History and exam

Key diagnostic factors

common

blood at one nostril or on both sides of nose

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

presence of risk factors

Risk factors for epistaxis are many and varied. They include:

  • Age:

    • Epistaxis is more common in children and older people.[10]

  • Environmental:

    • Cold, dry, low humidity weather, or marked variations in air temperature and pressure.[16]

  • Local nasal:

    • Minor trauma, such as nose picking or rubbing[10]

    • Rubbing, sneezing, coughing, or straining can precipitate epistaxis in children

    • Recent upper respiratory tract infection, rhinitis, or rhinosinusitis causing mucosal friability

    • Corticosteroid nasal spray causing friable nasal mucosa[16][17]

    • Drug misuse (particularly cocaine)[10]

    • Foreign body (particularly relevant to children).[10]

      • In practice, a unilateral foul-smelling nasal discharge is a more common presentation than epistaxis.

  • Increased risk of bleeding:

    • Anticoagulant or antiplatelet drugs, including herbal remedies[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 risk of recurrence, severity of the bleeding, and the need for surgery.[19]

    • Phosphodiesterase-5 inhibitors[16]

    • Alcohol intake, which may affect clotting mechanisms[16]

    • Patient or family history of bleeding disorders.[10]

  • Comorbidities that may affect the patient’s response to a bleed or indicate that they may be on antithrombotic therapy:

    • History of sustained ambulatory hypertension[6]

    • Chronic liver disease or chronic kidney disease, because of the association with bleeding tendency[10]

    • Diabetes mellitus[6]

    • Ischaemic heart disease.[6]

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 of the nose or down the throat is helpful.

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

recurrent epistaxis

Recurrent significant nosebleed suggests anterior vessel on affected side.

  • Common in children.[10] 

septal deviation

May increase likelihood for epistaxis.[10]

uncommon

bleeding starting in the throat

Suggests a posterior site as the source of bleeding.

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

signs of haemodynamic compromise

The following signs signify potentially significant blood loss:

  • Tachycardia[10]

    • May be due to hypovolaemia, anaemia, anxiety, or pain (from packing placement or cautery)

  • Syncope[10]

  • Orthostatic hypotension[10]

  • Pallor

    • May be due to anaemia, hypovolaemia, or vasovagal response.

intranasal polyp

A cause of recurrent epistaxis

  • Rare in children.

telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease leading to arteriovenous malformations and telangiectasias.[10]

  • Causes recurrent epistaxis in >90% of people with hereditary haemorrhagic telangiectasia.[10]

  • Associated with:[10]

    • Multiple telangiectasias of the face, lips, oral cavity, nasal cavity, and/or fingers

    • Arteriovenous malformations in the lungs, liver, gastrointestinal tract, or brain

    • Presence in a first-degree relative.

[Figure caption and citation for the preceding image starts]: Multiple telangiectasias visible on nasal examinationImage used with permission from BMJ 2019;367:l5393 doi: 10.1136/bmj.l5393 [Citation ends].Multiple telangiectasias visible on nasal examination

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