Epistaxis

Bilateral or posterior nasal epistaxis (nosebleed) suggests a medical etiology; unilateral epistaxis suggests a physical cause or local structural abnormality. Because the nose protrudes from the face, trauma is a common etiology. Further, the thin mucosal surface often becomes dry and cracked, exposing the rich blood supply beneath. The majority of bleeds originate from irritation to the anterior aspect of the nasal septum, Kiesselbach's area (seen easily with nasal speculum, the “picking zone”).

Differential Diagnosis

• Bilateral or posterior nasal epistaxis usually indicates a medical etiology
  –Bleeding disorder (e.g., leukemias, aplastic anemia, thrombocytopenia, von Willebrand's disease, hemophilia, liver failure)
  –Clotting disorders (e.g., liver failure, snake bite, infection, DIC)
  –Trauma (e.g., facial fracture)
  –Ectopic menstruation due to endometriosis
  –Hypertension (usually severe)
• Unilateral or anterior epistaxis usually indicates a physical cause or local structural abnormality
  –Irritation of the nose due to the common cold is the most common cause
  –Dryness of nasal mucosa (e.g., low humidity)
  –Allergic rhinitis
  –External trauma (e.g., fist fight)
  –Internal trauma (e.g., nose-picking)
  –Foreign body
  –Nasal polyps (often secondary to allergy, aspirin, or cystic fibrosis)
  –Status/post-sinus surgery
  –Bleeding from a sinus is an uncommon presentation of bony fracture from trauma or infection
  –Neoplasm: Most common malignancy is squamous cell carcinoma
  –Telangiectasias (can also be posterior epistaxis)
  –Arteriovenous malformation (can also be posterior epistaxis

• Infection
  –Sinusitis
  –Rhinitis
  –Scarlet fever
  –Malaria
  –Typhoid fever
• Septal deviation or perforation
  –In the presence of nasal perforation without significant trauma, cocaine use should be suspected

Workup and Diagnosis

• History and physical examination
  –History of nasal irritation or trauma, rhinorrhea, allergy symptoms, bleeding of other areas (e.g., gums, hematuria), prior epistaxis, sinus and/or tooth pain, frequency and inciting factors (e.g., dry air), and exposures (e.g., nasal sprays, cocaine)
  –Inspect for evidence of septal perforation or deviation and for the source of bleeding
  –Washing the area with normal saline or 1:1,000 epinephrine may increase visibility
  –Blood seen in the mouth without evident nasal bleeding suggests a posterior bleed

• Labs are only necessary in cases that do not respond to treatment: Include a CBC with platelet count, PT/PTT, and bleeding time
• Occasionally, leukemia or other bone marrow changes may present with epistaxis and/or bleeding from other sites (e.g., gums, urinary tract, rectal bleeding); thus, a bone marrow biopsy may be indicated if the clinical picture suggests one of these conditions
• CT scan of the sinuses and nasal area may be indicated to search for neoplasms of the nasopharynx and sinuses
• Consider biopsy of suspicious areas and/or nasolaryngoscopy, especially in smokers

Treatment

• Resuscitation with IV fluids or possibly blood transfusion may be necessary for severe blood loss
• Tilt head forward to prevent posterior blood drainage
• Apply continuous pressure by pinching nares together for 5–10 minutes
  –Pressure applied between the upper lip and gum may help in some difficult cases
  –If no improvement, pack nose with vasoconstrictor-soaked gauze and a heavy coat of petroleum jelly for 10 minutes

• If a bleeding vessel is identified (usually on the septal surface), apply silver nitrate to it for 5 seconds
• If a posterior bleed is suspected, apply pressure with specialized nasal balloons and packing or Foley catheter
• Further treatment may be indicated based on etiology
• Vitamin K, fresh frozen plasma, clotting factor replacement, and/or platelet transfusion may be necessary for bleeding disorders
• Consider ENT consult for some cases (e.g., trauma, intractable bleeding, neoplasm)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nosebleeds

Read excerpts from these other book chapters related to Nosebleeds:

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Nosebleeds

• Back to symptom: Nosebleeds: Introduction (review 260 causes)
• Next Book Extract About Nosebleeds: Hemoptysis (In a Page: Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Nosebleeds

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Hemoptysis (In a Page: Signs and Symptoms)

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• Hemoptysis (In A Page: Pediatric Signs and Symptoms)
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• EPISTAXIS (Differential Diagnosis in Primary Care)
• HEMOPTYSIS (Differential Diagnosis in Primary Care)

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