## Epistaxis: Causes and Risk Factors ### Anterior vs. Posterior Epistaxis | Feature | Anterior Epistaxis | Posterior Epistaxis | |---------|-------------------|--------------------| | Frequency | ~90% of cases | ~10% of cases | | Location | Kiesselbach's plexus (Little's area) | Sphenopalatine artery branches | | Patient Age | All ages, especially children | Elderly patients | | Bleeding Pattern | Visible, slow to moderate | Posterior pharyngeal drainage, rapid | | Severity | Usually mild–moderate | Often severe, requires hospitalization | ### Common Risk Factors **Local Factors:** - Trauma (nose-picking, digital trauma) - Dry mucosa (low humidity, air conditioning) - Intranasal masses or polyps - Deviated septum - Granulomatous diseases (sarcoidosis, TB) **Systemic Factors:** - Uncontrolled hypertension (contributory, not sole cause) - Antiplatelet agents (aspirin, NSAIDs, clopidogrel) - Anticoagulants (warfarin, DOACs, heparin) - Coagulopathies (hemophilia, von Willebrand disease, thrombocytopenia) - Liver disease - Hereditary hemorrhagic telangiectasia (HHT/Osler–Weber–Rendu syndrome) ### Why Option 3 is Incorrect **Key Point:** Aspirin and NSAIDs are NOT absolute contraindications in epistaxis patients. While they do increase bleeding risk by inhibiting platelet aggregation, they are not universally forbidden. The decision to continue or discontinue these agents depends on: - The indication for the drug (e.g., secondary prevention post-MI, stroke prevention) - Severity and frequency of epistaxis - Individual risk–benefit assessment - Availability of alternative antiplatelet agents **Clinical Pearl:** In patients with acute epistaxis on aspirin for cardiovascular protection, the benefit of continuing the drug often outweighs the epistaxis risk. Discontinuation should be individualized and discussed with the cardiologist or internist. **High-Yield:** Hypertension is a risk factor but rarely the *sole* cause—it is usually a contributory factor in patients with underlying local pathology (mucosal friability, trauma, or vascular abnormality). ### Mnemonic: EPISTAXIS Risk Factors **E** — Elderly (posterior epistaxis) **P** — Platelet inhibitors (aspirin, NSAIDs) **I** — Intranasal trauma (nose-picking) **S** — Systemic anticoagulation (warfarin, DOAC) **T** — Telangiectasia (HHT) **A** — Anticoagulants **X** — (Xerosis) dry mucosa **I** — Intranasal masses **S** — Systemic coagulopathy
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