Epistaxis

Surgery > Ear, nose & throat

Differential Diagnosis Schema 🧠

Local Causes

Trauma: Most common cause, often due to nose-picking, facial trauma, or nasal surgery
Dry air or environmental irritants: Drying of the nasal mucosa leads to cracking and bleeding
Infections: Upper respiratory tract infections, sinusitis, or rhinitis causing inflammation of the nasal mucosa
Allergic rhinitis: Chronic irritation and inflammation increase the risk of epistaxis
Nasal polyps or tumors: Benign or malignant growths causing local irritation or vascular disruption
Foreign body: Particularly in children, leading to localized trauma and infection
Septal deviation or perforation: Structural abnormalities increasing susceptibility to bleeding
Cocaine use: Chronic irritation and damage to the nasal mucosa from inhaled drugs

Systemic Causes

Hypertension: Poorly controlled blood pressure can exacerbate or trigger epistaxis
Coagulopathies: Includes inherited disorders like hemophilia or acquired conditions such as liver disease or anticoagulant therapy
Medications: Anticoagulants (e.g., warfarin, DOACs), antiplatelet agents (e.g., aspirin, clopidogrel), and NSAIDs can predispose to bleeding
Alcohol use: Chronic alcohol use can lead to liver dysfunction and coagulopathy
Vascular disorders: Conditions like hereditary hemorrhagic telangiectasia (HHT) or arteriosclerosis can cause recurrent epistaxis
Systemic infections: Such as dengue fever or other viral hemorrhagic fevers
Blood dyscrasias: Leukemia, thrombocytopenia, or other hematological disorders

Key Points in History 🥼

Symptom Characteristics

Unilateral vs bilateral: Unilateral bleeding is more commonly due to local causes, whereas bilateral may suggest a systemic issue
Frequency and duration: Recurrent or prolonged episodes may indicate an underlying systemic condition
Amount of bleeding: Assessing the volume can help determine the severity and need for intervention
Preceding events: Trauma, recent infections, or environmental exposures may provide clues to the cause
Associated symptoms: Headache, facial pain, or signs of systemic illness can indicate more serious underlying conditions

Background

Past medical history: History of hypertension, coagulopathies, or previous episodes of epistaxis
Medication history: Use of anticoagulants, antiplatelets, or other drugs affecting coagulation
Family history: Consider hereditary conditions like hereditary hemorrhagic telangiectasia (HHT)
Social history: Cocaine use, alcohol consumption, and occupational or environmental exposures
Surgical history: Previous nasal or sinus surgery, which could predispose to epistaxis
Allergies: History of allergic rhinitis or other atopic conditions

Possible Investigations 🌡️

Laboratory Tests

Full blood count: To check for anemia, thrombocytopenia, or signs of infection
Coagulation profile: Including PT, APTT, INR, and possibly fibrinogen levels, to assess for coagulopathies
Liver function tests: To evaluate for liver disease, which can cause coagulopathy and epistaxis
Renal function tests: As renal disease can affect platelet function and coagulation
Blood typing and crossmatch: If significant blood loss has occurred and transfusion may be necessary
Group and save: In preparation for possible transfusion in severe cases
HIV/Hepatitis screen: Consider in patients with risk factors for bloodborne infections
Nasal swabs: If infection is suspected, particularly in cases of chronic sinusitis or immunocompromised patients

Imaging and Specialist Tests

Nasal endoscopy: Direct visualization of the nasal cavity to identify the source of bleeding, particularly in recurrent or unexplained cases
CT scan of the sinuses: Useful in identifying structural abnormalities, tumors, or sinusitis
MRI: May be indicated if a vascular lesion or neoplasm is suspected, particularly in posterior epistaxis
Angiography: Considered in cases of severe, refractory epistaxis to identify and potentially embolize bleeding vessels
Allergy testing: If allergic rhinitis is a contributing factor, consider skin prick or specific IgE testing
Biopsy: If a mass or lesion is identified during endoscopy, to rule out malignancy

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