Epistaxis

BASICS

DESCRIPTION

  • Hemorrhage from the nares, nasal cavity, or nasopharynx involving either the anterior or posterior mucosal surfaces
  • Intractable or refractory epistaxis: recurrent or persistent despite appropriate packing or multiple episodes during a short period, each requiring medical attention
  • Synonym(s): nosebleed

EPIDEMIOLOGY

Incidence

  • Bimodal, with peaks in children up to 15 years old and in adults aged >50 years, particularly ages 70 to 79 years
  • Most common in males <49 years
  • Rare in children age <2 years
  • ~6% of patients require medical or surgical intervention; accounts for ~1 in 200 ER visits

Prevalence

Estimated lifetime prevalence: ~60%

ETIOLOGY AND PATHOPHYSIOLOGY

  • Most nosebleeds are due to local causes as opposed to systemic disease.
  • Anterior: 90–95% of all cases (Kiesselbach plexus)
  • Posterior: 5–10% of cases (Woodruff plexus); usually branches of sphenopalatine arteries: may be asymptomatic or may present with other symptoms (hematemesis, hemoptysis)
  • Trauma
    • Epistaxis digitorum (nose picking); foreign bodies; septal perforation; nasal fracture; nasal surgery; barotrauma
  • Local inflammation, irritation, and insult
    • Infection (viral URI, sinusitis, TB, syphilis); irritant inhalation (smoking, rhinitis, current or past cocaine use)
    • Topical steroid or antihistamine use; chronic and excessive use of nasal vasoconstrictors
    • Septal deviation (disproportionate, unilateral air movement)
    • Low humidity, nasal oxygen use, CPAP
    • Tumors: benign, malignant
    • Vascular malformations, especially in context of prior trauma (e.g., carotid artery aneurysm)
  • Systemic
    • Thrombocytopenia; congenital or acquired coagulopathies; liver or renal disease; chronic alcohol abuse
    • Leukemia; anticoagulant drug use; CHF; hereditary hemorrhagic telangiectasia (HHT)
    • Collagen abnormalities; mitral valve stenosis; multiple myeloma; polycythemia vera; HIV

RISK FACTORS

  • Local irritation from multiple causes
  • Medications/supplements including aspirin, clopidogrel, sildenafil, warfarin, ginseng, garlic, ginkgo biloba, and other anticoagulants
  • History of septoplasty/turbinate procedures, anemia, and thrombocytopenia are risk factors for recurrent epistaxis.

GENERAL PREVENTION

  • Humidification at night
  • Cut fingernails and minimize picking
  • For topical-nasal medication users, direct spray laterally away from septum. Use opposite hand to spray (i.e., right hand to spray in left nostril).
  • Petroleum jelly to prevent anterior mucosal drying

COMMONLY ASSOCIATED CONDITIONS

  • Vascular malformation/telangiectasia (HHT)
  • Neoplasm (rare; consider if persistent and unilateral)
  • Systemic conditions:
    • Coagulopathy: primary or iatrogenic; thrombocytopenia
    • Cirrhosis; renal failure; alcohol misuse
  • No proven association with hypertension but may make control of bleeding more difficult

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