What is the differential diagnosis for epistaxis (nasal bleeding)?

Differential Diagnosis of Epistaxis

Local/Anatomic Causes

The most common causes of epistaxis are local trauma and mucosal irritation affecting the anterior nasal septum (Kiesselbach's plexus), particularly from digital manipulation, dry environments, and nasal inflammation. 1

Anterior Bleeding Sources

• Digital trauma and nasal mucosal irritation are the most frequent causes in otherwise healthy individuals, typically affecting the anterior nasal septum where the Kiesselbach plexus provides rich vascular supply 1, 2
• Nasal septal deviation contributes to recurrent bleeding through altered airflow patterns and repeated mucosal trauma 1
• Mucosal dryness and inflammation from dry environments, nasal oxygen use, or CPAP therapy predispose to bleeding 2
• Intranasal drug use, including topical medication overuse (intranasal corticosteroids increase risk 2.7-fold) or illicit drug snorting (especially cocaine causing septal perforation), affects one nostril preferentially 2
• Nicotine exposure (smoking, vaping, intranasal tobacco) causes direct vasoconstriction and mucosal drying, making the anterior septum vulnerable to recurrent bleeding 2

Foreign Bodies and Masses

• Nasal foreign bodies present with unilateral epistaxis, rhinorrhea, and foul smell in 7% of cases; bleeding occurs in 30% either from the object itself or during removal 3, 1
• Disk battery foreign bodies are particularly dangerous, causing tissue necrosis and septal perforation in as little as 3 hours 1
• Juvenile nasopharyngeal angiofibroma occurs in adolescent males, presenting with unilateral, unprovoked, profuse epistaxis in 60-76% of cases; examination of the posterior nasal cavity and nasopharynx is mandatory in adolescent males with these symptoms 3, 1
• Nasal malignancies present with unilateral nasal obstruction (66.7%) and epistaxis (55%); these may not be visible on anterior rhinoscopy and delayed diagnosis can cause life-threatening bleeding 3, 1
• Intranasal tumors should be suspected with unilateral epistaxis accompanied by nasal obstruction, facial pain, or visual changes 2

Post-Surgical and Anatomic Variants

• Previous nasal or sinus surgery can affect one side of the nasal cavity and contribute to unilateral epistaxis 2
• Localized infection such as rhinosinusitis can affect one side of the nasal cavity 2

Vascular Abnormalities

• Hereditary hemorrhagic telangiectasia (HHT) occurs in 1 in 5,000-18,000 individuals and is often underdiagnosed; nosebleeds are the main symptom in >90% of HHT patients, typically presenting with recurrent bilateral nosebleeds starting in childhood or adolescence with visible telangiectasias on nasal or oral mucosa 1, 4
• Nasal vascular malformations are rare underlying conditions predisposing to bleeding 2
• Abnormal nasal vasculature, including thin-walled arterioles and capillaries with surrounding inflammation and dilated mucosal vessels, is a well-recognized cause of recurrent nosebleeds 1

Posterior Epistaxis (5-10% of Cases)

Posterior epistaxis originates from sites on the septum (70%) or lateral nasal wall (24%), is more common in older patients with hypertension, and is more difficult to control with higher likelihood of requiring hospitalization. 3, 4

• Advanced age dramatically increases epistaxis severity and complications, with significantly higher rates of posterior epistaxis 2
• Hypertension is independently associated with more severe bleeding requiring emergency intervention, with prevalence rates of 17-67% among epistaxis patients, though the causal relationship remains controversial 2, 4

Systemic and Hematologic Causes

Coagulation Disorders

• Von Willebrand disease is the most frequent congenital bleeding disorder with prevalence of approximately 1%; epistaxis is the cardinal symptom, and routine coagulation screening (PT, APTT, platelet count) is insufficient for diagnosis 5
• Hemophilia should be documented in personal or family history 1, 2
• Factor XIII deficiency can present with epistaxis and requires enhanced coagulation screening 5
• Platelet dysfunction may not be detected by routine screening 5
• Immune thrombocytopenia (ITP) can present with mucosal bleeding, including epistaxis, particularly in young children 1

Medication-Related Causes

• Anticoagulant medications (warfarin requiring INR checking, with supratherapeutic levels potentially requiring reversal agents for severe refractory bleeding) 2
• Direct oral anticoagulants (DOACs) have limited reversal options 2
• Antiplatelet agents (aspirin, clopidogrel) can cause persistent epistaxis 2
• 15% of epistaxis patients are on long-term anticoagulation 2, 4

Other Systemic Conditions

• Liver disease affects coagulation factor production 2
• Renal disease affects platelet function 2
• Cardiovascular disease is associated with epistaxis 2
• Malignant hematology disorders can cause epistaxis 2
• Ehlers-Danlos syndrome or other connective tissue disorders should be assessed through history and examination 1

Pediatric-Specific Considerations

• Adenoidal hypertrophy is a common acquired anatomic cause of nasal obstruction in infants and children, leading to mouth breathing and potential mucosal trauma 1
• Laryngopharyngeal reflux can cause nasal congestion and inflammation in infants, particularly those with prematurity, neuromuscular disease, or cleft palate 1

Red Flags Requiring Urgent Investigation

Nasal endoscopy is recommended for persistent unilateral epistaxis, recurrent bleeding despite treatment, or when bleeding was unusually difficult to control, as it localizes the bleeding site in 87-93% of cases. 3, 2

• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggests mass lesion 2
• Bleeding duration >30 minutes, bilateral bleeding, or >3 recent episodes defines severe epistaxis requiring prompt evaluation 1
• Hemodynamic instability (tachycardia, syncope, orthostatic hypotension) indicates significant blood loss requiring hospital-level care 1
• Associated bruising, petechiae, or other bleeding manifestations suggest coagulopathy or ITP 1
• Ineffective treatments or recurrent bleeding despite appropriate management requires assessment for underlying conditions 2