What are the causes of epistaxis (nosebleed)?

Common Causes of Epistaxis (Nosebleeds)

Epistaxis is most commonly caused by local trauma, nasal dryness, medication effects (especially anticoagulants and antiplatelets), and underlying medical conditions that affect blood clotting or vascular integrity. 1

Primary Risk Factors

Local Factors

• Digital trauma (nose picking) - particularly common in children 1
• Nasal dryness and crusting - from low humidity environments 1
• Nasal or facial trauma 2
• Prior nasal or sinus surgery 2
• Nasal foreign bodies - especially in children 1
• Nasal inflammation with crusting 1
• Intranasal medication use - particularly corticosteroids 2, 3
• Intranasal drug use 2

Systemic Factors

• Medications affecting coagulation:

  • Anticoagulants (warfarin, dabigatran, rivaroxaban) 2, 1, 3
  • Antiplatelet medications (aspirin) 2, 1, 4
  • Selective serotonin reuptake inhibitors 3

• Medical conditions:

  • Personal or family history of bleeding disorders (e.g., Von Willebrand disease, hemophilia) 2, 1
  • Chronic kidney disease 2, 1
  • Chronic liver disease 2, 1
  • Hereditary Hemorrhagic Telangiectasia (HHT) syndrome 1
  • Hematologic malignancies 1
  • Vascular malformations 1

• Device-related factors:

  • Nasal cannula oxygen use 2
  • CPAP (continuous positive airway pressure) use 2

Anatomical Considerations

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

  • Originates from Kiesselbach's plexus on the anterior nasal septum 1, 5
  • More common in children and younger adults 5
  • Usually easier to manage 5

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

  • Originates from sites on the lateral nasal wall or posterior nasal septum 1
  • More common in older adults 1, 5
  • Often more severe and difficult to control 5
  • More frequently associated with hypertension and atherosclerosis 5

Special Considerations

Age-Related Patterns

• Bimodal distribution:
  • First peak: Children under 10 years old 1
  • Second peak: Adults between 70-79 years old 1
  • Risk increases with advancing age 1

Hypertension and Epistaxis

• While hypertension is associated with epistaxis (odds ratio 1.532), a direct causal relationship has not been firmly established 1
• Routine lowering of blood pressure in acute epistaxis is not recommended due to potential risks of end-organ damage 2
• Blood pressure should be monitored, but treatment decisions should be based on individual patient factors 2

Common Pitfalls in Diagnosis

• Failure to identify the bleeding site through proper anterior rhinoscopy after clot removal 1
• Overlooking medication effects, particularly anticoagulants, antiplatelets, and intranasal corticosteroids 1, 3
• Assuming hypertension is the primary cause despite lack of clear causal evidence 1
• Missing underlying systemic disorders such as bleeding disorders or systemic diseases 1
• Inadequate history taking regarding medication use or personal/family history of bleeding disorders 1

Prevention Strategies

• Maintaining nasal moisture using saline nasal sprays, humidifiers, or petroleum jelly 1
• Modifying environment to increase humidity 1
• Proper use of intranasal medications to avoid local irritation 3
• Monitoring anticoagulation levels (e.g., INR for warfarin) 2, 1
• Avoiding sharing nasal spray containers to prevent infection spread 6

Understanding these various causes of epistaxis allows for more targeted prevention and treatment approaches, ultimately reducing morbidity and improving quality of life for affected patients.