Nosebleed
This is commonest in the very young and the very old. It may present routinely as a recurrent problem, or in the acute situation when the patient cannot control the bleeding. The latter cases usually result in trivial haemorrhage by clinical standards, but may create a disproportionate amount of alarm. Occasionally, a prolonged nosebleed can cause significant hypovolaemia, especially in the elderly.
Differential diagnosis
Common Diagnoses
- Spontaneous (from Little’s Area; May be Aggravated by Nose-Picking and Sneezing)
- Nasal Infection and Ulceration
- Drugs (e.g. Anticoagulants)
- Allergic Rhinitis (and Atrophic Rhinitis)
- Hypertension (often with Atherosclerosis)
Occasional Diagnoses
- Nasal Sprays (e.g. Corticosteroids)
- Septal Granulomas and Perforations
- Severe Liver Disease
- Tumours of Nose and/or Sinuses
- Abnormal Anatomy: Septal Deviation
- Trauma: Nasal Fracture
Rare Diagnoses
- Leukaemia
- Thrombocytopenia
- Coagulopathy: Haemophilia, Christmas and Von Willebrand’s Diseases
- Vitamin Deficiencies: C and K
- Hereditary Haemorrhagic Telangiectasia
Ready reckoner
Key distinguishing features of the most common diagnoses
| Spontaneous | Hypertension | Infection | Drugs | Rhinitis | |
|---|---|---|---|---|---|
| Recurrent | Possible | Yes | Possible | Yes | Yes |
| Generalised Bruising | No | No | No | Yes | No |
| Discharge or Crusting | No | No | Yes | No | No |
| Nasal Congestion | No | No | Possible | No | Yes |
| Soreness/Pain in Nose | Possible | No | Yes | No | No |
Possible investigations
Likely: None (INR if on warfarin).
Possible: FBC, clotting studies.
Small Print: LFT, sinus X-ray, CT scan.
- FBC: To check for thrombocytopenia or other signs of blood dyscrasia.
- LFT: Severe (e.g. alcoholic) liver disease causes clotting problems.
- Raised INR may reflect severe liver disease or warfarin overdose.
- Further clotting studies: If disorders such as haemophilia or von Willebrand’s disease are suspected.
- Sinus X-ray/CT scanning (usually secondary care): If tumour a possibility.
Top Tips
- Emergency calls for children with acute epistaxis can usually be dealt with by clear, calm and authoritative advice on the telephone. First-aid measures should also be advised in the elderly, but hospital referral may prove necessary, as the bleeding can be considerable and more difficult to stop.
- When children are presented in the surgery, establish any parental concerns. The main problem is often a fear of a blood disorder such as leukaemia rather than the inconvenience of the symptom itself.
- In young or middle-aged adults with recurrent bleeding and ulceration, consider cocaine abuse.
- Adults with recurrent epistaxis may well expect their blood pressure to be taken; either go ahead and take it, or, if the cause is obviously not hypertension, explain why there is no need.
Red Flags
- Severe nosebleed unresponsive to standard first-aid measures is best dealt with in hospital – especially in the elderly. Refer urgently to ENT or A&E.
- If recurrent nosebleeds with purpuric bruising, check FBC and coagulation screen urgently.
- Beware of recent onset of persistent unilateral bloodstained discharge and obstruction in the middle-aged and elderly. Carcinoma of the nose, nasopharynx or sinus is possible.
- Patients on warfarin should have an urgent INR and review of their dosage requirements.