- 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)
- 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)
- Epistaxis digitorum (nose picking)
- Foreign bodies
- Septal perforation
- Nasal fracture
- Nasal surgery
- Congenital or acquired coagulopathies
- Liver or renal disease
- Chronic alcohol abuse
- Anticoagulant drug use
- Hereditary hemorrhagic telangiectasia (HHT)
- Collagen abnormalities
- Mitral valve stenosis
- Multiple myeloma
- Polycythemia vera
- 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.
- 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)
- Coagulopathy: primary or iatrogenic
- Renal failure
- No proven association with HTN but may make control of bleeding more difficult
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Domino, Frank J., et al., editors. "Epistaxis." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. 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; 2020. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis. Accessed June 10, 2023.
Epistaxis. (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th 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; 2020. [cited 2023 June 10]. 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
TY - ELEC T1 - Epistaxis ID - 1688724 ED - Domino,Frank J, ED - Baldor,Robert A, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688724/all/Epistaxis PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -