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 aged <49 years
- Rare in children aged <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, ginseng, garlic, ginkgo biloba, sildenafil, warfarin, and other anticoagulants
- Prior 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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Citation
Domino, Frank J., et al., editors. "Epistaxis." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis.
Epistaxis. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis. Accessed November 5, 2024.
Epistaxis. (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis
Epistaxis [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 November 05]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis.
* Article titles in AMA citation format should be in sentence-case
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