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Key Points

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  • Anterior epistaxis is more common than posterior epistaxis.

  • Anterior epistaxis generally stops with pressure, but may require nasal packing.

  • Posterior epistaxis requires emergent ear, nose, and throat consultation and admission.

  • Any patient who requires nasal packing should be given antibiotics to prevent toxic shock syndrome or sinusitis.

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Introduction

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Epistaxis is common, occurring in 1 of every 7 persons in the United States. The incidence is highest in persons aged 2–10 and 50–80 years. Epistaxis, like all hemorrhage, needs prompt evaluation and treatment. The primary goal of diagnosis is to determine the location of bleeding: anterior versus posterior. Once the site of bleeding is identified, bleeding is stopped using various techniques ranging from chemical cautery (ie, silver nitrate) to nasal packing. Anterior epistaxis accounts for 90% of nosebleeds. Most commonly, the bleeding is venous from Kiesselbach plexus, which is located along the anteroinferior nasal septum. Posterior epistaxis typically originates from the posteroinferior turbinate and is more commonly arterial in origin, from the sphenopalatine artery. Posterior epistaxis represents 10% of nosebleeds.

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Clinical Presentation

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History

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Determine the onset and duration to assess severity of blood loss. Inquire about comorbidities and medications, especially blood thinners and antiplatelet drugs. Identify mechanisms already used by the patient to attempt to stop the bleeding.

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The most common etiologies of anterior epistaxis are trauma, dehumidification of the nasal mucosa (typically from dry air during winter months), and digital manipulation. Other common causes include allergies, nasal sprays, illicit drugs, and nasal infections. Posterior epistaxis is more common in elderly debilitated patients with comorbid diseases such as a coagulopathy, atherosclerosis, neoplasm, or hypertension.

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Physical Examination

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Inspect the nares to identify the site of bleeding. A nasal speculum is useful to enhance visualization of the nares. If the site of bleeding cannot be identified, have the patient pinch the anterior soft portion of the nose, and examine the patient's oropharynx. If blood is trickling down the oropharynx while the patient is holding anterior pressure, a posterior bleed may be present.

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Diagnostic Studies

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Laboratory

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Blood work is not indicated in the majority of patients with epistaxis. Obtain a complete blood count in patients at risk for thrombocytopenia or anemia. Obtain coagulation studies in patients taking the anticoagulant warfarin and in patients with cirrhosis. Perform blood typing for patients with severe bleeding who may require transfusion.

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Imaging

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Imaging studies are rarely indicated in the work-up and treatment of epistaxis. Angiography with interventional radiology embolization can be utilized in rare cases of refractory posterior bleeding from the sphenopalatine and greater palatine arteries.

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Medical Decision Making

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The mainstay of epistaxis evaluation and treatment is identification of the source of the bleed to facilitate ...

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