The differential diagnostic approach to epistaxis is anatomic and histologic. Table 27 breaks the nasal passages into anatomic and histologic components and cross-indexes them with the various etiologies.
By far, the most common cause of epistaxis is trauma from nose picking. Many people are particularly vulnerable to this because of the closeness of Kiesselbach plexus of veins and capillaries to the surface of the septal mucosa. This cause can quickly be ruled out by nasoscopic examination of the anterior portion of the septum. This same area may be inflamed or ulcerated by various infections, particularly syphilis, tuberculosis, leprosy, and mucormycosis. Carcinomas in this area are uncommon, but the Schmincke tumor of the nasopharynx should not be forgotten; more important are allergic polyps, which usually do not bleed unless traumatized. Wegener midline granulomatosis is an autoimmune disease that may present with a bloody or nonbloody nasal discharge. It usually involves the sinuses, however, and must be differentiated from mucormycosis.
Other systemic diseases are prominent causes of epistaxis. Back pressure from obstructed veins in emphysema, asthma, and right heart failure must be considered. Arterial hypertension, from whatever etiology, is a common cause from middle age onward. Rheumatic fever and blood dyscrasias round out the picture.
Other miscellaneous causes of epistaxis are skull fracture and menopause. In most cases, adequate examination of the nasal septum discloses the diagnosis, and coagulation or nasal packing will suffice in treatment. The blood pressure should always be checked and, in recurrent cases, nasopharyngoscopy, coagulation studies, and a search for systemic disease must be made.
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TABLE 27. Epistaxis |
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Other Useful Tests
1. CBC (anemia, thrombocytopenia)
2. Chemistry panel (liver disease, renal disease)
3. Rumpel–Leede test (thrombocytopenia)
4. Liver function test (cirrhosis)
5. Prothrombin time (liver disease, vitamin K deficiency, drug effects)
6. Partial thromboplastin time (disseminated intravascular coagulation [DIC], hemophilia)
7. X-rays of the sinuses (neoplasm)
8. Nasopharyngoscopy (polyps, neoplasm)
9. Circulation time (CHF)
10. Arterial blood gas analysis (lung disease)
11. Platelet count (thrombocytopenia)
12. Bleeding time (thrombocytopenia, vascular purpura)
Case Presentation #22
A 42-year-old black man came to the emergency room because of persistent epistaxis. He had a history of smoking cigarettes for 30 years. History also revealed that he had several previous nosebleeds in the past 6 months but not this severe.
Question #1. What would be the possible causes of this man's difficulties utilizing the above described methods?
Further history reveals he has had a chronic cough and mild shortness of breath for several years. Physical examination reveals sibilant and sonorous rales over both lungs and diminished alveolar breathing throughout.
Question #2. What is your diagnosis?