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Almost all persons have experienced a nosebleed at some time, and most nosebleeds resolve without requiring medical attention. Prolonged epistaxis, however, can be life-threatening, especially the elderly or debilitated.

Anterior epistaxis, in the anterior two thirds of the nose, is visible on the septum, and is the most common type of epistaxis. Anterior bleeding can often be resolved by pinching the cartilaginous part of the nose.

Posterior epistaxis from the posterior third of the nose accounts for 10% of nosebleeds. Bleeding is profuse because of the larger vessels in that location. Posterior epistaxis usually occurs in older patients, who have fragile vessels because of hypertension, atherosclerosis, coagulopathies, or weakened tissue. Posterior bleeds require aggressive treatment and hospitalization.

The anterior portion of the septum has a rich vascular supply, known as Kiesselbach's plexus, or Little's area, and most epistaxis originates in this region. Posterior hemorrhages originate from larger vessels near the sphenopalatine artery, behind the middle turbinate.

Causes of Epistaxis

Trauma. Nose picking, nose blowing, or sneezing can tear or abrade the mucosa and cause bleeding. Other forms of trauma include Nosebleeds nasal fracture and nasogastric and nasotracheal intubation.

Desiccation. Cold, dry air, and dry heat contribute to an increased incidence of epistaxis during the winter.

Other causes of nasal drying include dehydration (eg, from poorly controlled diabetes mellitus), nasal sprays (eg, corticosteroids and cromolyn), and nasal oxygen therapy.

Irritation. Upper respiratory infections, sinusitis, allergies, topical decongestants, and cocaine sniffing cause increased vulnerability to bleeding.

Hereditary Hemorrhagic Telangiectasia. This autosomal dominant condition weakens the capillaries and causes bleeding.

Nasal Septal Disease. Less common causes of anterior epistaxis include Wegener's granulomatosis, mid-line destructive disease, tuberculosis, and syphilis.

Systemic Disease. Epistaxis will be exacerbated by coagulopathy, blood dyscrasia, thrombocytopenia, or anticoagulant medication (NSAIDs, warfarin), hepatic cirrhosis, and renal failure.

Hypertension complicates active bleeding by promoting rigid arteries, and arteriosclerosis weakens vessels and inhibits vasoconstriction. These risk factors contribute to the posterior epistaxis most often seen in elderly patients.

Tumors. Juvenile nasopharyngeal angiofibroma, a benign, tumor, can cause profuse, life-threatening posterior epistaxis. Inverted papilloma less commonly presents with bleeding. Malignant neoplasms such as squamous cell carcinoma, adenocarcinoma, melanoma, esthesioneuroblastoma, and lymphoma can cause.

Foreign Bodies. A foreign body should be considered when a child has unilateral nasal obstruction, new-onset snoring, halitosis, or.

Clinical Evaluation of Epistaxis

Hemodynamic evaluation for tachycardia, hypotension, light-headedness should be completed immediately. Hypovolemic patients should be resuscitated with fluids and packed red blood cells.

After stabilization, the site, cause, and amount of bleeding is determined. Most patients require no immediate resuscitation. Posterior in an elderly and debilitated patient can be life-threatening because of aspiration, hypoxia, exsanguination, or myocardial infarction.

Determine the side on which the bleeding occurred: Unilateral nose bleeding suggests anterior in Kiesselbach's plexus. Bilateral bleeding suggests posterior caused by overflow around the posterior septum.

Determine whether epistaxis is anterior or posterior: When the patient is upright, blood drains primarily from the anterior part of the nose in anterior bleeding, or it drains from the nasopharynx in