History and exam

Key diagnostic factors

common

blood at both sides of nose

Blood is usually found on both sides of the nose by the time a patient presents with active epistaxis.

The initial side of bleeding should be identified.

For routine office cautery of quiescent epistaxis, the worst side is selected, as only one side may be treated at a time to avoid septal perforation.

Other diagnostic factors

common

bleeding starting at the nares

Suggests an anterior site for the source of bleeding.

Anterior epistaxis quickly causes blood in the pharynx, so identifying whether a bleed started in the front or down the throat is helpful.

Anterior epistaxis will present in the throat if originating while the patient is supine.

recurrent epistaxis

Occasional self-limited epistaxis is common and probably nonspecific.

Recurrent significant nosebleed suggests anterior vessel on affected side.

A common presentation in children.

septal deviation

May increase likelihood for epistaxis.

Should be noted because it may impair placement of packing, or mucosal damage may occur due to abrasion while packing is placed.

tachycardia

May be due to hypovolemia, anemia, anxiety, or pain (from packing placement or cautery).

uncommon

bleeding starting in the throat

Suggests a posterior site as the source of bleeding.

Anterior epistaxis will present in the throat if originating while the patient is supine.

hypotension

Signifies significant blood loss.

syncope

Signifies significant blood loss.

dizziness or lightheadedness

Suggests significant blood loss.

pallor

May be due to anemia, hypovolemia, or vasovagal response.

hypoesthesia and pain in the distribution of the second branch of the trigeminal nerve

Suggests neoplasm as a cause of epistaxis.

Neoplasm is an extremely rare cause of nosebleed.

Risk factors

strong

dry weather and low humidity

Often occurring in colder months.

Can dry nasal mucosa, resulting in excoriation and cracking.

Underlying blood vessels are exposed and traumatized, causing tears in the vessel lining and subsequent bleeding.​​[1][2][7][8][9]

prior nasal or sinus surgery

Can increase the risk of bleeding.[5]​ Any severe bleeding within one month of nasal surgery should be reported immediately to the operating surgeon and may need to be surgically controlled.

nasal cannula oxygen or continuous positive airways pressure (CPAP)

Oxygen via nasal cannulae (particularly if not humidified) can cause drying of the anterior nasal septum.[5]

Prongs of cannulae can cause direct mucosal trauma when tips rub against the septal surface.

nasal and other facial fracture

Laceration and avulsion of intranasal tissues may occur with nasal fracture and maxillofacial trauma.[5]

Results in atypical bleeding sites, such as at the lateral nasal wall.

Facial fractures (even if nondisplaced) may produce bleeding from torn sinus mucosa.​​[1][2][7][8][9]

other nasal trauma

Digital trauma (nose picking) prevents healing of any existing injury.[5]

Overly vigorous rubbing during nose blowing can excoriate mucosa (mainly on septum).

use of intranasal drug formulations or illicit drugs

Both prescribed (e.g., intranasal corticosteroids) and illicit (e.g., cocaine) drugs may result in mucosal irritation and bleeding.[5][18]

primary coagulopathy (e.g., hemophilia)

Personal or family history of a bleeding disorder.[5]

Epistaxis is the presenting symptom in almost one third of patients with von Willebrand disease, and occurs in 5% of patients with immune thrombocytopenia.[5][19]​ Hereditary hemorrhagic telangiectasia is the second most common inherited disorder that also commonly presents with epistaxis.[20]

Results in persistent nosebleed requiring medical attention.

Often resistant to initial treatment.

use of certain systemic drugs

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be a risk factor for epistaxis.[21]

Other agents that promote bleeding, such as the antiplatelet agent clopidogrel and the anticoagulant warfarin (especially at supratherapeutic levels) may also be implicated.[5]

Results in persistent nosebleed requiring medical attention.

May be resistant to initial treatment.

familial hereditary hemorrhagic telangiectasia

An autosomal dominant condition.

Blood vessels lack the elastic and muscular layer normally present in their walls.

Patients have multiple telangiectasias throughout the entire aerodigestive mucosal surfaces.

Vessels lack the ability to vasoconstrict normally in the presence of trauma and bleeding.[5][22][23]

juvenile nasal angiofibroma

A rare condition of young (usually adolescent) men, presenting with nasal obstruction and severe epistaxis.[5][12][13]

chronic kidney or liver disease

Can be associated with bleeding tendency due to reduced production of clotting factors.[5]

weak

septal deviation

May increase likelihood of epistaxis.

Septal mucosa may be exposed to drying and irritation on the side of deviation if there is marked caudal deflection.

If deviation causes unilateral obstruction, the contralateral side may experience drying because it carries the majority of the airflow.​​[1][2][7][8]​​[9]

nasal foreign body

Causes direct trauma and rupture of superficial vessels.

More common in children and in people with cognitive impairment or psychiatric illness.

Classically presents as purulent unilateral rhinorrhea rather than bleeding.

Mucosal inflammation and ulceration can result in bleeding.[7][8]

environmental irritants

Exposure to dust, chemicals, pollution, and cigarette smoke may result in mucosal hyperemia, friability, and excoriation, with attendant increased potential for bleeding.

barotrauma

Pressure change, such as occurs during air travel or underwater diving, is associated with epistaxis.

ulceration secondary to infection (e.g., herpes zoster, or bacterial infection)

There may be a previous history of herpetic infection if recurrent.

Bacterial or viral culture may help to confirm the diagnosis.

forceful coughing

An uncommon cause of epistaxis.

sinonasal neoplasm

Although rare, may cause bleeding.

Associated with exposure to wood dust and certain chemicals.[1][2]

Examination and nasal endoscopy are usually remarkable for the absence of any evident vessels and the presence of a mass.

There may be some fullness of one of the lateral nasal walls.

chronic granulomatous disease

Although not a common cause, diseases such as granulomatosis with polyangiitis and sarcoidosis can be associated with epistaxis.[24][25]

Usually seen as multiple bleeding points in conjunction with widespread mucosal changes or septal perforation.

Use of this content is subject to our disclaimer