What are the possible causes and management options for a patient with epistaxis (nose bleed)?

Differential Diagnosis for Epistaxis (Nosebleed)

Local Nasal Causes

The most common causes of epistaxis are local nasal factors, particularly anterior septal bleeding from Kiesselbach's plexus, which accounts for the majority of cases. 1

Mucosal Irritation and Trauma

• Nasal dryness and mucosal fragility from low humidity, dry heat, or environmental factors 2
• Digital trauma (nose-picking) and forceful nose-blowing 3
• Intranasal drug use (cocaine, nasal sprays) causing mucosal damage 1, 4
• Recent nasal trauma or surgery 1

Inflammatory Conditions

• Upper respiratory infections (colds) causing hyperemic, fragile mucosa 2
• Allergic rhinitis producing chronic inflammation 2
• Chronic rhinosinusitis with mucosal changes 2

Structural Abnormalities

• Septal deviation or perforation 1
• Nasal or nasopharyngeal tumors (must be excluded, particularly in unilateral recurrent bleeding) 1
• Vascular malformations of the head and neck 1

Systemic Causes

Coagulopathy and Bleeding Disorders

• Anticoagulant medications (warfarin, DOACs, heparin) 1, 4
• Antiplatelet agents (aspirin, clopidogrel) 1, 4
• Hereditary bleeding disorders (hemophilia, von Willebrand disease) 1
• Acquired coagulopathy (liver disease, vitamin K deficiency) 1
• Thrombocytopenia or platelet dysfunction 2

Cardiovascular Conditions

• Hypertension (associated with posterior epistaxis in elderly) 2
• Atherosclerosis affecting nasal vasculature 2

Hereditary Hemorrhagic Telangiectasia (HHT)

• Recurrent bilateral nosebleeds with family history 4
• Nasal and oral mucosal telangiectasias on examination 4
• This is a critical diagnosis not to miss, requiring specialist evaluation 3

Age-Related Patterns

Children and Young Adults

• Anterior epistaxis from Little's area is most common 2
• Typically related to minor trauma, nose-picking, or upper respiratory infections 2

Elderly Patients

• Posterior epistaxis is more frequent and severe 2
• Often associated with hypertension, atherosclerosis, and anticoagulation 2
• Higher risk of complications requiring hospitalization 1

Key Diagnostic Considerations

Document the following risk factors at initial contact: 1, 4

• Personal or family history of bleeding disorders
• Current anticoagulant or antiplatelet medication use
• Intranasal drug use (prescription or recreational)
• Frequency, duration, and severity of bleeding episodes
• Unilateral versus bilateral bleeding pattern

Perform nasal endoscopy when: 4

• Bleeding is difficult to control with first-line measures
• Concern exists for unrecognized pathology (tumor, vascular malformation)
• Patient has recurrent bleeding despite prior packing or cautery
• Recurrent bilateral bleeding suggests HHT 4

Critical Pitfalls to Avoid

• Do not assume hypertension is the primary cause—it is typically an associated finding rather than the direct etiology 2
• Do not overlook unilateral recurrent bleeding, which may indicate neoplasm and requires endoscopic evaluation 1, 4
• Do not miss HHT in patients with recurrent bilateral epistaxis and family history, as this requires specialized management 4, 3
• Do not immediately discontinue anticoagulation—initiate first-line treatments before considering medication adjustments 4, 5