**3. Causes of epistaxis**

The causes of the epistaxis cannot be found in 80 to 90% of patients. It is easy to injure nasal mucosa and generate epistaxis, as it is rich with blood vessels just underneath mucosa. A number of factors and conditions contribute to the development, severity and recurrence of epistaxis. (Table 1)

Epistaxis 27

Local causes Trauma

> Digital Nose blowing

Blunt Penetrating Iatrogenic

Inflammation Rhinitis Sinusitis

Tumors

Benign

Malignant

Systemic causes

Hypertension Cogulopathy

> Hemophilia Thrombocytopenia Renal failure

Cancer chemotherapy Medication-related Aspirin Coumadin Heparin

Hereditary Hemorrhagic Telangiectasia

Especially in children or patients with mental problem, finger manipulation of the nose is an almost ubiquitous behavior. Continuous mechanical trauma to the nasal mucosa can lead to mucosal abrasion and, eventually, ulceration. This initially leads to a small amount of blood that merely coats the ulceration, leading to a fibrous clot that dries into scab formation.

Age

Table 1. Causes of Epistaxis.

**3.1 Local causes 3.1.1 Trauma** 

Chronic irritation Mucosal dehydration Deviated septum Arid environment

> Autoimmune disorders Environmental irritants

> > Inverted papilloma

 Nasopharyngeal carcinoma Esthesioneuroblastoma

Juvenile nasopharyngeal angiofibroma

Fig. 1. Blood supply of nasal septum showing Kiesselbach area. (Cho, 2009 )

Fig. 2. Blood supply of lateral nasal wall showing Woodruff area. (Cho, 2009 )

Fig. 1. Blood supply of nasal septum showing Kiesselbach area. (Cho, 2009 )

Fig. 2. Blood supply of lateral nasal wall showing Woodruff area. (Cho, 2009 )


Table 1. Causes of Epistaxis.

#### **3.1 Local causes**

#### **3.1.1 Trauma**

Especially in children or patients with mental problem, finger manipulation of the nose is an almost ubiquitous behavior. Continuous mechanical trauma to the nasal mucosa can lead to mucosal abrasion and, eventually, ulceration. This initially leads to a small amount of blood that merely coats the ulceration, leading to a fibrous clot that dries into scab formation.

Epistaxis 29

In elderly, changes in vessel wall, especially in arterial wall fibrosis, are related with epistaxis. In children, previously mentioned mechanical trauma, nasal foreign body and

Hypertension and epistaxis commonly occur simultaneously among adults of general population. It is uncertain whether the hypertension is an etiologic factor in all of these patients. It is known that hypertension in epistaxis patients is caused by anxiety. However, one study that analyzed 200 epistaxis patients reported that 75% showed elevated blood pressure

Elevated blood pressure can contribute to epistaxis in two different ways. First, the high pressure causes chronic damage of a blood vessel wall in the nasal or sinus mucosa. Second, 20% of epistaxis patients experience elevated blood pressure because the natural response to seeing blood from one's nose is to get agitated, which can directly lead to elevation of the blood pressure. Practically, active bleeding patients in emergency department were related to hypertension and patients without active nasal bleeding had less related to hypertension.

Coagulopathy leads to unwanted bleeding due to the absence or inactivity of one of the clotting factors. These conditions are rare, but affected patients tend to have severe nosebleeds from an early age. There are also patients with inherent disorders of platelet function. Conditions such as hemophilia, von Willebrand disease, thrombocytopenia, AIDS or liver disease can often cause epistaxis. And among them, von Willebrand disease is most common. Patients with chronic renal failure commonly have problems with epistaxis. This is due to the two-prolonged problem of regularly receiving heparin during dialysis and having poor clotting secondary to the renal failure. In these patients, epistaxis tends to occur either while the patient is undergoing dialysis or shortly after the dialysis. Patients with septic shock develop a condition of poor clotting that may progress to disseminated intravascular coagulation (DIC). This starts out as uncontrolled clotting of the blood within the vascular system and progresses to a coagulopathy secondary to consumption of all available clotting

Finally, there are patients who acquire clotting deficiencies as a result of cancer therapy. This may occur secondary to high-dose chemotherapy, leading to transient decrease in the platelet count. Alternatively, the coagulopathy may be caused by depletion of bone marrow reserves of platelets due to bone marrow transplant. In both of these cases,

There are several medications that interfere normal blood clotting process, for example, warfarin, heparin and nonsteroid anti-inflammatory drugs(NSAIDs). Most commonly used

thrombocytopenia becomes a clinical reality and epistaxis may result.

during nose bleeding and 30% was severe hypertension patients. (Herkner et al., 2000)

**3.2 Systemic causes** 

**3.2.2 Hypertension** 

**3.2.3 Coagulopathy** 

factors.

**3.2.4 Medications** 

nasal mucosal inflammation are the causes of epistaxis.

**3.2.1 Age** 

Removal of the scab causes further injury to the mucosa, which can result in more significant bleeding.

It is possible to cause rupture of superficial vessels of the mucosa by violent nose blowing. Nose blowing is an especially prominent source of trauma in patients who have undergone recent surgery on the nose or sinuses or who have preexisting bleeding sites.

The trauma may be in the form of blunt trauma to the nose or sinuses as a result of traffic accident or during sports, resulting in fracture of the septum, lateral wall, or one of the sinuses. The fracture leads to disruption of the mucosal lining, tearing of blood vessels, and bleeding.

Chronic irritation of nasal mucosa can also cause epistaxis. For example, nasal abuse of cocaine, nasal smoke or misuse of nasal spray can cause nasal irritation and dehydration which can lead to epistaxis or even septal perforation.

#### **3.1.2 Dehydration**

Drying of the nasal mucosa is one of the common factors contributing to epistaxis. The possibility of epistaxis increases when the nasal humidifying function falls as the nasal secretion decreases, or when nasal mucosa expose to the cold, dry environmental air as a seasonal factor. Also, when the septum is significantly deviated, or when nasal airway is altered as a result of surgery, there can be an abnormally high airflow that are no longer able to humidify the air adequately and as a result, epistaxis can occur.

Number of epistaxis patients who visit emergency department increases as temperature and humidity decrease. Also, the number of patients who admit to hospital increases in winter. Comparing in-patients number with air temperature, admission increases 30% in days with average temperature under 5°C than days with average temperature over 5°C. (Viducich et al., 1995)

#### **3.1.3 Inflammation**

Inflammatory conditions such as acute upper respiratory infection, allergic rhinitis, sinusitis and nasal foreign bodies can often lead to nasal bleeding. Nasal decongestant or intranasal steroid spray also can cause nasal dryness and epistaxis. Any factors that cause nasal inflammation can make the mucosa more fragile and make patients to blow the nose more frequently, weak vessels can be damaged easily. Nasal granulomatous diseases such as Wegener's granulomatosis, sarcoidosis, nasal tuberculosis and nasal syphilis lead to mucosal ulceration or extreme inflammation that may predispose the patient to crusting, abrasion, and eventually, bleeding.

#### **3.1.4 Tumors and aneurysms**

Juvenile nasopharyngeal angiofibroma classically presents as recurrent epistaxis in adolescents or young adult men, malignant tumors such as malignant melanoma and squamous cell carcinoma present as unilateral nasal stuffiness with epistaxis in adults. Intracavernous aneurysm of internal carotid artery after trauma can cause severe epistaxis. This posttraumatic aneurysm occurs about 7 weeks after trauma, and mortality rate reaches 50%.

Removal of the scab causes further injury to the mucosa, which can result in more

It is possible to cause rupture of superficial vessels of the mucosa by violent nose blowing. Nose blowing is an especially prominent source of trauma in patients who have undergone

The trauma may be in the form of blunt trauma to the nose or sinuses as a result of traffic accident or during sports, resulting in fracture of the septum, lateral wall, or one of the sinuses. The fracture leads to disruption of the mucosal lining, tearing of blood vessels, and

Chronic irritation of nasal mucosa can also cause epistaxis. For example, nasal abuse of cocaine, nasal smoke or misuse of nasal spray can cause nasal irritation and dehydration

Drying of the nasal mucosa is one of the common factors contributing to epistaxis. The possibility of epistaxis increases when the nasal humidifying function falls as the nasal secretion decreases, or when nasal mucosa expose to the cold, dry environmental air as a seasonal factor. Also, when the septum is significantly deviated, or when nasal airway is altered as a result of surgery, there can be an abnormally high airflow that are no longer able

Number of epistaxis patients who visit emergency department increases as temperature and humidity decrease. Also, the number of patients who admit to hospital increases in winter. Comparing in-patients number with air temperature, admission increases 30% in days with average temperature under 5°C than days with average temperature over 5°C. (Viducich et

Inflammatory conditions such as acute upper respiratory infection, allergic rhinitis, sinusitis and nasal foreign bodies can often lead to nasal bleeding. Nasal decongestant or intranasal steroid spray also can cause nasal dryness and epistaxis. Any factors that cause nasal inflammation can make the mucosa more fragile and make patients to blow the nose more frequently, weak vessels can be damaged easily. Nasal granulomatous diseases such as Wegener's granulomatosis, sarcoidosis, nasal tuberculosis and nasal syphilis lead to mucosal ulceration or extreme inflammation that may predispose the patient to crusting,

Juvenile nasopharyngeal angiofibroma classically presents as recurrent epistaxis in adolescents or young adult men, malignant tumors such as malignant melanoma and squamous cell carcinoma present as unilateral nasal stuffiness with epistaxis in adults. Intracavernous aneurysm of internal carotid artery after trauma can cause severe epistaxis. This posttraumatic aneurysm occurs about 7 weeks after trauma, and mortality rate reaches

recent surgery on the nose or sinuses or who have preexisting bleeding sites.

which can lead to epistaxis or even septal perforation.

to humidify the air adequately and as a result, epistaxis can occur.

significant bleeding.

bleeding.

al., 1995)

50%.

**3.1.3 Inflammation** 

abrasion, and eventually, bleeding.

**3.1.4 Tumors and aneurysms** 

**3.1.2 Dehydration** 

#### **3.2 Systemic causes**

#### **3.2.1 Age**

In elderly, changes in vessel wall, especially in arterial wall fibrosis, are related with epistaxis. In children, previously mentioned mechanical trauma, nasal foreign body and nasal mucosal inflammation are the causes of epistaxis.

#### **3.2.2 Hypertension**

Hypertension and epistaxis commonly occur simultaneously among adults of general population. It is uncertain whether the hypertension is an etiologic factor in all of these patients. It is known that hypertension in epistaxis patients is caused by anxiety. However, one study that analyzed 200 epistaxis patients reported that 75% showed elevated blood pressure during nose bleeding and 30% was severe hypertension patients. (Herkner et al., 2000)

Elevated blood pressure can contribute to epistaxis in two different ways. First, the high pressure causes chronic damage of a blood vessel wall in the nasal or sinus mucosa. Second, 20% of epistaxis patients experience elevated blood pressure because the natural response to seeing blood from one's nose is to get agitated, which can directly lead to elevation of the blood pressure. Practically, active bleeding patients in emergency department were related to hypertension and patients without active nasal bleeding had less related to hypertension.

## **3.2.3 Coagulopathy**

Coagulopathy leads to unwanted bleeding due to the absence or inactivity of one of the clotting factors. These conditions are rare, but affected patients tend to have severe nosebleeds from an early age. There are also patients with inherent disorders of platelet function. Conditions such as hemophilia, von Willebrand disease, thrombocytopenia, AIDS or liver disease can often cause epistaxis. And among them, von Willebrand disease is most common.

Patients with chronic renal failure commonly have problems with epistaxis. This is due to the two-prolonged problem of regularly receiving heparin during dialysis and having poor clotting secondary to the renal failure. In these patients, epistaxis tends to occur either while the patient is undergoing dialysis or shortly after the dialysis. Patients with septic shock develop a condition of poor clotting that may progress to disseminated intravascular coagulation (DIC). This starts out as uncontrolled clotting of the blood within the vascular system and progresses to a coagulopathy secondary to consumption of all available clotting factors.

Finally, there are patients who acquire clotting deficiencies as a result of cancer therapy. This may occur secondary to high-dose chemotherapy, leading to transient decrease in the platelet count. Alternatively, the coagulopathy may be caused by depletion of bone marrow reserves of platelets due to bone marrow transplant. In both of these cases, thrombocytopenia becomes a clinical reality and epistaxis may result.

#### **3.2.4 Medications**

There are several medications that interfere normal blood clotting process, for example, warfarin, heparin and nonsteroid anti-inflammatory drugs(NSAIDs). Most commonly used

Epistaxis 31

After stabilize the patient, the initial examination of the nose should be performed to find the origin site by anterior rhinoscopy after removal of the blood clot and minimize the edema using decongestant, using adequate light source to visualize whole nasal cavity. If the bleeding has stopped after the removal of clots, additional immediate treatment is not needed. Packing of the nasal cavity without evidence of continuous bleeding can damage the nasal mucosa and cause epistaxis rather than stopping it. The most likely finding is a superficial vessel that has eroded on anterior nasal septum, or medial portion of the turbinate in patients with no specific cause, so special cautions are needed in those parts of

In cases of either acute or recurrent epistaxis without an obvious bleeding source on anterior rhinoscopy, an endoscopic examination is indicated to attempt to identify the site. This is usually performed bilaterally and with thorough decongestion and topical anesthesia. Either a flexible or rigid endoscope can be used. The flexible scope is perhaps easier to use and less uncomfortable. However, the rigid scopes have superior optics, with better image resolution

Routine radiologic studies have little role in the initial diagnosis of epistaxis. However, in patients with recurrent epistaxis without a known source or cause, imaging studies have important role in diagnosis. The imaging study of choice for initial evaluation of most nasal or sinus pathologic conditions, including epistaxis, is the CT scan and tumors that cause

It is important to evaluate epistaxis patients thoroughly because the method of controlling epistaxis depends largely on the specifics of an individual case, with an entire menu of

Anterior flexion of head can prevent nausea or airway obstruction, as blood does not flow back to pharynx. It is important to keep the blood pressure low and keep the airway clean. Also, fluid replacement can be considered according to the amount of blood loss. Systemic diseases can cause multiple bleeding sites or frequent recurrent epistaxis so blood testing should be performed in patients with those findings. Patients with posterior epistaxis, coagulopathy, coronary artery disease, uncontrolled hypertension, severe anemia or old age

On the first visit of a patient with minimal or moderate history of nasal bleeding, an empiric trial of medical therapy is advised. This includes several measures designed to increase humidification of the mucosa to allow the bleeding site to heal. This approach is based on the assumption that dryness is one of the most important factors causing epistaxis. The

**4.2 Physical examination** 

the nose.

**4.3 Endoscopy** 

and are easy to use instruments.

**4.4 Radiologic evaluation** 

epistaxis are often found.

options available. (Table 2)

**5.1 Medical treatment** 

should be considered to treat as in-patient basis.

**5. Management** 

medication is NSAIDs, including aspirin. Aspirin, by inhibiting the enzyme cyclooxygenase, interferes with platelet function. This results in significant increases in bleeding time, but should not increase the incidence of nosebleeds. Millions of patients are currently taking a regular dose of aspirin, as prescribed by their doctors, for prevention of stroke, heart attack, and clotting in prosthetic arteries. For this reason, aspirin use is becoming an increasingly important risk factor for epistaxis in adults.

#### **3.2.5 Hereditary hemorrhagic telangiectasia**

Hereditary hemorrhagic telangiectasia (HHT), also known as *Rendu-Osler-Weber disease*, is a rare systemic fibrovascular dysplasia with autosomal dominant inheritance. Multiple telangiectasic vascular malformations can be seen on the skin and in the mucosa of the digestive tract and respiratory airways. 20% of patients have family history and the incidence is 1~2 per 100,000. Several elevated small cherry red spots in lip and oral cavity mucosa can be seen and they become pale when pressed. Dilatation of arterioles under basement membrane is referred to as telangiectasia, and these arterioles can easily be damaged as they do not have elastic tissue under endothelial layer. If the patient is diagnosed of HHT, arteriovenous malformation should be checked in other organs. Other manifestations of the disease occur in the internal organs such as the lungs, liver, or the central nervous system. It is estimated that at least 30% of HHT patients have pulmonary, 30% hepatic, and 10–20% cerebral involvement. (Guttmacher et al., 1995)

Diagnosis is made according to the Curaçao Criteria: telangiectasia on the face, hands and in oral cavity, recurrent epistaxis, arteriovenous malformations with visceral involvement, family history. Diagnosis is confirmed upon the presence of at least three of these manifestations. HHT is an uncommon cause of epistaxis, but an important cause owing to the severity of the condition and the special measures required for treatment. In any patient with recurrent epistaxis, a careful examination of the mucosal surfaces in the nose should be performed to rule out HHT lesions. The presence of three or more suggestive vascular lesions should alert the physician to the possibility that the patient may have HHT. (Fuchizaki et al., 2003)

#### **4. Diagnosis**

When the patient with epistaxis initially presents for treatment, it is important to perform a systematic evaluation. One may be tempted to proceed directly to managing the patient's symptoms without performing a careful history and physical examination. Indeed, in cases of heavy bleeding, this may be necessary. For most patients, nose with Neo-Synephrinesoaked cotton pledgets, should control the bleeding sufficiently to allow the physician to perform a proper evaluation before initiating definitive treatment.

#### **4.1 History**

During the initial inquiry, it is important to investigate the duration of bleeding, frequency of bleeding, and amount of bleeding. If not in an emergency situation, it is also important to determine the side of the bleeding and its primary site of origin and flow: out the front of the nose, down the back of the nose or a combination of the two. It may be possible during history taking to elicit information that will provide clues to the underlying cause of the bleeding, such as trauma, surgery, history of coagulopathy or medication history.

medication is NSAIDs, including aspirin. Aspirin, by inhibiting the enzyme cyclooxygenase, interferes with platelet function. This results in significant increases in bleeding time, but should not increase the incidence of nosebleeds. Millions of patients are currently taking a regular dose of aspirin, as prescribed by their doctors, for prevention of stroke, heart attack, and clotting in prosthetic arteries. For this reason, aspirin use is becoming an increasingly

Hereditary hemorrhagic telangiectasia (HHT), also known as *Rendu-Osler-Weber disease*, is a rare systemic fibrovascular dysplasia with autosomal dominant inheritance. Multiple telangiectasic vascular malformations can be seen on the skin and in the mucosa of the digestive tract and respiratory airways. 20% of patients have family history and the incidence is 1~2 per 100,000. Several elevated small cherry red spots in lip and oral cavity mucosa can be seen and they become pale when pressed. Dilatation of arterioles under basement membrane is referred to as telangiectasia, and these arterioles can easily be damaged as they do not have elastic tissue under endothelial layer. If the patient is diagnosed of HHT, arteriovenous malformation should be checked in other organs. Other manifestations of the disease occur in the internal organs such as the lungs, liver, or the central nervous system. It is estimated that at least 30% of HHT patients have pulmonary,

Diagnosis is made according to the Curaçao Criteria: telangiectasia on the face, hands and in oral cavity, recurrent epistaxis, arteriovenous malformations with visceral involvement, family history. Diagnosis is confirmed upon the presence of at least three of these manifestations. HHT is an uncommon cause of epistaxis, but an important cause owing to the severity of the condition and the special measures required for treatment. In any patient with recurrent epistaxis, a careful examination of the mucosal surfaces in the nose should be performed to rule out HHT lesions. The presence of three or more suggestive vascular lesions should alert

When the patient with epistaxis initially presents for treatment, it is important to perform a systematic evaluation. One may be tempted to proceed directly to managing the patient's symptoms without performing a careful history and physical examination. Indeed, in cases of heavy bleeding, this may be necessary. For most patients, nose with Neo-Synephrinesoaked cotton pledgets, should control the bleeding sufficiently to allow the physician to

During the initial inquiry, it is important to investigate the duration of bleeding, frequency of bleeding, and amount of bleeding. If not in an emergency situation, it is also important to determine the side of the bleeding and its primary site of origin and flow: out the front of the nose, down the back of the nose or a combination of the two. It may be possible during history taking to elicit information that will provide clues to the underlying cause of the

bleeding, such as trauma, surgery, history of coagulopathy or medication history.

the physician to the possibility that the patient may have HHT. (Fuchizaki et al., 2003)

30% hepatic, and 10–20% cerebral involvement. (Guttmacher et al., 1995)

perform a proper evaluation before initiating definitive treatment.

important risk factor for epistaxis in adults.

**4. Diagnosis** 

**4.1 History** 

**3.2.5 Hereditary hemorrhagic telangiectasia** 

#### **4.2 Physical examination**

After stabilize the patient, the initial examination of the nose should be performed to find the origin site by anterior rhinoscopy after removal of the blood clot and minimize the edema using decongestant, using adequate light source to visualize whole nasal cavity. If the bleeding has stopped after the removal of clots, additional immediate treatment is not needed. Packing of the nasal cavity without evidence of continuous bleeding can damage the nasal mucosa and cause epistaxis rather than stopping it. The most likely finding is a superficial vessel that has eroded on anterior nasal septum, or medial portion of the turbinate in patients with no specific cause, so special cautions are needed in those parts of the nose.

#### **4.3 Endoscopy**

In cases of either acute or recurrent epistaxis without an obvious bleeding source on anterior rhinoscopy, an endoscopic examination is indicated to attempt to identify the site. This is usually performed bilaterally and with thorough decongestion and topical anesthesia. Either a flexible or rigid endoscope can be used. The flexible scope is perhaps easier to use and less uncomfortable. However, the rigid scopes have superior optics, with better image resolution and are easy to use instruments.

#### **4.4 Radiologic evaluation**

Routine radiologic studies have little role in the initial diagnosis of epistaxis. However, in patients with recurrent epistaxis without a known source or cause, imaging studies have important role in diagnosis. The imaging study of choice for initial evaluation of most nasal or sinus pathologic conditions, including epistaxis, is the CT scan and tumors that cause epistaxis are often found.
