Chapter 25: Epistaxis

Epistaxis, or nosebleed, represents a rupture of blood vessels within the nasal mucosa and affects approximately sixty percent of the population at some point in life, with a bimodal age distribution favoring children under ten and adults over fifty. The condition divides into two anatomically distinct presentations: anterior epistaxis originates at Kiesselbach's plexus on the nasal septum and accounts for roughly ninety percent of cases, typically presenting with bright red blood from the nostrils and responding well to conservative management, whereas posterior epistaxis arises from Woodruff's plexus and comprises only five to ten percent of cases but involves larger vessels, occurs more frequently in older adults, and presents greater clinical complexity with blood draining posteriorly into the throat, potentially causing hemoptysis, hematemesis, or melena. Causation predominantly involves local trauma and mucosal irritation, with digital manipulation being the most common trigger, though environmental factors like low humidity and high altitude contribute significantly to mucosal desiccation. Systemic risk factors encompassing coagulopathies such as hemophilia and von Willebrand disease, prolonged anticoagulant or intranasal corticosteroid use, chronic hypertension, and structural abnormalities including septal deviation and nasopharyngeal malignancies must be considered in recurrent or severe cases. Management follows a stepwise algorithm beginning with direct nasal pressure applied to the lower third while maintaining an upright posture with forward head flexion, progressing to topical vasoconstrictors like oxymetazoline or phenylephrine when initial pressure proves insufficient, advancing to chemical or electrocautery for persistent bleeding, and ultimately requiring nasal packing for refractory cases, with posterior bleeds frequently necessitating specialist intervention through balloon systems or complex posterior packing techniques. Diagnostic evaluation remains unnecessary for straightforward nosebleeds but becomes warranted in recurrent or severe presentations, where coagulation studies, complete blood count, and imaging may identify underlying hematologic disorders or structural pathology. Prevention focuses on mucosal hydration through saline irrigation and petroleum jelly application, environmental humidification, and patient education regarding avoidance of nasal trauma, vigorous nose-blowing, and medications that impair hemostasis, with acetaminophen preferred over nonsteroidal anti-inflammatory agents for analgesia.