Epistaxis / Nose Bleeding

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What is Epistaxis?

Epistaxis (also called a nosebleed) refers to a minor bleeding from the blood vessels of the nose. Epistaxis is a commonly-found complaint, especially in fields of emergency medicine related to the treatment of ear, nose, and throat (ENT) conditions. Epistaxis more commonly occurs in children (ages 2–10) and older adults (ages 50–80). There are two types of epistaxis depending on their origin:

  1. Anterior Epistaxis
  2. Posterior Epistaxis

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What is Anterior Epistaxis?

Anterior epistaxis refers to a nosebleed that originates from the anterior (frontal) part of the nose. Most of the time, cases of anterior epistaxis originate from the Kiesselbach plexus, which is a vascular network found on the nasal septum, as these arteries can be easily traumatized. Anterior epistaxis is the most common type of nosebleed, and usually involves one nostril.

What is Posterior Epistaxis?

Posterior epistaxis refers to bleeding from the posterior or superior nasal cavity. Most often, it originates from the Woodruff plexus, which is a vascular network found in the lateral wall of the nasal cavity. Posterior epistaxis usually involves both nostrils. For these types of nosebleeds, the blood may also flow backwards and uncomfortably get swallowed or coughed up (hemoptysis).

What causes Epistaxis?

Epistaxis generally occurs due to a rupture of blood vessels in the nasal mucosa. This rupture can be triggered by local or systemic causes, environmental factors, or medications.

Local causes

Local causes of epistaxis can include local trauma caused by nose-picking, a foreign body in the nose, anatomic irregularities such as a deviated septum, facial trauma, incorrect or excessive use of topical nasal sprays, inflammatory reactions, and rarely intranasal tumors. Smoking and snorting illicit drugs such as cocaine can also cause frequent nosebleeds due to irritation of the nasal mucosa, and can lead to further nasal damage in come cases.

Systemic causes

Some systemic conditions that increase the risk of epistaxis include high blood pressure (hypertension), vascular malformations, cardiovascular diseases, and bleeding disorders like von Willebrand disease and hemophilia A and B. Additionally, heavy alcohol use can also increase the risk for epistaxis, since it disrupts normal blood clotting activity and dilates superficial blood vessels, which increases the risk of a rupture.

Environmental factors

Common environmental causes of epistaxis include changes in temperature or humidity, as nose vessels are more prone to rupture in cold weather and dry environments. Additionally, environmental factors can trigger allergies. Allergies can increase the risk of epistaxis for multiple reasons. Not only can the allergic inflammatory reaction itself increase the risk, but excessive nose blowing and the use of allergy medications that dry the nasal mucosa—for instance, decongestants and antihistamines—can further compound the risk of developing a nose bleed.

Medications

Some medications can predispose individuals to epistaxis. This is especially true for blood thinners, which interfere with blood clotting. Anticoagulants such as warfarin, platelet aggregation inhibitors, NSAIDs (aspirin and ibuprofen), as well as homeopathic medications that prolong bleeding (like ginseng and Vitamin E), can all increase the risk of epistaxis.