Epistaxis Diagnosis and Management

Local Nasal Causes

The American Academy of Otolaryngology-Head and Neck Surgery states that the most common causes of epistaxis are local nasal factors, particularly anterior septal bleeding from Kiesselbach's plexus, which accounts for the majority of cases 1
Digital trauma (nose-picking) and forceful nose-blowing are associated with epistaxis 2
Intranasal drug use (cocaine, nasal sprays) can cause mucosal damage and lead to epistaxis 3, 4
Recent nasal trauma or surgery can also cause epistaxis 1
Septal deviation or perforation can contribute to epistaxis 1
Nasal or nasopharyngeal tumors (must be excluded, particularly in unilateral recurrent bleeding) can cause epistaxis 5
Vascular malformations of the head and neck can also lead to epistaxis 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends considering anticoagulant medications (warfarin, DOACs, heparin) as a potential cause of epistaxis 3, 4
Antiplatelet agents (aspirin, clopidogrel) can also contribute to epistaxis 3, 4
Hereditary bleeding disorders (hemophilia, von Willebrand disease) can increase the risk of epistaxis 3
Acquired coagulopathy (liver disease, vitamin K deficiency) can also lead to epistaxis 1

Elderly patients are at higher risk of complications requiring hospitalization due to epistaxis 5

The American Academy of Otolaryngology-Head and Neck Surgery suggests documenting personal or family history of bleeding disorders, current anticoagulant or antiplatelet medication use, intranasal drug use, frequency, duration, and severity of bleeding episodes, and unilateral versus bilateral bleeding pattern at initial contact 3, 4
Nasal endoscopy should be performed when bleeding is difficult to control with first-line measures, concern exists for unrecognized pathology (tumor, vascular malformation), or patient has recurrent bleeding despite prior packing or cautery 4

Unilateral recurrent bleeding should not be overlooked, as it may indicate neoplasm and requires endoscopic evaluation 5, 4
Hereditary Hemorrhagic Telangiectasia (HHT) should not be missed in patients with recurrent bilateral epistaxis and family history, as this requires specialized management 4, 2
Anticoagulation should not be immediately discontinued; instead, first-line treatments should be initiated before considering medication adjustments 4, 6