Professional Guide to Signs and Symptoms
5th Edition

Epistaxis
A common sign, epistaxis (nosebleed) can be spontaneous or induced from the front or back of the nose. Most nosebleeds occur in the anterior-inferior nasal septum (Kiesselbach’s plexus), but some occur at the point where the inferior turbinates meet the nasopharynx. Usually unilateral, they seem bilateral when blood runs from the bleeding side behind the nasal septum and out the opposite side. Epistaxis ranges from mild oozing to severe—possibly life-threatening—blood loss.
A rich supply of fragile blood vessels makes the nose particularly vulnerable to bleeding. Air moving through the nose can dry and irritate the mucous membranes, forming crusts that bleed when they’re removed; dry mucous membranes are also more susceptible to infections, which can produce epistaxis as well. Trauma is another common cause of epistaxis. Additional causes include septal deviations; hematologic, coagulation, renal, and GI disorders; and certain drugs and treatments.
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HISTORY AND PHYSICAL EXAMINATION
If your patient isn’t in distress, take a history. Does he have a history of recent trauma? How often has he had nosebleeds in the past? Have the nosebleeds been long or unusually severe? Has the patient recently had surgery in the sinus area? Ask about a history of hypertension, bleeding or liver disorders, and other recent illnesses. Ask if the patient bruises easily. Find out what drugs he uses, especially anti-inflammatories such as aspirin and anticoagulants such as warfarin.
Begin the physical examination by inspecting the patient’s skin for other signs of bleeding, such as ecchymoses and petechiae, and noting any jaundice, pallor, or other abnormalities. When examining a trauma patient, look for associated injuries, such as eye trauma or facial fractures.
MEDICAL CAUSES
  • Angiofibroma (juvenile). This rare disorder usually occurs in males and is characterized by severe recurrent epistaxis and nasal obstruction.
  • Aplastic anemia. This disorder develops insidiously, eventually producing nosebleeds as well as ecchymoses, retinal hemorrhages, menorrhagia, petechiae, bleeding from the mouth, and signs of GI bleeding. Fatigue, dyspnea, headache, tachycardia, and pallor may also occur.
  • Barotrauma. Commonly seen in airline passengers and scuba divers, barotrauma may cause severe, painful epistaxis when the patient has an upper tract respiratory infection.
  • Biliary obstruction. This disorder produces bleeding tendencies, including epistaxis. Typical features are colicky right-upper-quadrant pain after eating fatty food, nausea, vomiting, fever, flatulence and, possibly, jaundice.
  • Cirrhosis. Epistaxis is a late sign that occurs along with other bleeding tendencies (bleeding gums, easy bruising, hematemesis, melena) in cirrhosis. Other typical late findings include ascites, abdominal pain, shallow respirations, hepatomegaly or splenomegaly, and fever of 101° F to 103° F (38.3° C to 39.4° C). The patient may also exhibit muscle atrophy, enlarged superficial abdominal veins, severe pruritus, extremely dry skin, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema and, possibly, jaundice and central nervous system disturbances.
  • Coagulation disorders. Such disorders as hemophilia and thrombocytopenic purpura can cause epistaxis along with ecchymoses, petechiae, and bleeding from the gums, mouth, and I.V. puncture sites. Menorrhagia and signs of GI bleeding, such as melena and hematemesis, can also occur.
  • Glomerulonephritis (chronic). This disorder produces epistaxis as well as hypertension, proteinuria, hematuria, headache, edema, oliguria, hemoptysis, nausea, vomiting, pruritus, dyspnea, malaise, and fatigue.
  • Hepatitis. When hepatitis interferes with the clotting mechanism, epistaxis and other abnormal bleeding tendencies can result. Associated signs and symptoms typically include jaundice, clay-colored stools, pruritus, hepatomegaly, abdominal pain, fever, fatigue, weakness, dark amber urine, anorexia, nausea, and vomiting.
  • Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). This disease causes frequent, sometimes daily, epistaxis as well as hemoptysis and GI bleeding. It’s characterized by telangiectases—pinpoint, purplish red spots or flat, spiderlike lesions—on the mucous membranes
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    of the lips, mouth, tongue, nose, and GI tract and occasionally on the trunk and fingertips.
  • Hypertension. Severe hypertension can produce severe epistaxis, usually in the posterior nose, with pulsation above the middle turbinate. It may be accompanied by dizziness, a throbbing headache, anxiety, peripheral edema, nocturia, nausea, vomiting, drowsiness, and mental impairment.
  • Infectious mononucleosis. In patients with this infectious disorder, blood may ooze from the nose. Characteristic features include sore throat, cervical lymphadenopathy, and a fluctuating fever with an evening peak of 101° F to 102° F (38.3° C to 38.9° C).
  • Influenza. When influenza affects the capillaries, a slow, oozing nosebleed results. Other signs and symptoms of influenza include a dry cough, chills, fever, malaise, myalgia, sore throat, hoarseness or loss of voice, conjunctivitis, facial flushing, headache, rhinitis, and rhinorrhea.
  • Leukemia. In acute leukemia, sudden epistaxis is accompanied by a high fever and other types of abnormal bleeding, such as bleeding gums, ecchymoses, petechiae, easy bruising, and prolonged menses. These may follow less-noticeable signs and symptoms, such as weakness, lassitude, pallor, chills, recurrent infections, and a low-grade fever. Acute leukemia may also cause dyspnea, fatigue, malaise, tachycardia, palpitations, a systolic ejection murmur, and abdominal or bone pain.
    In chronic leukemia, epistaxis is a late sign that may be accompanied by other types of abnormal bleeding, extreme fatigue, weight loss, hepatosplenomegaly, bone tenderness, edema, macular or nodular skin lesions, pallor, weakness, dyspnea, tachycardia, palpitations, and headache.
  • Maxillofacial injury. A pumping arterial bleed usually causes severe epistaxis in a maxillofacial injury. Associated signs and symptoms include facial pain, numbness, swelling, and asymmetry; open-bite malocclusion or inability to open the mouth; diplopia; conjunctival hemorrhage; lip edema; and buccal, mucosal, and soft-palatal ecchymoses.
  • Nasal fracture. A nasal fracture may cause unilateral or bilateral epistaxis with nasal swelling, pain, and deformity; crepitation of the nasal bones; and periorbital ecchymoses and edema.
  • Nasal tumor. Blood may ooze from the nose when a tumor disrupts the nasal vasculature. Benign tumors usually bleed when touched, but malignant tumors produce spontaneous unilateral epistaxis along with a foul discharge, cheek swelling, and—in the late stage—pain.
  • Orbital floor fracture. This type of trauma may damage the maxillary sinus mucosa and, on rare occasions, cause epistaxis. More typical features include periorbital edema and ecchymoses, diplopia, infraorbital numbness, enophthalmos, limited eye movement, and facial asymmetry.
  • Polycythemia vera. A common sign of polycythemia vera, spontaneous epistaxis may be accompanied by bleeding gums; ecchymoses; ruddy cyanosis of the face, nose, ears, and lips; and congestion of the conjunctiva, retina, and oral mucous membranes. Other signs and symptoms vary according to the affected body system but may include headache, dizziness, tinnitus, vision disturbances, hypertension, chest pain, intermittent claudication, early satiety and fullness, marked splenomegaly, epigastric pain, pruritus, and dyspnea.
  • Renal failure. Chronic renal failure is more likely than acute renal failure to cause epistaxis and a tendency to bruise easily. More common signs and symptoms are oliguria or anuria, anorexia, weight loss, abdominal pain, diarrhea, nausea, vomiting, tissue wasting, dry mucous membranes, uremic breath odor, Kussmaul’s respirations, deteriorating mental status, and tachycardia.
    Skin changes include pruritus, pallor, yellow-bronze pigmentation, purpura, excoriation, uremic frost, and brown arcs under the nail margins. Neurologic signs and symptoms may include muscle twitching, fasciculations, asterixis, paresthesia, and footdrop. Cardiovascular effects include
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    hypertension, arrhythmias, signs of heart failure or pericarditis, and peripheral edema.
  • Sarcoidosis. Oozing epistaxis may be accompanied by a nonproductive cough, substernal pain, malaise, and weight loss in this disorder. Related findings include tachycardia, arrhythmias, parotid gland enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and arthritis in the ankles, knees, and wrists.
  • Scleroma. In this disorder, oozing epistaxis occurs with a watery nasal discharge that becomes foul-smelling and crusty. Progressive anosmia and turbinate atrophy may also occur.
  • Sinusitis (acute). In this disorder, a bloody or blood-tinged nasal discharge may become purulent and copious after 24 to 48 hours. Associated signs and symptoms include nasal congestion, pain, and tenderness; malaise; headache; a low-grade fever; and red, edematous nasal mucosa.
  • Skull fracture. Depending on the type of fracture, epistaxis can be direct (when blood flows directly down the nares) or indirect (when blood drains through the eustachian tube and into the nose). Abrasions, contusions, lacerations, or avulsions are common. A severe skull fracture may cause severe headache, decreased level of consciousness, hemiparesis, dizziness, seizures, projectile vomiting, and decreased pulse and respiratory rates.
    A basilar fracture may also cause bleeding from the pharynx, ears, and conjunctivae as well as raccoon eyes and Battle’s sign. Cerebrospinal fluid or even brain tissue may leak from the nose or ears. A sphenoid fracture may also cause blindness, whereas a temporal fracture may also cause unilateral deafness or facial paralysis.
  • Syphilis. Epistaxis is most common in patients with tertiary syphilis, as posterior septum ulcerations produce a foul, bloody nasal discharge. It may be accompanied by a painful nasal obstruction and nasal deformity. Occasionally, primary syphilis causes painful nasal crusting and bleeding accompanied by the characteristic chancre sores.
  • Systemic lupus erythematosus (SLE). Usually affecting women younger than age 50, SLE causes oozing epistaxis. More characteristic signs and symptoms include butterfly rash, lymphadenopathy, joint pain and stiffness, nausea, vomiting, myalgia, anorexia, and weight loss.
  • Typhoid fever. Oozing epistaxis and dry cough are common signs of typhoid fever, which may also cause sudden chills and high fever, vomiting, abdominal distention, constipation or diarrhea, splenomegaly, hepatomegaly, “rose-spot” rash, jaundice, anorexia, weight loss, and profound fatigue.
OTHER CAUSES
  • Chemical irritants. Some chemicals—including phosphorus, sulfuric acid, ammonia, printer’s ink, and chromates—irritate the nasal mucosa, producing epistaxis.
  • Drugs. Anticoagulants, such as warfarin, and anti-inflammatories, such as aspirin, can cause epistaxis. Cocaine use, especially if frequent, can also cause epistaxis.
  • Surgery and procedures. Epistaxis rarely results from facial or nasal surgery, including septoplasty, rhinoplasty, antrostomy, endoscopic sinus procedures, orbital decompression, and dental extraction.
  • Vigorous nose blowing. This may rupture superficial blood vessels, especially in elderly people and young people, causing nosebleeds.
SPECIAL CONSIDERATIONS
Until the bleeding is completely under control, continue to monitor the patient for signs of hypovolemic shock, such as tachycardia and clammy skin. If external pressure doesn’t control the bleeding, insert cotton that has been impregnated with a vasoconstrictor and local anesthetic into the patient’s nose.
If bleeding persists, expect to insert anterior or posterior nasal packing. (See Controlling epistaxis with nasal packing.)
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Administer humidified oxygen by face mask to a patient with posterior packing.
A complete blood count may be ordered to evaluate blood loss and detect anemia. Clotting studies, such as prothrombin time and activated partial thromboplastin time, may be required to test coagulation time. Prepare the patient for X-rays if he has had a recent trauma.
PEDIATRIC POINTERS
Children are more likely to experience anterior nosebleeds, usually the result of nose-picking or allergic rhinitis. Biliary atresia, cystic fibrosis, hereditary afibrinogenemia, and nasal trauma due to a foreign body can also cause epistaxis. Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash. Two rare childhood diseases—pertussis and diphtheria—can also cause oozing epistaxis.
Suspect a bleeding disorder if you see excess umbilical cord bleeding at birth or profuse bleeding during circumcision. Epistaxis commonly begins at puberty in patients with hereditary hemorrhagic telangiectasia.
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GERIATRIC POINTERS
Elderly patients are more likely to have posterior nosebleeds.
PATIENT COUNSELING
Teach the patient proper pinching techniques for applying pressure to the nose. For prevention, tell him to apply liberal amounts of petroleum jelly to nostrils to prevent drying, cracking, and picking. Also recommend using of a humidifier at night and trimming fingernails.