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

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