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Epistaxis

Last updated: October 26, 2020

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Epistaxis is the medical term for nosebleed, which is a common presenting complaint in the emergency room. The most common site of bleeding is the Kiesselbach plexus, where the vessels supplying the nasal mucosa anastomose with each other. Bleeding from this region causes blood to flow out through the nostrils (anterior epistaxis). Rarely, epistaxis may not be apparent because blood runs down the throat (posterior epistaxis). The most common causes of epistaxis include nose picking, foreign body in the nasal cavity, and a dry nose. Usually, the bleeding stops on its own, but severe epistaxis may occur with hypertension, bleeding disorders, and/or following severe traumatic injury. Hereditary hemorrhagic telangiectasia, which is an autosomal dominant vasculopathy characterized by telangiectasia on the skin and mucosa, is another cause of recurrent epistaxis. Immediate measures to control epistaxis include elevation of the upper body, application of ice packs, and nose pinching. If bleeding does not subside, the nasal cavity must be packed and the patient must be referred to an ENT surgeon.

In most cases, the exact cause of epistaxis remains unknown (idiopathic epistaxis). While a single episode of epistaxis usually does not require any investigation, recurrent epistaxis must be investigated for an underlying cause (e.g., a bleeding disorder).

Local causes [1][2]

Systemic causes [1][3]

Classification of epistaxis [4]
Criteria Anterior epistaxis Posterior epistaxis
Clinical features
  • Bleeding from the nostrils
Relative frequency
  • ∼ 90% of cases
  • ∼ 10% of cases
Peak incidence [5]
  • Children < 10 years of age
  • Older individuals (> 50 years of age)
Most common site of bleeding

Posterior epistaxis may be a sign of life-threatening hemorrhages.

To remember the vessels that form the Kiesselbach plexus, think of LEGS: Labial (superior), Ethmoidal (anterior), Greater palatine, and Sphenopalatine arteries.

Nasal packs can cause toxic shock syndrome if left in place for more than 24 hours.

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  2. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2009; 48 (2): p.73-87. doi: 10.1136/jmg.2009.069013 . | Open in Read by QxMD
  3. Yau S. An update on epistaxis.. Aust Fam Physician. 2015; 44 (9): p.653-6.
  4. Japhet M Gilyomacorresponding and Phillipo L Chalya. Etiological profile and treatment outcome of epistaxis at a tertiary care hospital in Northwestern Tanzania: a prospective review of 104 cases. BMC Ear, Nose and Throat Disorders. 2011 .
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  8. Alter H. Approach to the adult with epistaxis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis.Last updated: February 2, 2016. Accessed: March 30, 2017.
  9. Colucci WS. Hydralazine plus nitrate therapy in patients with heart failure with reduced ejection fraction. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/hydralazine-plus-nitrate-therapy-in-patients-with-heart-failure-with-reduced-ejection-fraction?source=search_result&search=hydralazine%20plus%20nitrate&selectedTitle=1~150.Last updated: July 12, 2016. Accessed: February 15, 2017.
  10. Focus On: Treatment of Epistaxis. https://www.acep.org/Clinical---Practice-Management/Focus-On--Treatment-of-Epistaxis/. Updated: June 1, 2009. Accessed: February 15, 2017.
  11. American Academy of Otolaryngology - Head and Neck Surgery Foundation. Primary Care Otolaryngology. American Academy of Otolaryngology - Head and Neck Surgery Foundation ; 2011