Epistaxis

Probability diagnosis

Idiopathic: spontaneous from Little’s area

URTI: common cold/flu/sinusitis

Rhinitis: allergic and atrophic

Vestibulitis

Trauma (incl. nose picking, nose injury)

Drugs (e.g. anticoagulants, aspirin)

Serious disorders not to be missed

Vascular:

• hypertension and arteriosclerosis

Infection:

• systemic febrile illness (e.g. malaria)

• HIV/AIDS

Cancer/neoplasia:

• tumours of nose/sinuses/nasopharynx

• intracranial tumours

• leukaemia

Other:

• thrombocytopenia

• coagulopathy (e.g. haemophilia, liver disease)

Pitfalls (often missed)

Exposure to toxic agents

Vitamin deficiencies: C and K

Septal granulomas and perforations

Foreign bodies (esp. in children)

Cocaine abuse

Rarities:

• hereditary haemorrhagic telangiectasia

Masquerades checklist

Drugs: anticoagulants, aspirin, nasal sprays Anaemia: aplastic anaemia

Key history

Recent trauma to nose. Significant past history (e.g. hypertension). Drug and alcohol history (e.g. anticoagulants). Bleeding or bruising tendency.

Key examination

• Nasal airways and sinuses

• Skin for evidence of purpura or ecchymoses

• Lymph node areas and abdomen for hepatosplenomegaly

• Vital signs (esp. blood pressure)

Key investigations

Probably none. Consider:

• FBE

• clotting studies

• sinus X-ray

• INR

• CT scan (occasionally).

Diagnostic tips

• Recent onset of persistent bleeding in elderly points to carcinoma.

• Severe epistaxis is often caused by liver disease coagulopathy.

• Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.