What causes epistaxis (nosebleeds)?

Causes of Nosebleeds (Epistaxis)

Nosebleeds are commonly caused by local trauma, mucosal dryness, inflammation, and systemic factors such as medication use and bleeding disorders. 1, 2

Common Local Causes

• Digital trauma (nose picking) - One of the most common causes, especially in children 2, 3
• Nasal mucosal dryness - Dry environments, heated indoor air, and low humidity can cause crusting and subsequent bleeding 1, 2
• Nasal or facial trauma - Direct injury to the nose can damage blood vessels 1
• Nasal inflammation - From allergies, colds, or sinus infections 2, 4
• Foreign bodies - Particularly in children 2, 3
• Intranasal drug use - Both prescribed medications and illicit substances 1, 2
• Nasal oxygen use - Continuous oxygen therapy can dry nasal mucosa 1, 2
• CPAP use - Can cause drying of nasal passages 1
• Post-surgical changes - Previous nasal or sinus surgery can alter nasal anatomy 1, 2

Anatomical Considerations

• Anterior bleeds (90-95% of cases):

  • Most commonly originate from Kiesselbach's plexus in the anterior nasal septum 2, 4
  • Generally less severe and easier to control 4
  • More common in children and young adults 1, 3

• Posterior bleeds (5-10% of cases):

  • Originate from posterior sites on the lateral nasal wall or nasal septum 1
  • More common in older adults 1, 4
  • Often more difficult to control and may require hospitalization 1, 4

Systemic Causes and Risk Factors

• Medication-related factors:

  • Anticoagulant medications (warfarin, dabigatran, rivaroxaban) 1, 5
  • Antiplatelet medications (aspirin, clopidogrel) 1, 5
  • Selective serotonin reuptake inhibitors (SSRIs) 5
  • Intranasal corticosteroids 5
  • Certain antibiotics 5

• Medical conditions:

  • Bleeding disorders (hemophilia, von Willebrand disease) 1, 2
  • Hereditary Hemorrhagic Telangiectasia (HHT) syndrome 1, 2
  • Chronic kidney or liver disease 1, 2
  • Hypertension - Associated with epistaxis but causal relationship not well established 1, 2
  • Atherosclerosis - Particularly in elderly patients with posterior bleeds 4, 6

Age-Related Patterns

• Bimodal age distribution of nosebleeds:

  • Peak frequency in children under 10 years of age 1, 3
  • Second peak in adults between 70-79 years 1
  • Patients over 85 years are 3.24 times more likely to present to emergency departments with epistaxis than those under 65 1, 2

• Children-specific causes:

  • Digital trauma (nose picking) is most common 2, 3
  • Nasal foreign bodies 2, 3
  • 30% of children under 5 years experience at least one episode 3
  • Average age of presentation is between 7.5-8.5 years 3

• Adolescent-specific concerns:

  • Persistent unilateral bleeding with nasal obstruction may suggest juvenile nasopharyngeal angiofibroma (rare vascular tumor) 1

Red Flags and Warning Signs

• Unilateral persistent epistaxis with nasal obstruction, facial pain, or visual changes may suggest a mass lesion 2
• Recurrent or severe epistaxis may indicate an underlying systemic disorder 1, 2
• Multiple bleeding sites beyond the nose may suggest a bleeding disorder 2
• Family history of bleeding may indicate hereditary conditions 1, 2

Epidemiology

• Approximately 60% of the population will experience epistaxis at some point 5
• Males are slightly more affected (52.7-67%) 1, 3
• Accounts for 0.32% of all emergency department visits in the US 1
• About 13.9% of treated patients present again within 30 days 1