Epidemiology

Most people will experience epistaxis at some stage, and the lifetime incidence is estimated to be around 60%; however, only a small proportion of patients require specialist treatment.[5] There are about 25,000 acute presentations to ENT services in the UK per year with increased prevalence in children and older adults.[6] There is no racial or gender predilection; but epistaxis secondary to trauma is slightly more common in men.

Nosebleeds occur more frequently in the drier, colder months, and in less humid environments. This is because dry air facilitates excoriation and cracking of the nasal mucosa, vessel trauma, and subsequent epistaxis.[1][2][3][4][7]

Risk factors

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dry weather and low humidity

Often occurring in colder months.

Can dry nasal mucosa, resulting in excoriation and cracking.

minor nasal trauma

Nose picking or overly vigorous rubbing during nose blowing can excoriate mucosa (mainly on septum).

primary coagulopathy (e.g., haemophilia)

Not a primary causative factor but very clinically significant.

Results in persistent nosebleed requiring medical attention.

Often resistant to initial treatment.

familial hereditary haemorrhagic telangiectasia

An autosomal dominant condition.

Patients have multiple telangiectasias throughout the entire aerodigestive mucosal surfaces.

Vessels lack the elastic and muscular layer normally present in their walls and therefore the ability to vasoconstrict normally in the presence of trauma and bleeding.[20][21]

juvenile nasal angiofibroma

A rare condition of young (usually adolescent) men, presenting with unilateral nasal obstruction and severe epistaxis.[8][9]

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septal deviation

May increase likelihood of epistaxis.

nasal foreign body

Causes direct irritation.

More common in children.

Classically presents as purulent unilateral rhinorrhoea rather than bleeding.

nasal polyp

Trauma to a polyp may cause bleeding.

topical nasal drugs

Corticosteroid nasal spray may cause friable nasal mucosa.[16][17]

Illicit drugs (e.g., cocaine) may result in mucosal irritation and bleeding.[10]

medication (e.g., aspirin, anticoagulant, non-steroidal anti-inflammatory drugs)

Anticoagulant or antiplatelet drugs, including herbal remedies, can increase the risk or severity of the bleed.[6][16][18]

  • Anticoagulants or antiplatelet drugs increase the risk of epistaxis (about 24% to 33% of all patients hospitalised for epistaxis take these drugs).[16]

  • Acetylsalicylic acid (aspirin) increases the severity of the bleeding, the need for surgery, and risk of recurrence.[19]

May be resistant to initial treatment.

Phosphodiesterase-5 inhibitors may also be associated with increased risk of bleeding.[16]

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