Nosebleed

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

SpontaneousHypertensionInfectionDrugsRhinitis
RecurrentPossibleYesPossibleYesYes
Generalised BruisingNoNoNoYesNo
Discharge or CrustingNoNoYesNoNo
Nasal CongestionNoNoPossibleNoYes
Soreness/Pain in NosePossibleNoYesNoNo

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.
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