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