Epistaxis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D., Liudvikas Jagminas, M.D., FACEP [2] José Eduardo Riceto Loyola Junior, M.D.[3]

Epistaxis is the relatively common occurrence of hemorrhage (bleeding) from the nose, usually noticed when it drains out through the nostrils. There are two types: anterior (the most common), and posterior (less common, and more severe). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting.

In past centuries, people thought epistaxis happened due to internal diseases. As the medical knowledge advanced, people found out that nasal compression can stop bleeding. Hippocrates was the first one who used some instruments to stop nasal bleeding. The term epistaxis was originally derived from the Greek word epistazein (epi – above, over; stazein – to drip).

Epistaxis may be classified according to the anatomical origin of the bleeding into 2 groups: anterior and posterior. It can also be further classified into primary (if idiopathic) or secondary (if there is a known cause) and acute or chronic.

Nosebleeding happen due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause tears, while inflammation, coagulation problems, and other disorders may make the injury harder to repair. In some patients, rupture of nasal blood vessels is spontaneous.

The causes of epistaxis can be divided into idiopathic and non-idiopathic causes. There are many diseases and medications that can cause epistaxis, but it can also start spontaneously. Usually, epistaxis is not dangerous but, in some cases, it can become life threatening. Trauma is the most common cause of epistaxis.

Many diseases can cause epistaxis. Based on patient history and physical examination, we can diagnose a cause of epistaxis. Differentiating anterior epistaxis from posterior epistaxis may be challenging. Rhinoscopy is the best way to distinguish between anterior and posterior epistaxis. In selected cases, endoscopy may be required.

Epistaxis is a prevalent symptom worldwide. About 60 percent of people experience epistaxis at least once, and about 6 percent of these people look for medical action at least once. It is more common in children and elderly patients

The most common risk factor of epistaxis in trauma. Other risk factors include coagulopathies, infections and vascular abnormalities. It can occur spontaneously. Childhood and senility are unchangeable risk factors.

No screening is indicated for epistaxis in asymptomatic patients.

Although epistaxis often ceases easily, it can become challenging to stop especially in posterior epistaxis which can cause aspiration. Most of the time bleeding stops without any intervention.Prognosis is generally good, and mortality is very rare.

The diagnostic study of choice to find the source of epistaxis is rhinoscopy. Cases in which rhinoscopy is ineffective in determining the vessel of bleeding, internal carotid artery (ICA) angiography is the preferred diagnostic study to find the bleeding site.

The hallmark of epistaxis is nosebleed. History of nose-picking, facial trauma, hypertension and coagulopathy may be found. The less common symptoms of epistaxis include fainting, dizziness, and hypovolemic shock.

Patients with epistaxis are usually well-appearing. Physical examination of patients with epistaxis is usually remarkable for bleeding from nostrils and posterior nose bleeding.

Laboratory findings is usually normal among patients with epistaxis, but when bleeding is heavy or physician it raises suspicion of coagulopathy. The following tests should be performed: CBC, PT, PTT, BT.

There are no ECG findings associated with epistaxis.

There are no X-ray findings associated with epistaxis.

There are no echocardiographic or ultrasonographic findings associated with epistaxis.

Paranasal sinuses CT scan is helpful in diagnosis causes of epistaxis, when the cause is unknown, also when epistaxis is heavy and/or recurrent.

Rhinoscopy and nasal endoscopy may be helpful in the diagnosis of epistaxis. It can help to assess the source of bleeding, distinguish between anterior and posterior epistaxis, and plan treatment.

Bone marrow biopsy is another diagnostic study to find cause of epistaxis, particularly when leukemia is suspected.

The majority of cases of epistaxis are self-limited and require only supportive care. If there is active bleeding, compression of the nostrils is the first measure to stop bleeding. If bleeding continues, ice application and nasal packing are possible measures to control bleeding. There are other options like cautery and some vasoconstrictive agents like oxymetazoline or phenylephrine to control bleeding.

Surgery is not the first-line treatment option for patients with epistaxis. Surgery is usually reserved for patients with either heavy active bleeding, recurrent epistaxis or non-compliant medical therapy.

Effective primary prevention measures for epistaxis include a vaporizer, nasal saline spray, and water soluble jelly, especially during winter months.

The primary and secondary prevention strategies for epistaxis are the same.

Most of the patients with epistaxis don’t need any medical procedure. Nasal compression is the best first option to stop bleeding. 95.5% of patients with epistaxis who attend emergency departments were discharged, patients were charged, on average, $1146.21 per visit.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

In past centuries, it was believed that epistaxis was caused by internal diseases. As the medical knowledge advanced, it was understood that that nasal compression can stop bleeding. Hippocrates is believed to be the first to use a instrument to stop nasal bleeding. The term epistaxis was originally derived from the Greek word epistazein (epi – above, over; stazein – to drip).

• The term epistaxis was originally derived from the Greek word epistazein (epi – above, over; stazein – to drip). ^[1]

• In past centuries, it was thought that epistaxis was due to internal diseases.

• In the late of 19th century, J. L. Little and W. Kiesselbach found that there is a plexus of vessels in the anterior part of nose which is source of most nasal bleedings.^[1]

• It was discovered empirically that nasal compression can stop bleeding. There were some beliefs that nasal bleeding could also be stopped by transfering blood to other parts of the body. Tourniquets were used for this purpose.^[1]

• Hippocrates is believed to be the first to use an instruments to stop nasal bleeding.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]

Epistaxis may be classified according to the anatomical origin of the bleeding into 2 groups: anterior and posterior. It can also be further classified into primary (if idiopathic) or secondary (if there is a known cause) and acute or chronic.

Epistaxis can be classified into anterior and posterior based upon the anatomical source of bleeding^[1]

Anterior epistaxis:

• Anterior epistaxis is more common, and source of this bleeding is usually Kiesselbach’s plexus.^[2]
• Anterior epistaxis is easier to control with nasal compression, nasal packing and cautery.

Posterior-epistaxis:

• Posterior bleeding is less common and harder to stop, and source of this bleeding is usually Woodruff’s plexus.
• Woodruff’s plexus is formed by vessels that are branches of the external carotid artery, thus, when it bleeds, it is usually much more severe than bleeding from Kiesselbach plexus’ bleeding.^[2]
• Bleeding from this plexus may cause aspiration and show bleeding with coughing and hemoptysis.
• This type of bleeding is more common in patients taking anticoagulants or hypertension.^[3]

• Acute epistaxis: as the name implies, it is a “de novo” bleeding.

• Chronic epistaxis : it is characterized by intermittent bleeding, that persists through a period of time.

• Primary: it is classified as primary if the source of the bleeding isn’t known.

• Secondary: it is classified as secondary if the bleeding is caused by another disease process (trauma, anticoagulants, arterial malformation).

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Editor in Chief:: C. Michael Gibson, M.S., M.D.. Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.José Eduardo Riceto Loyola Junior, M.D.[1]

Nosebleeding occurs due to tears in the mucosal lining and the many small blood vessels it contains. Fragility or injury may cause the tears, while inflammation, coagulation problems and other disorders may make the injury more difficult to repair. In some patients, rupture of nasal blood vessels is spontaneous.

Different causes tear vessels of the nose plexuses and lead to epistaxis:^[1]

• Epistaxis results from tears in the nasal mucosal lining, which contains many small blood vessels. It can be started by trauma, nasal picking, coagulopathies, and tumors.
• There is not enough evidence that hypertension is a risk factor for epistaxis. The technique of lowering blood pressure to control and prevent epistaxis remains controversial.
• Anterior epistaxis is more common, and the source of this bleeding is usually Kiesselbach’s plexus.
• Posterior bleeding is less common and harder to stop, and the source of this bleeding is usually Woodruff’s plexus. Bleeding from this plexus may cause aspiration and lead to bleeding with coughing and hemoptysis, as it generates a greater flow of blood. Posterior bleeding can compromise the airway if blood leaks into the posterior pharynx.^[2]

Location of the Kiesselbach’s and Woodruff’s plexus^[3]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Marcelo R. Zacarkim, M.D. [2] Kiran Singh, M.D. [3] Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[4]

The causes of epistaxis can be divided into idiopathic and non-idiopathic ones. There are many diseases and medications that can cause epistaxis but it also may be spontaneous. Usually epistaxis is not dangerous but in some cases it can become life threatening. Trauma is the most common cause of epistaxis.

• Hemophilia^[1]
• Congestive heart failure
• ITP
• Leukemia

• Local trauma
• Acute sinusitis
• Allergic rhinitis
• Anticoagulation
• Aspirin
• Chronic rhinitis
• Chronic sinusitis
• Barotrauma
• Cocaine
• Common cold
• Foreign bodies
• Nose-picking

• Neoplasia
  • Sinonasal squamous cell carcinoma
  • Papillomas
  • Juvenile nasopharyngeal angiofibroma
  • Esthesioneuroblastoma
  • Paraganglioma
• Vascular malformations
  • Capillary hemangioma
  • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
• Intracranial aneurysms^[2]

There is not enough evidence that hypertension is a risk factor for epistaxis.The role of lowering blood pressure to control and prevent epistaxis remains controversial.

In the table below different causes of epistaxis are classified based on organ system.

Cardiovascular	Aneurysm of the carotid artery, atherosclerosis, blood vessel disorders, cardiopulmonary resuscitation, coarctation of the aorta, congestive heart failure, hypertension, malignant hypertension, rheumatic fever, secondary hypertension, superior vena cava syndrome, vascular disorders
Chemical / poisoning	Aerosol abuse, ammonia, angiofibroma, biphenyl, borates rodenticide poisoning, brodifacoum rodenticide poisoning, bromadiolone rodenticide poisoning, brown snake rodenticide poisoning, calcium sulfate, chemical irritants, chlorophacinone rodenticide poisoning, chromates rodenticide poisoning, coumachlor rodenticide poisoning, coumafuryl rodenticide poisoning, coumatetralyl rodenticide poisoning, difenacoum rodenticide poisoning, difethialone rodenticide poisoning, diphacinone rodenticide poisoning, formaldehyde, indandione rodenticide poisoning, inhalant abuse, inhaled irritants, matikus rodenticide poisoning, metaldehyde, mouser rodenticide poisoning, mucormycosis, phosphorous, pindone rodenticide poisoning, ratak plus rodenticide poisoning, rodend rodenticide poisoning, rodenticides, solvent abuse, sulphuric acid, talon rodenticide poisoning, tetrachloroethylene, tetryl, vanadium, volak rodenticide poisoning, volid rodenticide poisoning, tobacco smoke
Dental	Dental extraction
Dermatologic	Benign mucosal pemphigoid, defibrination syndrome, leprosy, localized skin infection, melanoma, mucormycosis, nasal excoriation, Osler-weber-rendu disease, purpura, septal granulomas, staphylococcal furuncles, systemic lupus erythematosus, thrombocyopenic purpura
Drug Side Effect	Allegra, anticoagulants, antiplatelet drug, aspirin, bicalutamide, budesonide, butorphanol, cefpodoxime, ciclesonide,clemastine fumarate, clopidogrel, caspofungin acetate, clove (herbal agent), desmopressin, diquat dibromide, febuxostat, fexofenadine, flurbiprofen, fluticasone nasal spray, heroin, histrelin, Ibuprofen, corticosteroids, ipratropium bromide, isotretinoinleflunomide, lenvatinib, loratadine, meropenem, metipranolol, miltefosine, narcotics, nasal steroids, olopatadine, oxcarbazepine, palbociclib, pennyroyal oil (herbal agent), pramipexole, prasugrel, ramucirumab, retapamulin, rifaximin, riociguat,romiplostim, sertraline, sulindac, telfast, tiagabine, thalidomide, tobramycin, topiramate, triamcinolone acetonide, trimethadione, valproic acid, warfarin
Ear Nose Throat	Abnormal nasal anatomy , acute sinusitis, allergic rhinitis, antrochoanal polyps, antrostomy, barotrauma, benign nose tumors, broken nose, chronic irritation of the nasal mucosa, chronic rhinitis , chronic sinusitis common cold, deviated septum, dry nasal mucosa, epstein’s syndrome, esthesioneuroblastoma, ethmoidal polyps, hereditary haemorrhagic telangiectasia, increased nasal venous pressure, intranasal rhabdomyosarcoma, inverted papilloma, juvenile nasopharyngeal angiofibroma, maxillary sinus carcinoma, maxillofacial injury, middle ear barotrauma, nasal cancer, nasal cannula, nasal colonization with staphylococcus aureus , nasal congestion, nasal diphtheria, nasal excoriation, nasal foreign body, nasal fracture, nasal infection, nasal obstruction, nasal polyp, nasal septum deviation, nasal sprays, nasal tuberculosis, nasopharyngeal angiofibroma, nasopharyngeal carcinoma, nasal ulceration, non-allergic rhinitis, nose picking, rhinitis, rhinoplasty rhinoscleroma septal deviation, septal perforation, sinonasal undifferentiated carcinoma, sinus tumor, sinusitis, superior vena cava syndrome, trauma to littlee’s area, unilateral choanal atresia, viral rhinitis
Endocrine	Acthar, cystic fibrosis, corticotropin
Environmental	Cold air, dry air, environmental irritants, humidity
Gastroenterologic	Cirrhosis, hepatitis, mucormycosis, progressive familial intrahepatic cholestasis, Banti’s syndrome, rhinocerebral mucormycosis, rhinocerebral zygomycosis, Von Gierke Disease, Zygomycosis
Genetic	ADP platelet receptor P2Y12 deficiency, autoimmune lymphoproliferative syndrome, Banti’s syndrome, christmas disease, coarctation of the aorta, congenital afibrinogenemia, congenital hypoplastic anemia, congenital syphilis, Congential fibrinogen deficiency, connective tissue disease, cystic fibrosis, familial platelet syndrome, Fanconi’s anemia, Hemoglobin Lepore syndrome, hemophilia, Hermansky-Pudlak syndrome, inherited coagulation disorders, leukocyte adhesion deficiency, May-Hegglin anomaly, Osler-Weber-Rendu Disease, Owren parahemophilia, progressive familial intrahepatic cholestasis, prothrombin deficiency, sickle cell anemia, Von Gierke disease, Von Willebrand disease, X-linked dyserythropoietic anemia and thrombocytopenia
Hematologic	Acquired coagulation disorders, acquired factor XIII deficiency, acute erythroleukemia, acute leukemia, acute lymphocytic leukemia, acute promyelocytic leukemia, anemia, aplastic anemia, autoimmune lymphoproliferative syndrome, autoimmune thrombocytopenia, Bernard-Soulier syndrome, Bing-Neel syndrome, bleeding diathesis, bleeding disorders, bleeding tendency, blood dyscrasias, christmas disease, chronic leukemia, coagulation disorders, congenital afibrinogenemia, congenital hypoplastic anemia, congential fibrinogen deficiency, defibrination syndrome, Epstein’s syndrome, factor V deficiency, factor VII deficiency, factor X deficiency, familial blood dyscrasias, familial platelet syndrome, Fanconi’s anemia, hematological malignancy, Hemoglobin Lepore syndrome, hemoglobin SC, hemophilia, Hermansky-Pudlak syndrome, idiopathic thrombocytopenic purpura, Inability of the blood to clot, leukaemia, lymphomatoid granulomatosis, May-Hegglin anomaly, myelodysplastic syndromes, myeloproliferative diseases, Owren parahemophilia, pancytopenia, people with blood group O, platelet disorders, polycythemia vera, purpura, sickle cell anemia, stuart factor deficiency, superior vena cava syndrome, thrombasthenia, thrombocytopenic purpura, thrombocytopathy, thrombocytopenia, Von Willebrand disease, Waldenstrom macroglobulinemia, X-linked dyserythropoietic anemia and thrombocytopenia
Iatrogenic	Adenoidectomy, antrostomy, dental extraction, endoscopic sinus procedures, facial surgery, nasal cannula, nasal surgery, nasogastric tube placement, nasotracheal intubation, Orbital decompression, postoperative, rhinoplasty, septoplasty, sinus surgery, turbinectomy
Infectious Disease	Argentinean hemorrhagic fever, Bolivian hemorrhagic fever, congenital syphilis, dengue hemorrhagic fever, Hantavirosis, hepatitis, idiopathic fibrosing mediastinitis, infectious diseases, inflammatory disorders, leprosy, localized skin infection, Machupo virus, mucocutaneous leishmaniasis, mucormycosis, nasal diphtheria, nasal infection, Omsk hemorrhagic fever, nasal tuberculosis, pertussis, relapsing fever, respiratory tract infection, rhinocerebral mucormycosis, rhinocerebral zygomycosis, rheumatic fever, rhinoscleroma, rhinosporidiosis, scleroma, sinusitis, Stachybotrys chartarum, Soft tissue infection, Staphylococcal furuncles, Streptococcus pyogenes infection, systemic infection with nasal congestion, tuberculosis, typhoid fever, viral rhinitis, viral upper respiratory infections, Weil syndrome, whooping cough, zygomycosis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Acute cholinergic dysautonomia, Bing-Neel syndrome, head injury, Osler-Weber-Rendu syndrome
Nutritional / Metabolic	ADP platelet receptor p2y12 deficiency, clove (herbal agent), cystic fibrosis, excessive dieting, ginseng, glycogen storage disease, malnutrition, rapid weight loss, vitamin C deficiency, vitamin K deficiency, Von Gierke disease
Obstetric/Gynecologic	Menopause, pregnancy
Oncologic	Acute erythroleukemia, acute leukemia, acute lymphocytic leukemia, acute promyelocytic leukemia, adenoid cystic carcinoma, angiofibroma, chronic leukemia, esthesioneuroblastoma, hemangioma, hematological malignancy, Intranasal rhabdomyosarcoma, inverted papilloma, juvenile nasopharyngeal angiofibroma, leukaemia, maxillary sinus carcinoma, melanoma, myelodysplastic syndromes, myeloproliferative diseases, nasal cancer, nasal type natural killer/t-cell lymphoma, nasopharyngeal angiofibroma, nasopharyngeal cancers, nasopharyngeal carcinoma, neoplasm, pindborg tumor, polycythemia vera, rhabdomyosarcoma, Sinonasal undifferentiated carcinoma, squamous cell carcinoma, Waldenstrom macroglobulinemia
Opthalmologic	Orbital decompression
Overdose / Toxicity	Alcohol abuse, chronic usage of nasal sprays, chronic vitamin A toxicity, cocaine, heroin, narcotics
Psychiatric	Aerosol abuse, alcohol abuse, child abuse, inhalant abuse, solvent abuse, volatile inhalants
Pulmonary	Asphyxiation, barotrauma, common cold, cystic fibrosis, idiopathic fibrosing mediastinitis, pertussis, respiratory tract infection, sarcoidosis, Wegener’s granulomatosis, Whooping cough
Renal / Electrolyte	Chronic kidney disease, Epstein’s syndrome, renal artery stenosis, renal dialysis, renal disease, systemic lupus erythematosus, Wegener’s granulomatosis
Rheum / Immune / Allergy	Allergic rhinitis, allergies, autoimmune lymphoproliferative syndrome, autoimmune thrombocytopenia|autoimmune thrombocytopenia, benign mucosal pemphigoid, immune thrombocytopenic purpura, leukocyte adhesion deficiency, polychondritis, rheumatic fever, rhinitis, sarcoidosis, systemic lupus erythematosus, Wegener’s granulomatosis
Sexual	No underlying causes
Trauma	Barotrauma, blunt trauma, broken nose, facial trauma, head injury, maxillofacial injury, nasal fracture, post-traumatic pseudoaneurysm, Skull fracture, sphenoidal fracture, trauma to littlee’s area
Urologic	Inverted papilloma
Miscellaneous	Foreign bodies, pennyroyal oil

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Editor in Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

Many diseases can cause epistaxis. Based on patient history and physical examination we can diagnose the cause of epistaxis. The challenging part is differentiating anterior epistaxis from posterior epistaxis. Rhinoscopy is the best way to distinguish between anterior and posterior epistaxis. In selected cases, endoscopy may be required.

Epistaxis can be differentiated between anterior and posterior epistaxis.^{[1] [2]}

• Anterior epistaxis is more common than posterior epistaxis, but posterior epistaxis is harder to stop.
• Anterior and posterior epistaxis can be differentiated during clinical management, as anterior epistaxis is much more easily controlled. In case of refractory or profuse bleeding, suspect of posterior epistaxis.
• Causes of both anterior and posterior epistaxis are almost the same.
• Bleeding from nostrils usually refers to anterior epistaxis (it can occur in heavy posterior epistaxis too).
• Epistaxis in children is usually anterior but incidence of posterior epistaxis is more common in elderly patients.
• Rhinoscopy is the best way to distinguish between anterior and posterior epistaxis, in the case of not finding the source of bleeding with anterior rhinoscopy, treatment for posterior epistaxis must be started.
• Posterior epistaxis may cause cough and aspiration.

The more common and important causes of epistaxis are listed below:^[3]

• Nasal tumor
• DIC
• Hemophilia
• Rhinitis
• Foreign body in the nose
• Drug toxicity
• Von Willebrand disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]

Epistaxis is a prevalent symptom worldwide. About 60 percent of people experience epistaxis at least once in their lifetime, and about 6 percent of these people seek medical attention. It is more common in children and elderly patients.

• The incidence of patients with epistaxis, who required inpatient treatment to control bleeding was estimated to be 42 cases per 100,000 for men, 28 cases per 100,000 for women. For men over 85 years, the incidence is 222 per 100,000 in Thuringia, Germany.^[1]
• Only 6-10% of the patients who experience epistaxis seek medical help.^[2]

• “About 1 in 200 visits to emergency departments, is for epistaxis In the United States”.^[3]

• About 60 percent of Americans experienced epistaxis at least once, and about 6 percent of people seek medical attention. ^[4][2]

• Although epistaxis is the most common emergency in ENT, mortality from epistaxis is rare. ^[5]

• Patients of all age groups may experience epistaxis, but it is more prevalent in children and elderly patients.^[3]

• Based on some studies epistaxis is more common in Caucasian compared with African-Americans.^[6]

• Epistaxis is more common in males than in females.^[7]

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Editor in Chief: C. Michael Gibson, M.S., M.D. [[1]], Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[1]

The most common risk factor of epistaxis is trauma. Other risk factors include coagulopathies, infections and vascular abnormalities. It can occur spontaneously. Childhood and senility are unchangeable risk factors.

• Trauma is the most common risk factor of epistaxis. Childhood and senility are unchangeable risk factors. Other risk factors are:^[1]
• Vascular abnormalities^{[2] [3]}
  • Hereditary Hemorrhagic Telangiectasia
  • Congestive hearth failure
  • Granulomatosis with polyangitis
• Infections
• Coagulopathies:
  • Anticoagulants
  • Antiplatelet
  • von Willebrand disease
  • Leukemia
  • Other medications causing coagulopathy

• Hypertension may be associated with epistaxis. A study has shown that incidence rates for epistaxis were significantly higher in the hypertensive patients, and they required posterior nasal packing more often than the control group (1.9% vs. 0.4%).^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

No screening is indicated for epistaxis in asymptomatic patients.

No screening is indicated for epistaxis in asymptomatic patients.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

Although epistaxis often ceases easily, it can become challenging to stop especially in posterior epistaxis which can cause aspiration. Most of the time bleeding stops without any intervention. Prognosis is generally good, and mortality is very rare.

There are two types of epistaxis:^[1][2][3]

• Anterior epistaxis is more common, and the source of this bleeding is usually Kiesselbach’s plexus. The most common cause is nasal picking and trauma, and it is usually self-limiting being easily controlled pressing the nose or with nasal packing.
• Posterior epistaxis is harder to control, and the source of this bleeding is usually Woodruff’s plexus. It is more commonly associated with coagulopathies, use of anticoagulants and other causes. It usually demands nasal packing and bleeding can be profuse and life-threatening, due to airway compromise.

• Although epistaxis often stops easily it can become challenging to control, especially in posterior epistaxis which can cause aspiration.
• Heavy epistaxis may cause hypovolemia.

• Aspiration^[4]
• Sinusitis
• Hypovolemia in heavy bleeding
• Cerebral abscess is very uncommon^[5]

• Prognosis is generally good, and mortality is very low.

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