Epistaxis

Differential Overview

❑ Trauma

❑ Sinusitis

❑ Uncontrolled hypertension

❑ Excessive anticoagulation

❑ Septal ulceration

❑ Bleeding diathesis

❑ Hereditary hemorrhagic telangiectasia

❑ Nasopharyngeal carcinoma

Diagnostic Approach

Anterior epistaxis originates in the septal vascular plexus (Kiesselbach area). Bleeding comes from one nostril and is easily reduced with external pressure. The bleeding site can be seen on visual inspection.

Posterior epistaxis originates in the sphenopalatine or ethmoid artery. Bleeding is brisk and continually swallowed, and it may occasionally present as melena. Blunt nasal trauma is the most common cause.

Clinical Findings

Trauma  Low-humidity air or old age can predispose persons to epistaxis with forceful blowing. Out of shame, the patient may disguise the history of digital trauma or being punched in the nose.

Sinusitis  A purulent, bloody nasal discharge, accompanied by unilateral facial fullness, pressure, or tenderness, and fever indicate the diagnosis.

Uncontrolled hypertension  This is a less common cause of epistaxis than is usually assumed, but it is easily confirmed by blood pressure measurement.

Excessive anticoagulation  In a patient taking therapeutic warfarin, this may be a signal event, helping avert a more serious bleed.

Septal ulceration  Intranasal cocaine may cause ulceration or perforation. Wegener granulomatosis is a rare cause of ulceration.

Bleeding diathesis  Petechiae or purpura and a history of easy bleeding with surgery or minor injury are often found. Consider this when there is a history of recurrent spontaneous epistaxis.

Hereditary hemorrhagic telangiectasia  Epistaxis can be the presenting symptom. Friable lesions appear to bleed more with treatment.

Nasopharyngeal carcinoma  Consider this in a patient of Asian origin with posterior epistaxis, a neck mass and idiopathic facial pain. Serous otitis with decreased hearing is a subtle early sign and abnormal function of CN II–VI is a late sign of invasive disease.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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