Can vascular abnormalities in the nasal cavity cause epistaxis?

Blood Vessel Abnormalities as a Cause of Nosebleeds

Yes, vascular abnormalities in the nasal cavity are a well-recognized cause of epistaxis, including abnormal nasal vasculature seen in hereditary hemorrhagic telangiectasia (HHT) syndrome, prominent thin-walled arterioles and capillaries with surrounding inflammation, and dilated blood vessels in the nasal mucosa. 1

Specific Vascular Abnormalities That Cause Epistaxis

Hereditary Hemorrhagic Telangiectasia (HHT)

• HHT is the most clinically significant vascular abnormality causing recurrent nosebleeds, affecting 1 in 5,000-18,000 individuals, with nosebleeds being the main symptom in >90% of HHT patients. 2
• The American Academy of Otolaryngology-Head and Neck Surgery recognizes abnormal nasal vasculature in HHT syndrome as a known cause of recurrent epistaxis. 1
• HHT requires visible telangiectasias on nasal or oral mucosa and typically presents with recurrent bilateral nosebleeds starting in childhood or adolescence. 3
• Assessment for HHT should occur in patients with recurrent bilateral nosebleeds or positive family history of recurrent nosebleeds. 4

Prominent Septal Vessels and Inflammatory Changes

• Research demonstrates that prominent vessels visible on the nasal septum in children with epistaxis are thin-walled arterioles and capillaries with surrounding inflammatory infiltrate, representing septal neovascularization due to chronic low-grade inflammation. 5
• There is no evidence of venous varicosities or arterial microaneurysms in these prominent vessels. 5

Dilated Blood Vessels in Nasal Mucosa

• Epistaxis typically originates from the nasal septum when nasal mucosa overlying a dilated blood vessel is injured. 6, 7
• Most nosebleeds originate from the nasal septum, which has a rich vascular supply from the Kiesselbach plexus. 1, 4

Other Vascular Lesions Causing Epistaxis

Nasal Hemangiomas

• Nasal hemangiomas present with a visible mass lesion on examination, typically causing unilateral obstruction with associated symptoms like facial pain, though they are uncommon causes of epistaxis. 3

Juvenile Nasopharyngeal Angiofibroma

• This vascular tumor occurs in adolescent males, presenting with unilateral, unprovoked, profuse epistaxis in 60-76% of cases. 2
• Examination of the posterior nasal cavity and nasopharynx is mandatory in adolescent males with these symptoms. 2

General Nasal Vascular Malformations

• Nasal vascular malformations are rare underlying conditions predisposing to bleeding. 4

Clinical Implications

The presence of vascular abnormalities should be suspected when:

• Recurrent bilateral nosebleeds occur, especially starting in childhood or adolescence (suggests HHT). 3, 2
• Visible telangiectasias are present on nasal or oral mucosa (confirms HHT). 3
• Prominent vessels are visible on anterior rhinoscopy of the nasal septum. 5
• Unilateral profuse epistaxis occurs in adolescent males (suggests angiofibroma). 2
• A positive family history of recurrent nosebleeds exists (suggests hereditary vascular conditions). 4, 2

Diagnostic Approach for Suspected Vascular Abnormalities

• Perform anterior rhinoscopy after removing blood clots to identify prominent vessels, telangiectasias, or masses. 4, 2
• Use nasal endoscopy for recurrent unilateral bleeding or when bleeding persists despite treatment, as it localizes bleeding sites in 87-93% of cases. 2
• In adolescent males with profuse unilateral epistaxis, examine the posterior nasal cavity and nasopharynx to rule out angiofibroma. 2