• Hemorrhage from the nose 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



  • Very common in the United States
  • Estimated lifetime prevalence: ~60%
  • Bimodal, with peaks in children up to 15 years and in adults >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

Etiology and Pathophysiology

  • Local versus systemic disease. Most nosebleeds are due to local causes.
  • 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)
  • Idiopathic
  • 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)
  • Trauma
    • Epistaxis digitorum (nose picking)
    • Foreign bodies
    • Septal perforation
    • Nasal fracture
    • Nasal surgery
    • Barotrauma
  • 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
  • Control hypertension (HTN) (controversial association with increased risk for recurrent epistaxis).

Commonly Associated Conditions

  • Vascular malformation/telangiectasia (hereditary hemorrhagic telangiectasia-HHT)
  • Neoplasm (rare; consider if persistent and unilateral)
  • Systemic
    • Coagulopathy: primary or iatrogenic
    • Thrombocytopenia
    • Cirrhosis
    • Renal failure
    • Alcoholism
  • No proven association with HTN but may make control of bleeding more difficult

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