Epistaxis

What it is

Epistaxis is bleeding from the nose, and it divides by site. Anterior epistaxis is about 90% of cases and arises from the Kiesselbach plexus, in the Little area, an anastomosis of four arteries in the anteroinferior portion of the nasal septum: the anterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries, held by the mnemonic GASS. Posterior epistaxis is about 10% of cases and arises from the Woodruff plexus, a collection of arteries in the posteroinferior region of the lateral nasal cavity. The Woodruff plexus is formed by anastomoses of the sphenopalatine artery, a branch of the maxillary artery, and the pharyngeal artery, and the mnemonic PAS names three arteries in it: the posterior nasal, the ascending pharyngeal and the sphenopalatine.

Causes and risk

The local causes are idiopathic bleeding; trauma such as nose picking, facial injury or a foreign body; inflammation, whether infection, allergic or polyps; iatrogenic causes such as surgery and interventions in the nasal apparatus with an NGT or endoscopy; topical drugs, nasal sprays such as decongestants and steroids, and cocaine abuse; nasal dryness, barometric changes, septal perforation and chemicals such as ammonia; vascular causes, congenital as in HHT or acquired; and neoplasia, benign such as juvenile angiofibroma or malignant such as SCC.

The systemic causes are bleeding disorders and coagulopathies, thrombocytopenia and platelet dysfunction, anticoagulants and antiplatelets, liver failure, uremia or cirrhosis, hypertension and atherosclerotic disease, SLE, and environmental temperature, humidity and altitude. Anterior bleeding is usual in children under 10 years of age, and the causes listed with it are trauma or epistaxis digitorum, summer/winter syndrome, allergies, irritants such as cocaine and chronic use of nasal sprays, and pregnancy; posterior bleeding is usual over 50 years of age, where coagulopathy, atherosclerosis and neoplasm weigh more.