What causes epistaxis (nasal bleeding)?

Causes of Epistaxis (Nosebleeds)

Epistaxis is most commonly caused by local factors affecting the nasal mucosa, with anterior nasal septum bleeding (Kiesselbach's plexus) accounting for 90-95% of cases, while systemic factors like anticoagulant use, hypertension, and bleeding disorders contribute to the remaining cases, particularly posterior epistaxis. 1

Common Causes by Category

Local Factors

• Trauma and Irritation:

  • Digital trauma (nose picking) - especially common in children 2
  • Nasal foreign bodies 2
  • Nasal inflammation with crusting 2
  • Dry heat and abrupt temperature changes 3
  • Intranasal medication or drug use 1

• Anatomical Factors:

  • Septal deviation 1
  • Vascular malformations 1
  • Juvenile nasopharyngeal angiofibroma (in adolescent males with unilateral bleeding) 2
  • Prior nasal or sinus surgery 1

Systemic Factors

• Medication-Related:

  • Anticoagulants (warfarin, dabigatran, rivaroxaban) - present in 15% of emergency department epistaxis cases 1
  • Antiplatelet medications (aspirin) 1
  • New-generation anticoagulants appear to increase risk 2

• Hematologic Disorders:

  • Bleeding disorders (von Willebrand disease, hemophilia) - found in 13% of hospitalized epistaxis patients in one study 4
  • Factor XIII deficiency 4
  • Platelet dysfunction 4

• Vascular Conditions:

  • Hypertension - associated with epistaxis (OR 1.532) but causal relationship not established 2, 1
  • Atherosclerosis - especially in elderly patients with posterior epistaxis 3
  • Hereditary Hemorrhagic Telangiectasia (HHT) syndrome 2

• Other Medical Conditions:

  • Chronic kidney disease 1
  • Chronic liver disease 1
  • Hematologic malignancies 1
  • Chronic inflammatory diseases 4

Epidemiology and Distribution

• Age Distribution:

  • Bimodal distribution with peaks in children <10 years and adults 70-79 years 2, 1
  • Risk increases with advancing age - patients >85 years are 3.24 times more likely to present to emergency rooms than those <65 years 2

• Anatomical Distribution:

  • Anterior epistaxis (90-95%): Originates from Kiesselbach's plexus on anterior nasal septum 1
  • Posterior epistaxis (5-10%): More difficult to control, more common in older patients 2, 1

Risk Factors for Severe or Recurrent Epistaxis

• Advanced age 2
• Posterior bleeding source 2
• Anticoagulant or antiplatelet medication use 1
• Underlying bleeding disorders 1
• Hypertension (33% of epistaxis patients have hypertension) 2
• Chronic kidney or liver disease 1

Clinical Pearls and Pitfalls

• Important Clinical Considerations:

  • Persistent or recurrent unilateral nasal bleeding in adolescent males should raise suspicion for juvenile nasopharyngeal angiofibroma 2
  • Routine lowering of blood pressure in acute nosebleeds is not recommended despite the association between hypertension and epistaxis 1
  • Patients taking warfarin should have INR checked to evaluate if they are in therapeutic range 1

• Common Pitfalls:

  • Assuming hypertension is the primary cause of epistaxis despite lack of clear causal relationship 1
  • Overlooking medication effects, particularly anticoagulants, antiplatelets, and intranasal corticosteroids 1
  • Missing underlying systemic disorders such as bleeding disorders or systemic diseases 1
  • Inadequate history taking, including not inquiring about medication use or personal/family history of bleeding disorders 1

Understanding the specific cause of epistaxis is crucial for effective management and prevention of recurrence, with treatment approaches varying based on the underlying etiology and location of bleeding.