What investigations should be done for epistaxis (nosebleed)?

Investigations for Epistaxis

The investigation approach for epistaxis should begin with anterior rhinoscopy in all patients to identify the bleeding source, followed by nasal endoscopy for recurrent, unilateral, or difficult-to-control bleeding, with additional diagnostic testing reserved for patients with suspected underlying pathology or bleeding disorders. 1

Initial Diagnostic Evaluation

Anterior Rhinoscopy (First-Line Investigation)

• Perform anterior rhinoscopy on all patients after removing any blood clot to identify the bleeding source 1
• Use an otoscope for visualization in young children 2
• Examine for septal deviation, perforation, telangiectasias, masses, and foreign bodies 2
• This basic examination should be performed before considering more invasive investigations 3

Nasal Endoscopy (Second-Line Investigation)

Nasal endoscopy localizes the bleeding site in 87-93% of cases and is indicated when anterior rhinoscopy is insufficient 3

Specific Indications for Nasal Endoscopy:

• Recurrent epistaxis despite prior treatment with packing or cautery 3
• Unilateral bleeding (to exclude masses or foreign bodies) 2
• Bleeding that is difficult to control 3
• When there is concern for unrecognized pathology 3
• Posterior epistaxis (can identify sources on the septum in 70% and lateral nasal wall in 24% of cases) 3

Critical caveat: Even when a bleeding site is identified in Kiesselbach's plexus, endoscopy may still be indicated if bleeding was unusually difficult to control or if clinical symptoms suggest additional bleeding sites 3

Risk Factor Documentation (Essential Investigation Component)

Document factors that increase bleeding frequency or severity in all patients 1:

• Personal or family history of bleeding disorders 1
• Anticoagulant or antiplatelet medication use 1
• Intranasal drug use 1
• Prior nasal/sinus surgery 1
• Nasal trauma 1
• Nasal cannula oxygen or CPAP use 1
• Chronic kidney or liver disease 1
• Hypertension 1
• Cardiopulmonary disease 1
• Anemia 1

Investigations for Specific Clinical Scenarios

Adolescent Males with Unilateral Profuse Bleeding

Examination of the posterior nasal cavity and nasopharynx is mandatory to exclude juvenile nasopharyngeal angiofibroma, which presents with unilateral, unprovoked, profuse epistaxis in 60-76% of cases 3, 2

Children with Unilateral Bleeding

Nasal endoscopy should be performed to exclude foreign bodies, which present with epistaxis in 7% of cases and are associated with bleeding in 30% of cases 3, 2

• Disk battery foreign bodies are particularly urgent as they can cause tissue necrosis and septal perforation in as little as 3 hours 3, 2

Recurrent Bilateral Nosebleeds or Family History

Assess for hereditary hemorrhagic telangiectasia (HHT) by examining for nasal and oral mucosal telangiectasias 1, 2

• HHT occurs in 1 in 5,000-18,000 individuals and is often underdiagnosed 2
• Nosebleeds are the main symptom in >90% of HHT patients 2

Suspected Bleeding Disorders

Obtain coagulation studies with hematology referral when there is a positive family history of bleeding or severe/bilateral recurrent episodes 2

Suspected Malignancy

Nasal endoscopy is essential as nasal malignancies present with unilateral nasal obstruction (66.7%) and epistaxis (55%), but may not be visible on anterior rhinoscopy 3

• Life-threatening bleeding has been associated with delayed diagnosis 3

Investigations for Refractory Cases

When treatments are ineffective or recurrent bleeding is documented, additional diagnostic testing should be obtained to assess for underlying conditions including 3:

• Primary bleeding disorders 3
• Hematologic malignancies 3
• Intranasal tumors or vascular malformations 3

Common Pitfalls to Avoid

• Do not rely solely on anterior rhinoscopy when bleeding is difficult to control or recurrent, as posterior sources require endoscopic identification 3
• Do not delay endoscopy in adolescent males with unilateral profuse bleeding, as juvenile nasopharyngeal angiofibroma requires early diagnosis 3, 2
• Do not miss foreign bodies in children, particularly disk batteries which require urgent removal 3, 2
• Do not overlook HHT screening in patients with recurrent bilateral epistaxis or positive family history 1, 2