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A 56 year old woman presented to the emergency department with a 2 hour history of bleeding from the right nostril. She had tried to stop it by pinching her nose but had then also experienced bleeding from her right eye and ear (Fig 1).
Bloody tears, or haemolacria, are an occasional feature of hereditary haemorrhagic telangiectasia,1 and tumours of the lacrimal apparatus.2 In the emergency department, however, they are more commonly encountered accompanying epistaxis. To date, Medline lists only a single case report of haemolacria in this context,3 and the photograph presented here may well be the first of the phenomenon.
Its anatomical basis lies in the intimate connection of nose and eye via the lacrimal apparatus. An increase in pressure within the nasal cavity during epistaxis—for example, by pinching or blowing the nose, can cause retrograde flow of blood through the system and thus lead to bloody tears emerging from the ipsilateral eye.
As our patient had longstanding perforation of both tympanic membranes, the blood in her nose was also able to travel retrograde via the auditory tube and middle ear into the external auditory canal. This led to the additional bleeding from the right ear.
Bleeding was readily controlled by nasal sponge tamponade. The patient made an uneventful recovery.