Tests
1st tests to order
clinical diagnosis
Test
Diagnosis is based on patient history and exam.
Result
current nosebleed or history of nosebleeds
Tests to consider
CBC
Test
Usually necessary only in unusual or persistent/recurrent epistaxis.[8]
Time for volume equilibration since time of blood loss must be allowed.
Bedside point-of-care test for hemoglobin may be used to screen for anemia.
Result
Hb and hematocrit usually normal; low if prolonged or large amount of bleeding
coagulation studies (prothrombin time, activated partial thromboplastin time, platelet function tests)
Test
Only performed if epistaxis is atypically persistent, recurrent, or recalcitrant to treatment.
Coagulopathy may be due to primary condition or acquired (such as medication impairing clotting mechanisms).
Result
usually normal; abnormal if coagulopathy
BUN, serum creatinine
Test
Only performed if there is concern about the patient's general medical condition.
Result
usually normal; abnormal if liver disease, renal disease, volume depletion
LFTs
Test
Only performed if there is concern about the patient's general medical condition or if there are unexplained clotting abnormalities. Measurement of gamma-glutamyl transpeptidase (GGT) can be useful if high alcohol intake is suspected.
Result
usually normal; abnormal if underlying liver disease
autoimmune screen/autoantibodies
Test
Antineutrophil cytoplasmic antibodies (ANCA) can be used to assess for granulomatosis with polyangiitis, serum ACE for sarcoid.
Result
usually normal; abnormal in the presence of certain granulomatous diseases
CT scan of paranasal sinuses
Test
Rarely indicated.
Imaging modality of choice for trauma to view bony structures with axial and coronal facial CT.
Contrast may be used if concern about neoplasm, but often unable to differentiate sinusitis from neoplasm.
Result
normal; may demonstrate: fracture; expansile, erosive process suggesting neoplasm; sinus opacification if sinusitis or neoplasm; intranasal soft-tissue density if polyposis present
MRI of head
Test
Very rarely indicated.
Useful for differentiating sinus opacification due to sinusitis from opacification due to neoplasm.
Poor imaging of fractures as bone not visualized well.
Result
normal; may demonstrate: neoplasm; sinus opacification if sinusitis; intranasal soft-tissue density if polyposis; fracture
internal and external carotid angiography
Test
For refractory and complicated epistaxis despite otolaryngology involvement.
Indicated if persistent epistaxis despite packing.
Obtained when embolization or surgical management are anticipated.
Magnetic resonance angiography, CT angiography, or traditional angiography are options, though the latter can be performed by an interventional radiologist and embolization accomplished simultaneously.
Result
vascular structure to the nose displayed, may identify vascular anomaly
nasal endoscopy and nasopharyngoscopy
Test
Very useful diagnostic modality when obvious epistaxis source not seen, and to examine for tumor.
Therapeutic option for endonasal cautery or laser ablation (laser for vessels from hereditary hemorrhagic telangiectasias).
Requires general anesthetic or intravenous sedation for more than simple anterior or midnasal cavity cautery.
Result
demonstrates bleeding site and may demonstrate neoplasm
plain nasal or sinus x-ray
Test
The cheapest and most readily available radiographic study, so may be performed but is not generally recommended.
Nasal x-ray unhelpful for fracture as this is a clinical diagnosis.
Plain sinus and facial x-ray not optimally sensitive for trauma or neoplasm.
Result
normal or may demonstrate fracture, or expansion or erosion of structures due to neoplasm
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