Aetiology

Approximately 95% of epistaxis is caused by bleeding originating from blood vessels in Little's area, located at the anterior inferior septum. This area contains a confluence of vessels from the various nasal sources called the Kiesselbach plexus.

[Figure caption and citation for the preceding image starts]: Nasal vasculature demonstrating the vessels that form the Kiesselbach plexusFrom the collection of David A. Randall, Springfield Ear Nose Throat and Facial Plastic Surgery, MO [Citation ends].Nasal vasculature demonstrating the vessels that form the Kiesselbach plexus 

Posterior epistaxis originates from the posterior nasal cavity or nasopharynx.[3][4]

Vessels may bleed due to:

  • Mucosal compromise

  • Impairment of vasoconstriction and inadequate activation of the clotting mechanism.

Neoplasm represents an atypical and, if located in a paranasal sinus, particularly difficult cause to identify. Neoplasms associated with nosebleed include:

  • Sinus tumours: associated with exposure to wood dust and certain chemicals

  • Juvenile nasal angiofibroma: a rare nasopharyngeal tumour of young men that can produce significant posterior haemorrhage, and may be associated with nasal obstruction.[8][9][10]

Adults with nosebleed often have elevated blood pressure (BP), although there is uncertainty about whether hypertension is a causative factor or the elevated BP is secondary to anxiety.[10][11][12][13][14][15]

Whether atherosclerotic change, secondary to hypertension, increases vessel fragility is also debated, but is plausible in that elevated BP impairs intraoperative surgical haemostasis.[11][12][13][14][15]

Recent or regular high alcohol intake is associated with an increased risk of epistaxis, probably due to the effect of alcohol on bleeding time.[16]

Pathophysiology

The physiological demands of the nose require a robust blood supply. Loss of mucosal integrity, for any reason, exposes underlying vessels, which may be damaged and bleed.

Vasoconstriction and activation of the clotting mechanism normally regains haemostasis. Impairment of these processes may prolong bleeding.

Classification

Commonly used classification according to site of bleeding source

Anterior epistaxis:

  • Accounts for approximately 95% of nosebleeds

  • Usually originates from the Kiesselbach plexus, a rich vascular anastomosis located at the anterior nasal septum; this region is called Little's area.

Posterior epistaxis:

  • Originates from the posterior nasal cavity or nasopharynx[3][4]

  • Posterior nasal and nasopharyngeal vessels often have a larger calibre and may produce more active bleeding.

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