiao Di Huang Tang Jia Jian.
     Constituents:
     Buffalo horn  30g
     Fresh or dried root of rehmannia 30g
     Unpeeled root of herbaceous peony  30g
     Root-bark of peony 15g
     Skullcap  12g
     Cogongrass rhizome 50g
     Field thistle 25g
     Node of lotus rhizome  25g
     Cape jasmine  12g
     Donkey-hide gelation 15g
     Root of pseudo-ginseng 2g
     Decoction and dosage. All the above herbs are put together into a boiler to be simmered twice and then the broth of each mixed, half of the mixed broth each time, twice a day. Two to four doses are prescribed.
     B. 30 grams of Chinese parasol seeds is ground into fine powder and taken with
water three times daily. We tried this in 320 cases and found it was very effective in 240. In other 80 cases, though the effect was not remarkable, it certainly relieved the condition to some degree.
     2. Acupuncture therapy
     Points: LI20 Yingxiang, L11 Shaoshang, GV23 Shangxing and LI4 Hegu.
     Method: All the above points are punctured with moderate stimulation and the
needles are retained for 20 minutes.