What are the causes of epistaxis?

Causes of Epistaxis

Epistaxis is primarily caused by local factors including trauma, intranasal medication use, and nasal/sinus surgery, with systemic factors such as anticoagulant use, bleeding disorders, and hypertension also playing significant roles. 1

Local Causes (50-90% of cases)

Traumatic Factors

• Digital trauma (nose picking) - most common local cause 1
• Nasal or facial trauma 1
• Prior nasal or sinus surgery 1
• Foreign bodies (particularly in children)

Medication-Related Local Factors

• Intranasal corticosteroids (increases risk by 2.74 times) 1
• Intranasal drug use 1
• Topical nasal medications causing mucosal drying

Anatomical and Environmental Factors

• Septal deviation 1
• Nasal dryness/low humidity environments 1
• Seasonal variations (more common in winter months) 2
• Inflammation (rhinitis, sinusitis)

Systemic Causes (approximately 38% of cases)

Medication-Related Systemic Factors

• Anticoagulant medications (warfarin, dabigatran, rivaroxaban) 1, 3
• Antiplatelet medications (aspirin, clopidogrel) 1, 3
• Selective serotonin reuptake inhibitors (SSRIs) 3
• Certain antibiotics 3

Medical Conditions

• Hypertension (present in 33% of epistaxis cases) 1
• Bleeding disorders (Von Willebrand disease, hemophilia) 1
• Chronic kidney disease 1
• Chronic liver disease 1
• Hematologic malignancies 4
• Vascular malformations 4

Epidemiological Patterns

• Bimodal age distribution:
  • First peak: children under 10 years old 1
  • Second peak: adults 70-79 years old 1
• Risk increases with age:
  • 1.36x increase for ages 66-75
  • 2.37x increase for ages 76-85
  • 3.24x increase for ages over 85 1
• Anatomical distribution:
  • Anterior epistaxis (90-95% of cases) - from Kiesselbach's plexus 1
  • Posterior epistaxis (5-10% of cases) - more common in older adults 1

Clinical Pearls and Pitfalls

• Always consider medication effects, particularly anticoagulants, antiplatelets, and intranasal corticosteroids 1
• Don't assume hypertension is the primary cause despite its association with epistaxis 1
• Recurrent unilateral epistaxis in adolescent males warrants thorough investigation for underlying pathology 1
• Seasonal variation is significant, with winter months showing increased incidence due to lower humidity 2
• Underlying systemic disorders may be missed without comprehensive history-taking 1

Diagnostic Approach

• Anterior rhinoscopy after clot removal is essential to identify the bleeding site 1
• Nasal endoscopy is recommended for:
  • Difficult-to-control epistaxis
  • Concern for unrecognized pathology
  • Adolescent males with unilateral epistaxis
  • Posterior epistaxis 1
• Check INR for patients on warfarin 1
• Consider bleeding disorder workup for recurrent or severe epistaxis without obvious cause

Understanding these causes helps direct appropriate management strategies and prevent recurrence of epistaxis, which can range from simple first-aid measures to more invasive interventions depending on the severity and underlying etiology.