A 35-year-old man with uncontrolled hypertension presents with recurrent epistaxis. On examination, bleeding originates from the anteroinferior part of the nasal septum. Another patient, a 28-year-old with hereditary hemorrhagic telangiectasia (HHT), presents with epistaxis from multiple sites in the nasal cavity. Which feature best distinguishes bleeding from Kiesselbach's plexus versus HHT-related epistaxis?

Explanation

## Distinguishing Kiesselbach's Plexus Bleeding from HHT-Related Epistaxis ### Anatomical and Clinical Characteristics | Feature | Kiesselbach's Plexus Bleeding | HHT-Related Epistaxis | |---------|-------------------------------|----------------------| | **Location** | Anteroinferior nasal septum (Little's area) | Multiple sites: septum, lateral wall, nasopharynx | | **Laterality** | Unilateral (usually) | Bilateral and multifocal | | **Bleeding Pattern** | Single source, easy to identify | Recurrent from multiple telangiectatic vessels | | **Associated Findings** | Often with hypertension, trauma, or dry mucosa | Telangiectasias on lips, oral mucosa, GI tract | | **Severity** | Usually mild to moderate, self-limited | Can be severe and recurrent | | **Age of Onset** | Any age, common in hypertension | Hereditary; often childhood/adolescence | **Key Point:** Kiesselbach's plexus is a highly vascular anastomotic area formed by terminal branches of the anterior ethmoidal, sphenopalatine, and superior labial arteries. It accounts for ~90% of anterior epistaxis. The anteroinferior septal location and unilateral presentation are pathognomonic. **High-Yield:** HHT (Osler-Weber-Rendu syndrome) presents with: - Recurrent epistaxis (often the first manifestation) - Mucocutaneous telangiectasias (lips, oral mucosa, fingertips) - Visceral involvement (pulmonary, hepatic, cerebral AVMs) - Autosomal dominant inheritance (mutations in ENG or ALK1 genes) **Clinical Pearl:** The **multifocal, bilateral nature** of HHT-related bleeding and the presence of telangiectasias elsewhere on the body are the key discriminators. Kiesselbach's bleeding is classically a single anterior septal source. **Mnemonic:** **KIESSELBACH** — **K**ey location is **anteroinferior**, **I**solated (unilateral), **E**asy to cauterize, **S**ingle source, **S**eptal, **E**asily controlled. In contrast, HHT is **H**ereditary, **H**ypertensive-like (recurrent), **T**elangiectasias (multifocal).