eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Epistaxis: Differential Diagnoses & Workup

Author: Ola Bamimore, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Contributor Information and Disclosures

Updated: Jul 16, 2009

Differential Diagnoses

Barotrauma
Toxicity, Cocaine
Disseminated Intravascular Coagulation
Toxicity, Nonsteroidal Anti-inflammatory Agents
Endometriosis
Toxicity, Rodenticide
Foreign Bodies, Nose
Toxicity, Salicylate
Hemophilia, Type A
Toxicity, Warfarin and Superwarfarins
Hemophilia, Type B
von Willebrand Disease
Plant Poisoning, Glycosides - Coumarin
Sinusitis

Other Problems to Be Considered

Chemical irritants
Hepatic failure
Leukemia
Osler-Weber-Rendu syndrome
Rhinitis
Thrombocytopenia
Heparin toxicity
Ticlopidine toxicity
Dipyridamole toxicity
Trauma
Tumor

Workup

Laboratory Studies

  • Routine laboratory studies are rarely indicated or helpful for nosebleeds but are recommended in the presence of major bleeding or if a coagulopathy is suspected.
    • Obtain a hematocrit count and type and cross if a history of persistent heavy bleeding is present.
    • Obtain a complete blood count (CBC) if a history of recurrent epistaxis, a platelet disorder, or neoplasia is present.
    • The bleeding time is an excellent screening test if suspicion of a bleeding disorder is present.
    • Obtain the international normalized ratio (INR)/prothrombin time (PT) if the patient is taking warfarin or if liver disease is suspected.

Imaging Studies

  • Sinus films are rarely indicated for a nosebleed.
  • CT scanning and/or nasopharyngoscopy may be performed if a tumor is the suspected cause of bleeding.
  • Angiography is rarely indicated.

More on Epistaxis

Overview: Epistaxis
Differential Diagnoses & Workup: Epistaxis
Treatment & Medication: Epistaxis
Follow-up: Epistaxis
Multimedia: Epistaxis
References
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References

  1. Cummings CW. Epistaxis. In: Cummings: Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, Pa: Elsevier, Mosby; 2005:Chap 40.

  2. Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin North Am. Jun 2008;41(3):525-36, viii. [Medline].

  3. Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. Feb 19 2009;360(8):784-9. [Medline].

  4. Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. Jun 2007;15(3):180-3. [Medline].

  5. Teymoortash A, Sesterhenn A, Kress R, et al. Efficacy of ice packs in the management of epistaxis. Clin Otolaryngol Allied Sci. Dec 2003;28(6):545-7. [Medline].

  6. Badran K, Malik TH, Belloso A, Timms MS. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. Aug 2005;30(4):333-7. [Medline].

  7. Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: a preliminary report. Laryngoscope. Aug 1971;81(8):1261-6. [Medline].

  8. Choudhury N, Sharp HR, Mir N, Salama NY. Epistaxis and oral anticoagulant therapy. Rhinology. Jun 2004;42(2):92-7. [Medline].

  9. Cook PR, Renner G, Williams F. A comparison of nasal balloons and posterior gauze packs for posterior epistaxis. Ear Nose Throat J. Sep 1985;64(9):446-9. [Medline].

  10. Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis. Clin Otolaryngol Allied Sci. Aug 1995;20(4):305-7. [Medline].

  11. Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg. Mar 1986;94(3):412-5. [Medline].

  12. Fuchs FD, Moreira LB, Pires CP, et al. Absence of association between hypertension and epistaxis: a population-based study. Blood Press. 2003;12(3):145-8. [Medline].

  13. Guarisco JL, Graham HD 3d. Epistaxis in children: causes, diagnosis, and treatment. Ear Nose Throat J. Jul 1989;68(7):522, 528-30, 532 passim. [Medline].

  14. Hashmi SM, Gopaul SR, Prinsley PR, Sansom JR. Swallowed nasal pack: a rare but serious complication of the management of epistaxis. J Laryngol Otol. May 2004;118(5):372-3. [Medline].

  15. Herkner H, Havel C, Mullner M. Active epistaxis at ED presentation is associated with arterial hypertension. Am J Emerg Med. Mar 2002;20(2):92-5. [Medline].

  16. Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med. Mar 2005;23(2):106-10. [Medline].

  17. Keen MS, Moran WJ. Control of epistaxis in the multiple trauma patient. Laryngoscope. Jul 1985;95(7 Pt 1):874-5. [Medline].

  18. Larsen K, Juul A. Arterial blood gases and pneumatic nasal packing in epistaxis. Laryngoscope. May 1982;92(5):586-8. [Medline].

  19. Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. May 2005;81(955):309-14. [Medline].

  20. Singer AJ, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. Feb 2005;45(2):134-9. [Medline].

  21. Van Wyk FC, Massey S, Worley G, Brady S. Do all epistaxis patients with a nasal pack need admission? A retrospective study of 116 patients managed in accident and emergency according to a peer reviewed protocol. J Laryngol Otol. Mar 2007;121(3):222-7. [Medline].

  22. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. May 1995;25(5):592-6. [Medline].

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Further Reading

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Keywords

epistaxis, nose bleed, nasal hemorrhage, nosebleed, bloody nose, nasal packing, nosebleed treatment, nosebleed causes

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Contributor Information and Disclosures

Author

Ola Bamimore, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Ola Bamimore, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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