Epistaxis: A Clinician’s Guide to Differential Diagnosis

Epistaxis, commonly known as a nosebleed, is a frequent emergency in otolaryngology, as well as in primary and emergency care settings. While most cases are benign and self-limiting, understanding the potential underlying causes is crucial for effective management and preventing recurrence. This guide provides a comprehensive overview of the Differential Diagnosis For Epistaxis, aiding clinicians in accurately identifying the etiology and implementing appropriate treatment strategies. Epistaxis is broadly categorized into anterior and posterior bleeds, with anterior bleeds being more prevalent and typically originating from Kiesselbach’s plexus. Posterior bleeds, although less common, are often more severe and necessitate medical intervention. Effective diagnosis and management require a collaborative approach involving various healthcare professionals, ensuring optimal patient outcomes.

Etiology of Epistaxis: A Broad Spectrum of Causes

Nosebleeds are not diseases themselves but symptoms with a wide range of potential causes. These causes can be broadly classified into local, systemic, environmental, and medication-related factors. A thorough understanding of these categories is essential for developing a robust differential diagnosis.

Local Factors Contributing to Epistaxis

Local causes are often the most straightforward to identify and manage in epistaxis. These directly affect the nasal mucosa and vasculature, predisposing them to bleeding.

• Digital Manipulation: Nose picking is a very common cause, especially in children, and can easily traumatize the delicate mucosa of Kiesselbach’s plexus.
• Nasal Trauma: Blunt trauma to the nose, facial fractures, or even seemingly minor injuries can rupture blood vessels in the nasal cavity.
• Deviated Septum: A deviated nasal septum can cause turbulent airflow and dryness, making the mucosa more susceptible to irritation and bleeding, particularly in the anterior septum.
• Chronic Nasal Cannula Use: Prolonged use of nasal cannulas for oxygen therapy can dry out and irritate the nasal mucosa, leading to epistaxis.
• Nasal and Sinus Infections (Rhinosinusitis): Inflammation from infections can increase mucosal friability and vascularity, predisposing to nosebleeds.
• Topical Nasal Medications: While often therapeutic, improper or overuse of topical nasal steroids and antihistamines can cause dryness and irritation, paradoxically leading to epistaxis.

Systemic Diseases and Epistaxis

Systemic conditions can significantly impact the body’s hemostatic mechanisms or vascular integrity, increasing the risk and severity of epistaxis.

• Hypertension: Elevated blood pressure, especially acutely, can increase the force on nasal blood vessels, making them more prone to rupture. While not a primary cause of recurrent epistaxis, it can exacerbate bleeding episodes.
• Coagulopathies: Inherited bleeding disorders like von Willebrand disease and hemophilia, as well as acquired coagulopathies (e.g., liver disease, vitamin K deficiency), impair the body’s clotting ability, leading to more prolonged and severe nosebleeds.
• Vascular Malformations: Conditions like Hereditary Hemorrhagic Telangiectasia (HHT) or Osler-Weber-Rendu disease are characterized by abnormal blood vessel formation, making patients highly susceptible to recurrent and often severe epistaxis. These malformations can be present throughout the body but are commonly found in the nasal mucosa.
• Hematologic Malignancies: Leukemia and other blood cancers can cause thrombocytopenia (low platelet count) and other clotting abnormalities, increasing bleeding risk, including epistaxis.
• Alcoholism: Chronic alcohol abuse can lead to liver disease and coagulopathy, as well as mucosal dryness and irritation, increasing susceptibility to nosebleeds.
• Vitamin Deficiencies: Deficiencies in vitamins C and K, crucial for collagen synthesis and coagulation respectively, can contribute to weakened blood vessels and increased bleeding tendency.

Environmental and Lifestyle Factors

The environment and lifestyle choices play a significant role in the frequency and severity of epistaxis, primarily by affecting nasal mucosal moisture and integrity.

• Low Humidity/Dry Air: Dry air, particularly during winter months with indoor heating, is a major contributing factor. It dries out the nasal mucosa, making it fragile and prone to cracking and bleeding.
• Allergies (Allergic Rhinitis): Nasal allergies cause inflammation and increased vascularity of the nasal mucosa, making it more susceptible to bleeding with minor trauma, such as nose blowing or sneezing.
• Irritants and Pollutants: Exposure to environmental irritants, smoke, and pollutants can inflame and dry the nasal mucosa, increasing the risk of epistaxis.

Medication-Induced Epistaxis

A significant number of medications, both prescription and over-the-counter, can increase the risk of epistaxis, primarily by affecting coagulation or causing mucosal dryness.

• Anticoagulants: Medications like warfarin, heparin, and direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban, are designed to reduce blood clotting and are a major risk factor for epistaxis, particularly posterior bleeds which can be more challenging to manage.
• Antiplatelet Agents: Drugs like aspirin, clopidogrel, and other platelet aggregation inhibitors reduce platelet function, increasing bleeding risk. Even low-dose aspirin can contribute to epistaxis.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs like ibuprofen and naproxen, while having antiplatelet effects, also can irritate the gastrointestinal mucosa, and their impact on epistaxis risk is less pronounced than anticoagulants and antiplatelets but should still be considered.
• Topical Nasal Steroid Sprays: While intended to reduce nasal inflammation, overuse or improper technique with nasal steroid sprays can cause mucosal dryness, irritation, and septal perforation in rare cases, leading to epistaxis.
• Supplements and Alternative Medications: Certain supplements like vitamin E, ginkgo biloba, and ginseng can have anticoagulant or antiplatelet effects, increasing bleeding risk. Patients should be questioned about supplement use.
• Illicit Drugs: Cocaine use, particularly intranasal, is a well-known cause of epistaxis. Cocaine is a vasoconstrictor, but chronic use can cause mucosal damage, ulceration, and septal perforation, leading to significant nosebleeds.

Differential Diagnosis: Distinguishing Epistaxis from Other Conditions

While epistaxis is usually straightforward to identify as bleeding from the nose, a differential diagnosis is crucial to rule out less common but potentially serious underlying conditions, particularly when epistaxis is recurrent, severe, or associated with atypical symptoms. It is important to differentiate epistaxis from other conditions that may mimic or exacerbate nosebleeds.

• Nasal Tumors: Benign or malignant tumors of the nasal cavity and paranasal sinuses can present with unilateral epistaxis, nasal obstruction, pain, facial swelling, or cranial nerve deficits. These are less common causes of epistaxis, but should be considered, especially in cases of persistent unilateral bleeding or when accompanied by other nasal symptoms. Key differentiating features: Unilateral presentation, nasal obstruction, pain, persistent bleeding despite usual management, imaging (CT/MRI) required for diagnosis.

• Hereditary Hemorrhagic Telangiectasia (HHT): As mentioned previously, HHT is a genetic disorder causing abnormal blood vessel formation (telangiectasias) throughout the body, commonly in the nasal mucosa. Patients with HHT often experience recurrent and severe epistaxis starting from a young age. Key differentiating features: Family history of HHT, mucocutaneous telangiectasias (lips, tongue, fingers), recurrent epistaxis since childhood, genetic testing and clinical criteria for diagnosis.

• Disseminated Intravascular Coagulation (DIC): DIC is a serious condition characterized by widespread activation of the coagulation system, leading to depletion of clotting factors and platelets, and paradoxically, both thrombosis and bleeding. Epistaxis can be a manifestation of DIC, often accompanied by bleeding from other sites (gums, IV sites, etc.) and signs of underlying critical illness (sepsis, trauma, malignancy). Key differentiating features: Bleeding from multiple sites, signs of systemic illness, abnormal coagulation studies (PT, PTT, fibrinogen, platelets), requires urgent management of underlying condition.

• Von Willebrand Disease (vWD) and Hemophilia: These inherited bleeding disorders impair specific clotting factors. vWD is the most common inherited bleeding disorder and can present with mucocutaneous bleeding, including epistaxis, easy bruising, and heavy menstrual bleeding in women. Hemophilia A and B are less common but more severe, typically presenting with joint and muscle bleeds, but epistaxis can also occur. Key differentiating features: Family history of bleeding disorders, prolonged bleeding time or specific factor deficiencies on lab testing, bleeding disproportionate to the injury.

• Rhinitis (Infectious or Allergic): While rhinitis is a common cause of epistaxis due to mucosal inflammation and increased vascularity, it is important to differentiate it from other causes of nosebleeds in patients presenting with nasal congestion, rhinorrhea, and sneezing. Epistaxis in rhinitis is usually mild and resolves with treatment of the underlying rhinitis. Key differentiating features: Associated symptoms of nasal congestion, sneezing, rhinorrhea, often bilateral epistaxis, improves with rhinitis management.

• Foreign Body in the Nose: Particularly in children, a foreign body in the nasal cavity can cause unilateral purulent nasal discharge, foul odor, and sometimes epistaxis. Key differentiating features: Unilateral purulent discharge, foul odor, history of foreign body insertion (in children), visualization of foreign body on nasal examination.

• Drug Toxicity (Anticoagulants, Antiplatelets, NSAIDs): As discussed in etiology, medication-induced epistaxis is common. It’s crucial to consider medication history in all patients with epistaxis. Key differentiating features: Temporal relationship to medication initiation or dose increase, improvement with medication adjustment or reversal (if possible), medication history is key.

• Factitious Epistaxis: In rare cases, epistaxis may be self-induced, particularly in patients with psychological issues or Munchausen syndrome. This should be considered in cases of unexplained, recurrent epistaxis, especially if there are inconsistencies in the history or clinical presentation. Key differentiating features: Inconsistencies in history, lack of identifiable cause, potential psychological factors, often a diagnosis of exclusion after ruling out organic causes.

Evaluation and Diagnostic Approach

A systematic approach to evaluating epistaxis is crucial for accurate diagnosis and effective management. The initial evaluation focuses on assessing the severity of bleeding, identifying the bleeding site (anterior vs. posterior), and obtaining a detailed history.

History Taking: Key Information for Differential Diagnosis

A thorough history is paramount in narrowing down the differential diagnosis for epistaxis. Key aspects to inquire about include:

• Bleeding History: Duration, frequency, severity, laterality (unilateral or bilateral), triggers, prior episodes, previous treatments and their effectiveness.
• Medical History: Hypertension, bleeding disorders, liver disease, kidney disease, vascular diseases, recent infections, allergies, nasal surgeries, neoplasms.
• Medication History: Anticoagulants, antiplatelets, NSAIDs, topical nasal steroids, supplements, illicit drug use (cocaine).
• Family History: Bleeding disorders (vWD, hemophilia, HHT), hypertension.
• Associated Symptoms: Nasal obstruction, pain, facial swelling, headache, visual changes, cranial nerve deficits, systemic symptoms (fever, weight loss, fatigue).

Physical Examination: Identifying Clues

A focused physical examination, including a thorough nasal examination, is essential.

• General Examination: Assess vital signs (blood pressure, heart rate), signs of hemodynamic instability, pallor, bruising, mucocutaneous telangiectasias.
• Nasal Examination:
  • Anterior Rhinoscopy: Using a nasal speculum and headlight, visualize the nasal septum and anterior nasal cavity to identify the bleeding site. Suction may be needed to remove clots and improve visualization.
  • Posterior Pharynx Examination: Assess for active bleeding into the posterior pharynx, suggesting a posterior bleed.
  • Nasal Endoscopy: If anterior rhinoscopy is inconclusive or posterior bleed is suspected, nasal endoscopy provides a more detailed view of the nasal cavity and nasopharynx, aiding in identifying the bleeding source and ruling out tumors or other structural abnormalities.

Investigations: Guiding the Differential Diagnosis

Laboratory and imaging investigations are selectively used to support the differential diagnosis, particularly when systemic causes or underlying structural lesions are suspected.

• Laboratory Tests:
  • Complete Blood Count (CBC): Assess hemoglobin, hematocrit, and platelet count. May be indicated in severe or recurrent epistaxis, or suspicion of underlying hematologic disorder.
  • Coagulation Studies (PT, PTT, INR, Fibrinogen): Indicated in patients with suspected coagulopathies, medication-induced bleeding, liver disease, or DIC.
  • Von Willebrand Factor Studies: If vWD is suspected based on history or clinical presentation.
  • Type and Crossmatch: In cases of significant blood loss or anticipated surgical intervention.
• Imaging Studies:
  • CT Scan of Paranasal Sinuses: Indicated if nasal tumor, sinusitis, or structural abnormality is suspected, especially with unilateral symptoms, pain, or persistent epistaxis.
  • MRI of Paranasal Sinuses: May be preferred for soft tissue detail when tumor or vascular malformation is high in the differential.

Management Based on Differential Diagnosis

Management of epistaxis is initially focused on controlling the acute bleeding episode. However, addressing the underlying cause is crucial for preventing recurrence and managing associated conditions.

• Initial Management (All Epistaxis): Direct pressure, topical vasoconstrictors (oxymetazoline), cautery (silver nitrate), nasal packing (anterior or posterior as needed).
• Specific Management based on Differential:
  • Medication-Induced: Adjust or discontinue offending medications if possible, reverse anticoagulation if necessary and safe.
  • Hypertension: Blood pressure control.
  • Coagulopathies: Management of underlying bleeding disorder, factor replacement if needed.
  • HHT: Humidification, topical treatments, laser cautery, septodermoplasty, systemic therapies (anti-angiogenics in severe cases), genetic counseling.
  • Nasal Tumors: Biopsy, surgical excision, radiation therapy, chemotherapy depending on tumor type and stage.
  • Rhinitis: Management of allergic or infectious rhinitis with topical nasal steroids, antihistamines, saline irrigation, antibiotics if bacterial infection.
  • Foreign Body: Removal of foreign body.

Conclusion: A Comprehensive Approach to Epistaxis

Epistaxis is a common presentation with a broad differential diagnosis ranging from benign local causes to serious systemic conditions. A thorough history, physical examination, and selective investigations are essential for accurate diagnosis and effective management. Clinicians must consider the various etiologies to guide treatment, prevent recurrence, and address any underlying systemic diseases. Interprofessional collaboration, including primary care physicians, emergency medicine physicians, otolaryngologists, hematologists, and radiologists, is often crucial for optimal patient care, particularly in complex or recurrent cases of epistaxis. By systematically considering the differential diagnoses, clinicians can provide comprehensive and patient-centered care, improving outcomes and quality of life for individuals experiencing epistaxis.

References

1.Fishman J, Fisher E, Hussain M. Epistaxis audit revisited. J Laryngol Otol. 2018 Dec;132(12):1045. [PubMed: 30674370]

2.Send T, Bertlich M, Eichhorn KW, Ganschow R, Schafigh D, Horlbeck F, Bootz F, Jakob M. Etiology, Management, and Outcome of Pediatric Epistaxis. Pediatr Emerg Care. 2021 Sep 01;37(9):466-470. [PubMed: 30624421]

3.Kitamura T, Takenaka Y, Takeda K, Oya R, Ashida N, Shimizu K, Takemura K, Yamamoto Y, Uno A. Sphenopalatine artery surgery for refractory idiopathic epistaxis: Systematic review and meta-analysis. Laryngoscope. 2019 Aug;129(8):1731-1736. [PubMed: 30613985]

4.INTEGRATE (UK National ENT research trainee network) on its behalf: Mehta N, Stevens K, Smith ME, Williams RJ, Ellis M, Hardman JC, Hopkins C. National prospective observational study of inpatient management of adults with epistaxis – a National Trainee Research Collaborative delivered investigation. Rhinology. 2019 Jun 01;57(3):180-189. [PubMed: 30610832]

5.Clark M, Berry P, Martin S, Harris N, Sprecher D, Olitsky S, Hoag JB. Nosebleeds in hereditary hemorrhagic telangiectasia: Development of a patient-completed daily eDiary. Laryngoscope Investig Otolaryngol. 2018 Dec;3(6):439-445. [PMC free article: PMC6302722] [PubMed: 30599027]

6.Ramasamy V, Nadarajah S. The hazards of impacted alkaline battery in the nose. J Family Med Prim Care. 2018 Sep-Oct;7(5):1083-1085. [PMC free article: PMC6259556] [PubMed: 30598962]

7.Joseph J, Martinez-Devesa P, Bellorini J, Burton MJ. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018 Dec 31;12(12):CD004328. [PMC free article: PMC6517002] [PubMed: 30596479]

8.Wong AS, Anat DS. Epistaxis: A guide to assessment and management. J Fam Pract. 2018 Dec;67(12):E13-E20. [PubMed: 30566119]

9.Santander MJ, Rosenbaum A, Winter M. Topical tranexamic acid for spontaneous epistaxis. Medwave. 2018 Dec 10;18(8):e7372. [PubMed: 30550535]