Anterior epistaxis

• Bleeding from the nostrils
  • Failure of anterior packing to control bleeding is highly suggestive of posterior epistaxis.
• ∼ 90% of cases, mostly kids
• Kiesselbach plexus

Posterior epistaxis

• Bleeding through the posterior nasal aperture
  • Bleeding down the throat (no external signs of bleeding)
  • Hemoptysis, hematemesis, and/or melena may occur due to swallowing of large amounts of blood.
• ∼ 10% of cases
• May be life-threatening

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

• Definition: a hereditary, systemic vasculopathy characterized by telangiectasia on the skin and mucosa, particularly in the area of the face (nose, lips, tongue)
• Pattern of inheritance: autosomal dominant
• Pathophysiology: mutations in genes which code for TGF-β receptors (e.g., endoglin or ALK-1) → structural defects in the vessel wall → postcapillary venous pooling → formation of small and large arteriovenous shunts
• Clinical features
  • Recurrent epistaxis
  • Telangiectasia
    • Even light contact with telangiectatic lesions can cause bleeding in the skin and mucosa.
  • Cyanosis
• Complications
  • High-output cardiac failure
  • Paradoxical emboli → brain abscess and/or stroke
  • Chronic GI bleeding and/or hematuria → anemia