What are the causes of epistasis?

Causes of Epistaxis

Epistaxis (nosebleed) is most commonly caused by nasal mucosal dryness, trauma to nasal blood vessels, and increased blood flow to the nasal mucosa, with specific causes varying by age group and underlying conditions. 1

Common Causes of Epistaxis

Local Factors

• Nasal mucosal dryness and trauma
  • Digital trauma (nose picking) - especially common in children 2
  • Nasal inflammation with crusting 2
  • Nasal foreign bodies (particularly in children) - presenting with unilateral epistaxis, rhinorrhea, and foul smell in 7% of cases 2
  • Trauma to nasal blood vessels during physical exertion 1

Systemic Factors

• Vascular/Hematologic Disorders

  • Hereditary Hemorrhagic Telangiectasia (HHT) - abnormal nasal vasculature causing recurrent epistaxis 2
  • Inherited bleeding disorders (von Willebrand disease, hemophilia) 2
  • Coagulation disorders (present in 0.9% of emergency department epistaxis cases) 2

• Medication-Related

  • Anticoagulant use (15% of emergency department epistaxis cases) 2
  • Antiplatelet medications 2
  • New-generation anticoagulants increase risk of nosebleed 2

• Cardiovascular Factors

  • Hypertension - associated with epistaxis (OR 1.532; 95% CI 1.181-1.986) but causal relationship not established 2, 1
  • Prevalence of hypertension in epistaxis patients ranges from 24-64% 2

Age-Related Patterns

• Bimodal age distribution 2
  • Peak frequency in children <10 years old
  • Second peak in adults between 70-79 years old
  • Increased risk with advancing age: 66-75 years (1.36x), 76-85 years (2.37x), >85 years (3.24x) compared to those <65 years

Anatomical Considerations

• Anterior epistaxis (90-95% of cases)

  • Originates from Kiesselbach's plexus on the anterior nasal septum 2
  • More common in children 2

• Posterior epistaxis (5-10% of cases)

  • From sites on lateral nasal wall or nasal septum not visible by anterior rhinoscopy 2
  • More common in older patients 2
  • More difficult to control 2
  • Can originate from septum (70%) or lateral nasal wall (24%) 2

Special Considerations

Pediatric Causes

• 75% of children experience at least one episode of epistaxis 2
• Most common causes in children:
  • Digital trauma (nose picking) 2
  • Nasal inflammation with crusting 2
  • Nasal foreign bodies 2

Concerning Causes Requiring Further Evaluation

• Tumors and Masses

  • Juvenile nasopharyngeal angiofibroma - presents with unilateral, unprovoked, profuse epistaxis in adolescent males (60-76% of cases) 2
  • Nasal malignancies - present with epistaxis in 55% of cases 2
  • Pyogenic granuloma 2

• Systemic Diseases

  • 45% of hospitalized epistaxis patients have systemic illnesses contributing to nosebleeds 2
  • Hematologic, hepatic, renal, genetic, or cardiovascular diseases 2

Diagnostic Approach

• Nasal endoscopy is recommended for:
  • Difficult to control epistaxis 2
  • Concern for unrecognized pathology 2
  • Adolescent males with unilateral epistaxis (to rule out juvenile nasopharyngeal angiofibroma) 2
  • Posterior epistaxis (allows localization of bleeding site in 87-93% of cases) 2

Management Considerations

• Treatment should target the identified site of bleeding with appropriate interventions 2
• Options include:
  • Topical vasoconstrictors 2
  • Nasal cautery 2
  • Moisturizing or lubricating agents 2
  • Tranexamic acid (for HHT-related epistaxis) 2

Prevention Strategies

• Maintaining nasal moisture using saline sprays, humidifiers, or petroleum jelly 1
• Managing underlying conditions like hypertension 1
• Evaluating anatomical issues such as septal deviation 1

Understanding the specific cause of epistaxis is crucial for effective management and prevention of recurrent episodes, particularly in cases with underlying systemic disease or concerning features that may indicate more serious pathology.