A. Causes of Epistaxis

1. Trauma
   1. Excessive nose blowing and sneezing
   2. Fracture
   3. Intubation
   4. Nose Picking
   5. Surgery
2. Dessication (Dryness)
   1. Cold Air and Dry Heat
   2. Nasal Oxygen Therapy
   3. Nasal Sprays
   4. Septal Deviation / Perforation
3. Inflammation
   1. Allergies - usually with rhinorrhea
   2. Infection - sinusitis, upper respiratory
4. Anticoagulant Medication
   1. Non-steroidal anti-inflammatory drugs (NSAIDs)
   2. Aspirin
   3. Warfarin
   4. Heparin
5. Coagulopathy
   1. Alcoholism
   2. Liver Disease
   3. Chronic Renal Failure
   4. Hemophilia and von-Willebrand's Disease
   5. Diabetes Mellitus
   6. Disseminated Intravascular Coagulopathy (DIC)
6. Nasal Septal Disease
   1. AIDS
   2. Cocaine Abuse - septal ulceration
   3. Wegener's Granulomatosis
   4. Sarcoidosis
   5. Tuberculosis
   6. Syphilis
   7. Relapsing Polychondritis
7. Blood Dyscrasia
   1. Leukemia
   2. Multiple Myeloma
   3. Thrombocytopenia
8. Neoplasm
   1. Benign - angiofibroma, inverting papilloma
   2. Malignant - adenocarcinoma, neuroblastoma, lymphoma, melanoma, squamous cell Ca
9. Anatomic
   1. Nasal Polyps
   2. Hereditary Hemorrhagic Telangiectasia

B. Evaluation of Epistaxis

1. Use topical anesthetic
   1. Lidocaine with vasoconstrictor, eg. oxymetazoline or epinephrine
   2. Local cocaine application may also be effective
2. Visible bleeding site - anterior epistaxis
3. No visible bleeding site - posterior epistaxis
4. Pinching nose stops bleeding suggests septal bleeding site
5. Evaluation for underling disease (see above)

C. Anterior Epistaxis

1. Most common type
2. Usually unilateral, often from Kiesselbach's plexus
3. This plexus derives primarily from anterior ethmoidal artery
4. Usually treat with cauterization, typically using silver nitrate sticks

D. Posterior Epistaxis

1. Bilateral Epistaxis and/or nasopharyngeal bleeding most common
2. More difficult to control requiring posterior packing
3. Almost always associated with hypertension or coagulopathy
4. Otolaryngologist referral usually indicated (may use rigid nasal endoscope)

E. Management

1. Head back with nasal pinching
2. Ice on nasal area
3. Application of topical vasoconstrictor - eg. oxymetazoline
4. Application of anterior or posterior packing
   1. Usual duration is 3-5 days
   2. Antibiotic coverage for S. aureus recommended since sinus ostia are blocked
5. Silver nitrate cauterization (usually for anterior or septal bleeding site)
6. Most repeat bleeding after packing should be referred
   1. Full otolaryngologic evaluation
   2. Nasal endoscopy to rule out tumor, etc.
7. Consider stool softeners to limit straining
8. Address underlying cause

F. Severe Intractable Epistaxis

1. Coagulopathy must be ruled out
2. Otolaryngologic referral for nasal endoscopy
   1. Rule out tumor
   2. Osler-Weber-Rendu
3. Options
   1. Operative endoscopic cautery of bleeding site
   2. Operative ligation of the internal maxillary and/or anterior ethmoid arteries
   3. Endovascular embolization of vessels

G. Prevention

1. No nose picking
2. Hospitalized patients should receive oxygen by tent or humidified mask, not nasal canula
3. Vaseline gently applied to anterior nasal septum as protectant
4. Household humidifiers