What are the differential diagnoses for epistaxis (nosebleed)?

Differential Diagnosis of Epistaxis

The differential diagnosis of epistaxis encompasses local nasal causes (trauma, inflammation, tumors), systemic conditions (bleeding disorders, hypertension, liver/renal disease), medications (anticoagulants, antiplatelets), and vascular abnormalities (hereditary hemorrhagic telangiectasia), with the majority being idiopathic anterior bleeds from the Kiesselbach plexus. 1, 2

Local/Anatomic Causes

Traumatic

• Digital trauma (nose picking) is one of the most common causes, particularly in children and requires targeted examination 2
• Nasal foreign bodies can cause unilateral bleeding and require removal 2
• Recent nasal or sinus surgery creates post-surgical changes that predispose to bleeding 2
• Nasal trauma with septal fracture requires evaluation for hemodynamic stability 3
• Nasal cannula oxygen or CPAP use causes localized mucosal injury 2

Inflammatory/Infectious

• Mucosal dryness from dry environments is a major contributor to epistaxis 2
• Rhinosinusitis can affect one side of the nasal cavity causing unilateral bleeding 2
• Nasal infections account for 18% of epistaxis cases 4
• Allergic rhinitis produces fragile hyperemic mucosa that bleeds easily 5

Neoplastic

• Intranasal tumors should be suspected with unilateral epistaxis accompanied by nasal obstruction, facial pain, or visual changes 1, 2
• Hematologic malignancies can present with epistaxis 2

Vascular Abnormalities

• Hereditary hemorrhagic telangiectasia (HHT) presents with recurrent bilateral epistaxis and family history of recurrent nosebleeds, requiring assessment for nasal and oral mucosal telangiectasias 3, 6
• Nasal vascular malformations are rare underlying conditions predisposing to bleeding 1

Systemic Causes

Hematologic Disorders

• Primary bleeding disorders including von Willebrand disease and hemophilia should be documented in the history 1, 2
• Coagulation disorders may initially present with unilateral epistaxis 2
• Thrombocytopenia from various causes decreases platelet function 5

Cardiovascular

• Hypertension is present in 24-64% of patients with epistaxis, though no causal relationship is established; it exacerbates bleeding from pre-existing vulnerable vessels 2
• Atherosclerosis is associated with posterior epistaxis in elderly patients 5

Organ Dysfunction

• Liver disease impairs coagulation factor synthesis 2
• Chronic kidney disease affects platelet function and should be documented 2

Medication-Related Causes

Anticoagulants

• Warfarin requires INR checking, with supratherapeutic levels potentially requiring reversal for severe bleeding 2
• Direct oral anticoagulants (DOACs) are relatively new with limited reversal options 1

Antiplatelet Agents

• Aspirin and clopidogrel cause persistent epistaxis and affect 15% of hospitalized epistaxis patients 2

Topical Medications

• Intranasal drug use including topical medication overuse or illicit drug snorting affects one nostril 2
• Nasal decongestant overuse can cause rebound congestion and bleeding 2

Age-Related Patterns

Pediatric (Under 10 Years)

• Anterior epistaxis from Kiesselbach plexus is most common, often related to digital trauma and dry mucosa 2, 4

Elderly (70-79 Years Peak)

• Posterior epistaxis (5-10% of cases) originates from lateral nasal wall or posterior septum, is more difficult to control, and has higher hospitalization rates 2
• Patients over 85 years have 3.24 times higher likelihood of emergency department visits for epistaxis 2

Critical Red Flags Requiring Further Investigation

• Hemodynamic instability (tachycardia, hypotension, orthostatic changes, syncope) indicates significant blood loss requiring hospital-level care 3
• Bleeding duration >30 minutes meets threshold for severe epistaxis requiring prompt management 3
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggests mass lesion 2
• Recurrent bilateral epistaxis with family history warrants HHT evaluation 3, 6
• Ineffective treatments or recurrent bleeding despite appropriate management requires assessment for underlying conditions 1

Documentation Requirements

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting specific risk factors for every epistaxis patient: 2, 6

• Personal or family history of bleeding disorders
• Current anticoagulant or antiplatelet medications
• Intranasal medication use
• Prior nasal or sinus surgery
• Chronic kidney or liver disease
• Hypertension and cardiovascular disease