• Clinical science

Epistaxis (Nosebleed)

Summary

Epistaxis is the medical term for nosebleed, which is a common presenting complaint in the emergency room. The most common site of bleeding is the Kiesselbach plexus, where the vessels supplying the nasal mucosa anastomose with each other. Bleeding from this region causes blood to flow out through the nostrils (anterior epistaxis). Rarely, epistaxis may not be apparent because blood runs down the throat (posterior epistaxis). The most common causes of epistaxis include nose picking, foreign body in the nasal cavity, and a dry nose. Usually, the bleeding stops on its own, but severe epistaxis may occur with hypertension, bleeding disorders, and/or following severe traumatic injury. Hereditary hemorrhagic telangiectasia, which is an autosomal dominant vasculopathy characterized by telangiectasia on the skin and mucosa, is another cause of recurrent epistaxis. Immediate measures to control epistaxis include elevation of the upper body, application of ice packs, and nose pinching. If bleeding does not subside, the nasal cavity must be packed and the patient must be referred to an ENT surgeon.

Etiology

In most cases, the exact cause of epistaxis remains unknown (idiopathic epistaxis). While a single episode of epistaxis usually does not require any investigation, recurrent epistaxis must be investigated for an underlying cause (e.g., a bleeding disorder).

Local causes [1][2]

Systemic causes [1][3]

Classification

Classification of epistaxis [4]
Criteria Anterior epistaxis Posterior epistaxis
Clinical features
  • Bleeding from the nostrils
Relative frequency
  • ∼ 90% of cases
  • ∼ 10% of cases
Peak incidence [5]
  • Children < 10 years of age
  • Older individuals (> 50 years of age)
Most common site of bleeding

Posterior epistaxis may be a sign of life-threatening hemorrhages.

To remember the vessels that form the Kiesselbach plexus, think of LEGS: Labial (superior), Ethmoidal (anterior), Greater palatine, and Sphenopalatine arteries.

Treatment

Nasal packs can cause toxic shock syndrome if left in place for more than 24 hours.

Hereditary hemorrhagic telangiectasia