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For further information, see CMDT Part 8-13: Epistaxis
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Essentials of Diagnosis
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Bleeding from a unilateral anterior nasal cavity along the septum is most common
Most cases can be successfully treated by direct pressure on the bleeding site for 15 minutes
When this is unsuccessful, topical sympathomimetics or various nasal tamponade methods are usually effective
Posterior, bilateral, or large-volume epistaxis should be triaged immediately to a specialist in a critical care setting
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General Considerations
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Anterior nasal cavity bleeding originates from Kiesselbach plexus, a vascular plexus on the anterior nasal septum
Posterior nasal cavity bleeding
Originates from the posterior half of the inferior turbinate or the top of the nasal cavity
More commonly associated with atherosclerotic disease and hypertension
Only 5% of nasal bleeding originates in the posterior nasal cavity
Predisposing factors
Nasal trauma (eg, nose picking, forceful nose blowing, foreign body)
Nasal mucosa drying from low humidity or supplemental nasal oxygen
Allergic or viral rhinitis
Deviation of the nasal septum
Inhaled corticosteroids
Inhaled cocaine use
Excessive alcohol intake
Anticoagulation or antiplatelet medications (eg, aspirin, clopidogrel)
Atherosclerotic disease
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Poorly controlled hypertension is associated with epistaxis
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Differential Diagnosis
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Thrombocytopenia
Immune thrombocytopenia
Thrombotic thrombocytopenic purpura
Hemophilia
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Polycythemia vera
Leukemia
Granulomatosis with polyangiitis
Nasal tumor
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Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays, or oxymetazoline), which act as vasoconstrictors, may help
If a posterior pack is required for > 5 days, administer antistaphylococcal antibiotics to limit possibility of toxic shock syndrome
Cephalexin, 500 mg orally four times daily
Clindamycin, 150 mg orally four times daily
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Ligation of the nasal arterial supply (internal maxillary artery and ethmoid arteries) is indicated when direct pressure and nasal packing fail
Endoscopic sphenopalatine artery ligation
Endovascular epistaxis control
Highly effective (75–92%)
Can address all potential sources of bleeding
However, risk of stroke is 1.1–1.5%
Therefore, may be reserved for cases in which surgery failed
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Therapeutic Procedures
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Anterior nasal bleeding
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