What are the causes of epistaxis (nosebleeds)?

Causes of Nosebleed (Epistaxis)

Nosebleeds are typically caused by digital trauma, nasal mucosal dryness, nasal inflammation with crusting, hypertension, anticoagulant/antiplatelet medication use, inherited bleeding disorders, anatomical factors, and systemic diseases. 1

Common Causes of Epistaxis

Local Factors:

• Digital trauma (nose picking) - especially common in children 1
• Nasal mucosal dryness - leading to crusting and subsequent bleeding 1
• Nasal inflammation - with crusting 1
• Anatomical factors:
  • Septal deviation 1
  • Nasal foreign bodies (particularly in children) 1
• Prior nasal or sinus surgery 2
• Nasal or facial trauma 2
• Intranasal medication or drug use - especially nasal corticosteroids 2
  • Intranasal corticosteroids increase risk of nosebleeds with a relative risk of 2.74 2

Systemic Factors:

• Medications affecting coagulation:
  • Anticoagulant medications (warfarin, dabigatran, rivaroxaban) 2, 3
  • Antiplatelet medications (aspirin) 2, 3
  • 15% of emergency department epistaxis cases involve patients on long-term anticoagulation 2
• Bleeding disorders:
  • Personal or family history of bleeding disorders 2
  • Von Willebrand disease 2
  • Hemophilia 2
• Vascular disorders:
  • Hereditary Hemorrhagic Telangiectasia (HHT/Rendu-Osler-Weber disease) 1, 4
• Chronic diseases:
  • Chronic kidney disease 2
  • Chronic liver disease 2
• Hypertension - associated with epistaxis (odds ratio 1.532) but causal relationship not established 2, 1
  • 33% of epistaxis patients have a history of hypertension 2

Environmental/Mechanical Factors:

• Nasal cannula oxygen use 2
• CPAP (continuous positive airway pressure) use 2
• Low humidity environments 1

Anatomical Considerations

• Anterior epistaxis (90-95% of cases):

  • Originates from Kiesselbach's plexus on the anterior nasal septum 1
  • More easily visualized and treated 2

• Posterior epistaxis (5-10% of cases):

  • Originates from sites on the lateral nasal wall or nasal septum not visible by anterior rhinoscopy 2
  • More common in older patients 2
  • Often more difficult to control 2

Risk Factors by Age

• Children and young adults:

  • Digital trauma (nose picking) 1
  • Nasal foreign bodies 1
  • 75% of children experience at least one episode of epistaxis 1

• Older adults:

  • Risk increases with advancing age 1
  • 1.36x increase in risk for ages 66-75 years 1
  • 2.37x increase for ages 76-85 years 1
  • 3.24x increase for those over 85 years 1
  • More likely to have posterior epistaxis 2
  • More likely to have systemic factors contributing to bleeding 2

Important Clinical Considerations

• Anterior rhinoscopy should be performed to identify the source of bleeding after removal of any blood clot 2
• For patients with recurrent or severe nosebleeds who use nasal corticosteroids, cessation of these medications should be considered 2
• Patients taking warfarin should have an INR checked to evaluate if they are in the therapeutic range 2
• Although hypertension is associated with epistaxis, there is no clear causal relationship, and routine lowering of blood pressure in acute nosebleeds is not recommended 2

Common Pitfalls

1. Failure to identify the bleeding site - Proper anterior rhinoscopy after clot removal is essential 2
2. Overlooking medication effects - Particularly anticoagulants, antiplatelets, and intranasal corticosteroids 2, 3
3. Assuming hypertension is the primary cause - While associated, causal relationship is not established 2
4. Missing underlying systemic disorders - Bleeding disorders or systemic diseases may present with epistaxis 2
5. Inadequate history taking - Not inquiring about medication use, recent changes in dosage, or personal/family history of bleeding disorders 2

Understanding these various causes helps guide appropriate management strategies and prevent recurrence of epistaxis.