eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Epistaxis

Author: Quoc A Nguyen, MD, Associate Clinical Professor, Director, Sinus and Allergy Center, Department of Otolaryngology-Head & Neck Surgery, University of California, Irvine Medical Center
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Updated: Nov 29, 2007

Introduction

Background

Epistaxis, or bleeding from the nose, is common in its frequency and varied in its manifestation. The true prevalence of epistaxis is not known because most episodes are self-limited and thus are not reported. When medical attention is needed, it is usually because of either the recurrent or severe nature of the problem. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services.

Pathophysiology

The nose has a rich vascular supply with contribution from the internal and external carotid arteries.

The external carotid system supplies blood to the nose via the facial and internal maxillary arteries. The superior labial artery is one of the terminal branches of the facial artery. This artery subsequently contributes to the blood supply of the anterior nasal floor and anterior septum through a septal branch. The internal maxillary artery enters the pterygomaxillary fossa and divides into 6 branches: posterior superior alveolar, descending palatine, infraorbital, sphenopalatine, pterygoid canal, and pharyngeal. The descending palatine artery descends through the greater palatine canal and supplies the lateral nasal wall. It then returns to the nose via a branch in the incisive foramen to provide blood to the anterior septum. The sphenopalatine artery enters the nose near the posterior attachment of the middle turbinate to supply the lateral nasal wall. It also gives off a branch to provide blood supply to the septum.

The internal carotid artery contributes to the nasal vascularity through the ophthalmic artery. This artery enters the bony orbit via the superior orbital fissure and divides into several branches. The posterior ethmoid artery exits the orbit through the posterior ethmoid foramen, located 2-9 mm anterior to the optic canal. The larger anterior ethmoid artery leaves the orbit through the anterior ethmoid foramen. Both of these vessels cross the ethmoid roof to enter the anterior cranial fossa and then descend into the nasal cavity through the cribriform plate. Here, they divide into lateral and septal branches to supply the lateral nasal wall and the septum.

The Kiesselbach plexus, or Little area, is located on the anterior cartilaginous septum and is the location of most anterior epistaxis. Many of the arteries supplying the septum have anastomotic connections at this site.

Frequency

United States

Frequency of epistaxis is difficult to determine because most episodes resolve with self-treatment and, therefore, are not reported.

Mortality/Morbidity

For most of the general population, epistaxis is a nuisance. However, the problem can be life-threatening, especially in elderly patients and in those patients with underlying medical problems.

Sex

Prevalence of epistaxis tends to be higher in males (58%) than in females (42%).

Age

Distribution is bimodal, with peaks in young children and elderly individuals.

Clinical

History

• Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed.
• Inquire about precipitating and aggravating factors and methods used to stop the bleeding.
• Obtain a head and neck history with an emphasis on nasal symptoms.
• In addition, elicit a general medical history concerning relevant medical conditions (eg, hypertension, arteriosclerosis, coagulopathies, liver disease), current medications (eg, warfarin sodium [Coumadin], nonsteroidal anti-inflammatory drugs [NSAIDs]), and smoking and drinking habits.

Physical

• Perform a thorough head and neck examination if the patient's condition permits.
• Remove all packings even if bleeding is not active.
• Perform anterior rhinoscopy before and after topical administration of medication. A topical anesthetic, such as 4% aqueous lidocaine, and a vasoconstrictor, such as 0.05% oxymetazoline, may be used. They can be applied via aerosolizing spray or cotton pledgets.
• Finally, perform fiberoptic endoscopy using a flexible or preferably rigid endoscope to inspect the entire nasal cavity, including the nasopharynx. The rigid endoscope is preferred because of its superior optics and its ability to allow endoscopic suction and cauterization.

Causes

Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic causes.

• Trauma
  • Self-induced trauma from repeated nasal picking can cause anterior septal mucosal ulceration and bleeding. This scenario is frequently observed in young children.
  • Acute facial and nasal trauma commonly leads to epistaxis. If the bleeding is from minor mucosal laceration, it is usually limited. However, extensive facial trauma can result in severe bleeding requiring nasal packing. In these patients, delayed epistaxis may signal the presence of a traumatic aneurysm.
  • Patients undergoing nasal surgery should be warned of the potential for epistaxis. As with nasal trauma, bleeding can range from minor (due to mucosal laceration) to severe (due to transection of a major vessel).
• Mucosal irritation: Dry, hot weather and topical nasal sprays can also cause mucosal irritation and epistaxis.
• Septal abnormality
  • Septal deviations and spurs may disrupt the normal nasal airflow, leading to dryness and epistaxis. The bleeding sites are usually located anterior to the spurs in most patients.
  • The edges of septal perforations frequently harbor crusting and are common sources of epistaxis.
• Inflammatory disease
  • Bacterial, viral, and allergic rhinosinusitis causes mucosal inflammation and may lead to epistaxis. Bleeding in these cases is usually minor and frequently manifests as blood-streaked nasal discharge.
  • Granulomatosis diseases such as sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, and rhinoscleroma often lead to crusting and friable mucosa and may be a cause of recurrent epistaxis.
• Tumors: Benign and malignant tumors can manifest as epistaxis. Affected patients may also present with signs and symptoms of nasal obstruction and rhinosinusitis, often unilateral.
• Blood dyscrasias
  • Congenital coagulopathies should be suspected in individuals with a positive family history, easy bruising, or prolonged bleeding from minor trauma or surgery. Examples of congenital bleeding disorders include hemophilia and von Willebrand disease.
  • Acquired coagulopathies can be primary (due to the diseases) or secondary (due to their treatments). Among the more common acquired coagulopathies are thrombocytopenia and liver disease with its consequential reduction in coagulation factors. Even in the absence of liver disease, alcoholism has also been associated with coagulopathy and epistaxis.
• Arteriosclerosis: Arteriosclerotic vascular disease is considered a reason for the higher prevalence of epistaxis in elderly individuals.
• Hereditary hemorrhagic telangiectasia
  • Hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber disease) is an autosomal dominant disease associated with recurrent bleeding from vascular anomalies. The condition can affect vessels ranging from capillaries to arteries, leading to the formation of telangiectasias and arteriovenous malformations.
  • Pathologic examination of these lesions reveals a lack of elastic or muscular tissue in the vessel wall. As a result, bleeding can occur easily from minor trauma and tends not to stop spontaneously.
  • Various organ systems such as the respiratory, gastrointestinal, and genitourinary systems may be involved. The epistaxis in these individuals is variable in severity but is almost universally recurrent.
• Idiopathic causes: Approximately 10% of patients with epistaxis have no identifiable causes even after a thorough evaluation.

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